How do I manage a patient with a life-threatening bleed on warfarin?
General approach as follows:
- Withdrawal of anticoagulants and supportive care
- Stop anti-coagulants and determine time of last dose
- Stop anti-platelet agents
- Laboratory investigations: CBC, INR/aPTT/fibrinogen, group & screen
- Consider blood transfusion - if the patient requires ≥ 3 units of RBCs in 1 hour, consider massive haemorrhage protocol activation
- Uncrossmatched blood sent stat if group & screen pending (~10 min) – O negative for women age ≤45, O positive for everyone else
- Reversal of warfarin - Both fast and slow reversal required:
- Fast reversal: Administer Prothrombin Complex Concentrates (PCCs) – dosed based on INR ± Weight (see chart below)
- If INR is unknown administer 2000 IU
- Do not wait for INR results during life-threatening bleeding
- Slow reversal: Administer Vitamin K – 10 mg IV
- Frozen plasma transfusion despite being common is not appropriate standard of care, unless PCCs unavailable or history of heparin induced thrombocytopenia (HIT)
- Fast reversal: Administer Prothrombin Complex Concentrates (PCCs) – dosed based on INR ± Weight (see chart below)
- Adjunct treatments to stop the bleed
- Tranexamic Acid - consider up to 2 g IV total
- Not studied specifically in bleeding patients on warfarin
- Consult interventional radiology or surgery
- Tranexamic Acid - consider up to 2 g IV total
Dosing based on NAC recommendations:
INR Based Dosing:
| PCC dose if INR <3 | PCC dose if INR 3-5 | PCC dose if INR > 5 | |
|---|---|---|---|
| Dose | 1000 IU ( 40 mL) | 2000 IU (80 mL) | 3000 IU (120 mL) |
Weight plus INR based dosing:
| Weight (kg) | PCC dose if INR 2-2.9 (20 units/kg) | PCC dose if INR 3-6 (30 units/kg) | PCC dose if INR > 6 (40 units/kg) |
|---|---|---|---|
| 35-37 | 500 IU ( 20 mL) | 1000 IU ( 40 mL) | 1500 IU (60 mL) |
| 38-41 | 1000 IU ( 40 mL) | 1000 IU ( 40 mL) | 1500 IU (60 mL) |
| 42-43 | 1000 IU ( 40 mL) | 1500 IU (60 mL) | 1500 IU (60 mL) |
| 44-56 | 1000 IU ( 40 mL) | 1500 IU (60 mL) | 2000 IU (80 mL) |
| 57-58 | 1000 IU ( 40 mL) | 1500 IU (60 mL) | 2500 IU (100 mL) |
| 59-62 | 1000 IU ( 40 mL) | 2000 IU (80 mL) | 2500 IU (100 mL) |
| 63-68 | 1500 IU (60 mL) | 2000 IU (80 mL) | 2500 IU (100 mL) |
| 69-75 | 1500 IU (60 mL) | 2000 IU (80 mL) | 3000 IU (120 mL) |
| 76-87 | 1500 IU (60 mL) | 2500 IU (100 mL) | 3000 IU (120 mL) |
| 88-91 | 2000 IU (80 mL) | 2500 IU (100 mL) | 3000 IU (120 mL) |
| 92-112 | 2000 IU (80 mL) | 3000 IU (120 mL) | 3000 IU (120 mL) |
| 113-136 | 2500 IU (100 mL) | 3000 IU (120 mL) | 3000 IU (120 mL) |
| 137 or greater | 3000 IU (120 mL) | 3000 IU (120 mL) | 3000 IU (120 mL) |