Neurocritical Care Society and Society for Critical Care Medicine recommendations for reversal of antithrombotic agents in patients with intracranial hemorrhage

Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage : A Statement for Healthcare Professionals from the Neurocritical Care Society... - PubMed - NCBI http://www.ncbi.nlm.nih.gov/pubmed/26714677

Antithrombotic: Timing, Antidote, Factor Replacement, antifibrinolytics

Vitamin K antagonists (warfarin) If INR > 1.3 then Vitamin K 10 mg IV, plus 3 or 4 factor PCC IV

(dosing based on weight, INR and PCC type) OR FFP 10–15 ml/kg IV if PCC not available

Direct factor Xa inhibitors: activated charcoal (50 g) within 2 h of ingestion, activated PCC (FEIBA) 50 units/kg IV OR 4 factor PCC 50 units/kg IV

Direct thrombin inhibitors (dabigatran): Activated charcoal (50 g) within 2 h of ingestion, AND Activated PCC (FEIBA) 50 units/kg IV OR 4 factor PCC 50 units/kg IV Idarucizumab 5 g IV (in two 2.5 g/50 mL vials) consider hemodialysis or idarucizumab redosing for refractory bleeding after initial administration if 1) dabigatran was taken with 3-5 half lives and NO evidence of renal insufficiency or 2) dabigatran was taken beyond 3-5 half lives WITH renal insufficiency

For other DTIs: Activated PCC (FEIBA) 50 units/kg IV OR 4 factor PCC 50 units/kg IV

Unfractionated heparin: Protamine 1 mg IV for every 100 units of heparin administered in the previous 2–3 h (up to 50 mg in a single dose)

LMWH

Enoxaparin: Dosed within 8 h: Protamine 1 mg IV per 1 mg enoxaparin (up to 50 mg in a single dose) Dosed within 8–12 h: Protamine 0.5 mg IV per 1 mg enoxaparin (up to 50 mg in a single dose) Minimal utility in reversal >12 h from dosing

Dalteparin, Nadroparin and Tinzaparin: Dosed within 3–5 half-lives of LMWH: Protamine 1 mg IV per 100 anti-Xa units of LMWH (up to 50 mg in a single dose) OR rFVIIa 90 mcg/kg IV if protamine is contraindicated

Danaparoid: rFVIIa 90 mcg/kg IV

Pentasaccharides: Activated PCC (FEIBA) 20 units/kg IV or rFVIIa 90 mcg/kg IV

Thrombolytic agents (plasminogen activators): Cryoprecipitate 10 units IV OR antifibrinolytics (tranexamic acid 10–15 mg/kg IV over 20 min or e-aminocaproic acid 4–5 g IV) if cryoprecipitate is contraindicated

Antiplatelet agents: DDAVP 0.4 mcg/kg x 1, if neurosurgical intervention, transfuse one apheresis unit