Neurocritical Care Society and Society of Critical Care Medicine just published guidelines for the reversal of antithrombotics in intracranial hemorrhage.
Summary is here in this table.
|Antithrombotic agent||Reversal agent|
|Vitamin K antagonists||If INR more than 1.4
vitamin K 10 mg IV,
plus 3- or 4-factor PCC IV (dosing based on weight, INR, and PCC type) (Strong recommendation)or
fresh frozen plasma 10-15 mU kg IV if PCC not available
|Direct factor Xa inhibitors||Activated charcoal (50g) within 2 hr of ingestion, activated PCC (FEIBA) 50 U/kg IV or 4-factor
PCC 50 U/kg IV
|DTis||For dabigatran reversal:
Activated charcoal (50g) within 2 hr of ingestion, and idarucizumab 5g IV (in two 2.5 gm/ 50 ml vial) Consider hemodialysis or idarucizumab redosing for refractory bleeding after initial administration
For other DTis:
Activated PCC (FEIBA) 50 U/kg IV or
4-factor PCC 50 U/kg IV
|Unfractionated heparin||Protamine 1 mg IV for every 100 units of heparin administered in the previous 2-3 hr (up to 50 mg in a single dose)
Dosed within 8 hr: protamine 1 mg IV per 1mg enoxaparin (up to 50mg in a single dose) Dosed within 8-12 hr: protamine 0.5 mg IV per 1 mg enoxaparin (up to 50mg in a single dose) Minimal utility in reversal> 12hr 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 pg/kg IV if protamine is contraindicated
|Danaparoid||rFVIIa 90 pg/kg IV
|Pentasaccharides||Activated PCC (FEIBA) 20 U/kg IV or rFVIIa 90 f.lg/kg IV
|Cryoprecipitate 10 units IV or antifibrinolytics (tranexamic acid 10 -15 mg/kg IV over 20min or alpha- aminocaproic acid 4-5g IV) if cryoprecipitate is contraindicated
|Antiplatelet agents||Desmopressin 0.4 mcg/kg IV x 1
If neurosurgical intervention: platelet transfusion (one apheresis unit)
Few more points
- They recommend against VKA reversal in patients where there is a high suspicion of intracranial hemorrhage due to cerebral venous thrombosis (Conditional recommendation, very low quality evidence).
- They recommend assessing risks and benefits when considering VKA reversal in intracranial hemorrhage patients with concurrent symptomatic or life-threatening thrombosis, ischemia, heparin-induced thrombocytopenia, or DIC (Good Practice statement).
- They recommend against administration of rFVIIa or FFP in DTI-related intracranial hemorrhage
- They recommend against protamine for reversal of pentasaccharides
- In intracranial hemorrhage patients receiving pentasaccharides for venous thromboembolism prophylaxis, we suggest against reversal unless there is evidence of bioaccumulation or impaired clearance (Good Practice statement).
- They recommend platelet function testing prior to platelet transfusion if possible (Strong recommendation, moderate quality evidence).