Tag Archives: anticoagulation

General

The Downside Of Not Taking Your Anticoagulant

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Yesterday I wrote about one reader’s experience with a trauma patient on Dabigatran. We’ve all been faced with injured patients who are taking some kind of anticoagulant, and it complicates their care. Why can’t we just stop them in patients at risk for injury (e.g. an elderly patient who falls frequently)?

Two major risk groups come to mind: those taking the meds who have DVT (or a propensity to get it), and patients with atrial fibrillation who take them to decrease stroke risk. I was not able to find much info (yet) on the former category. But there is a series of nicely done studies based on work from the Framingham Heart Study.

The Framingham study started in 1948, and has been following over 5,000 people for the development of cardiovascular disease. In this particular analysis, 5070 patients who were initially free of disease were analyzed for development of atrial fib and occurrence of stroke. Anticoagulants were seldom used in this group.

The authors found that the prevalence of stroke increased with age in patients with atrial fib. The percentage that could be attributed to a-fib also increased. The following summarizes their numbers:

  • Age 50-59: 0.5 strokes per 100 patients, attributable risk 1.5%
  • Age 60-69: 1.8 strokes per 100 patients, attributable risk 2.8%
  • Age 70-79: 4.8 strokes per 100 patients, attributable risk 9.9%
  • Age 80-89: 8.8 strokes per 100 patients, attributable risk 23.5%

Bottom line: The risk of having a stroke just because a patient has atrial fibrillation goes up significantly with age. So setting an age cutoff for taking an anticoagulant doesn’t make sense. Unfortunately, increasing age also means increasing risk of injury from falls. Warfarin definitely cuts that risk, and it happens to be relatively easily reversbile. However, the newer non-reversible drugs change the equation, shifting the risk/benefit ratio too far toward the dark side. We need some good analyses to see if it really makes sense to move everybody to these new (expensive) drugs just to make it easier to dose and monitor. The existing studies on them only look at stroke, but don’t take injury morbidity and mortality into account.

Reference: Atrial fibrillation as an independent risk factor for stroke: the Framingham study. Stroke 22:983-988, 1991.

Click here to download a reference sheet for dabigatran reversal.

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General

Yet More On Dabigatran??

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Following is a comment I received about one reader’s experience with this drug. Why don’t we just set some hard parameters or age limits on the use of such drugs? I’ll provide the opposing view tomorrow.

“So far, one clinical trauma experience- 70+ yo male cut his fingers working with a model airplane engine; on dabigatran. Blood loss nearly 1 L., no control of bleeding w. 2 hours of tourniquet time. Required microvascular ligation of digital vessels. Impressively powerful anticoagulant.

You have to be aware of dosing times to know how long anti-coag effect is likely to endure. Lab tests of little help. No demonstrated efficiacy of Factor VIIa or PCC; in fact, PCC has been shown not to help in one trial. It is effective with Xarelto, though.

Our blood bank stays up at night worrying about this drug, with good reason, since we do our own collections.

Clinicians prescribing this drug should look at bleeding risk scoring systems (HEMORR2HAGE, HAS-BLED) as well as the CHADS2 score before deciding to use this drug.

I suspect it will be ultimately replaced by the Factor Xa inhibitors.
N.B- New Zealand has been reporting a myriad of bleeding issues with this drug. Since it is a relatively closed system, their experience should be a bellweather.”

Shockdoc
Trauma Program Director

Click here to download a reference sheet for dabigatran reversal.

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Emergency Care Of Bleeding From Dabigatran

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Finally, a consensus report has been finalized by the Institute for Clinical Systems Improvement (ICSI) regarding bleeding in patients taking dabigatran (Pradaxa). I’ve written about the special problems posed by patients who are injured while taking this drug and related ones. I’ve also provided some management algorithms for consideration while complete ones were crafted. Well, here they are.

A workgroup of experts from hospitals here in Minnesota were convened to consider and provide a framework for managing these patients. A document was released recently to help guide their care.

To summarize, patients who experience a severe bleed, say from trauma, should be managed with:

  • Holding the medication
  • Evaluating bleeding. In trauma, this will generally involve CT scan.
  • Consider the need for surgery
  • Give activated charcoal if the drug was taken within 2 hours
  • Consider dialysis
  • Transfuse blood if hemoglobin / hematocrit needs to be improved
  • Infuse plasma after 4 units of red cells, and cryoprecipitate after 8 units packed cells / 4 units plasma if needed
  • Consider prothrombin complex concentrate or activated Factor VII in extreme cases

Click here to download the official document from ICSI.

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General

Anticoagulation Reversal In Trauma

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I’ve previously written about reversing specific agents that may interfere with clotting in trauma patients. Today I’m going to provide a reference sheet to help you reverse any of the common agents that your trauma patients may be taking. 

This reference is a work in progress and will change as new drugs are introduced. I’ll update it as revisions are made. And as always, comments and suggestions are welcome!

Click here to download the reference sheet.

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Thanks to Colleen Morton MD from Regions Hospital for sharing this draft