A 70-year-old male is admitted with haematemesis.
He is currently being treated with warfarin for atrial fibrillation and his INR returns as 10.
Which of the following is the most appropriate immediate treatment of his INR?
1- Cryoprecipitate
2-FFP
3-IV Vit K
4-PO Vit K
5-Prothrombin complex concentrate
2-FFP
3-IV Vit K
4-PO Vit K
5-Prothrombin complex concentrate
This gentleman is having a potentially life threatening bleed in the setting of a grossly elevated INR.
Due to his warfarin therapy he will have reduced levels of factors II, VII, IX and X and requires replacement to correct his INR rapidly. This is most effectively achieved by the administration of prothrombin complex concentrate (Beriplex or Octaplex, 25-50 units/kg IV).
These result in complete reversal of the warfarin-induced anticoagulation within 10 minutes but the clotting factors have a finite half life and therefore 5 mg IV vitamin K should be given at the same time.
Fresh frozen plasma (FFP ) contains more dilute clotting factors and therefore produces inferior correction and should not be used in the management of life threatening bleeding (unless prothrombin complex concentrate is not available).
Cryoprecipitate and oral vitamin K are not recommended for the management of life threatening bleeding.
Notes:
ReplyDeleteUse the following formal risk assessment scores for all patients with acute upper
gastrointestinal bleeding:
the Blatchford score at first assessment
the full Rockall score after endoscopy.
Do not offer platelet transfusion to patients who are not actively bleeding and are haemodynamically stable.
Offer platelet transfusion to patients who are actively bleeding and have a platelet count of less than 50 x 109/litre.
Offer fresh frozen plasma to patients who have either:
-a fibrinogen level of less than 1 g/litre, or
-a prothrombin time (international normalised ratio) or activated partial
-thromboplastin time greater than 1.5 times normal.
Offer prothrombin complex concentrate to patients who are taking warfarin and actively bleeding.
Treat patients who are taking warfarin and whose upper gastrointestinal bleeding has stopped in line with local warfarin protocols.
Do not use recombinant factor Vlla except when all other methods have failed.
Offer endoscopy to unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation.
Offer endoscopy within 24 hours of admission to all other patients with upper gastrointestinal bleeding.
Do not offer acid-suppression drugs (proton pump inhibitors or H2-receptor antagonists) before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding.
Management of variceal bleeding
ReplyDeleteOffer terlipressin to patients with suspected variceal bleeding at presentation.
Stop treatment after definitive haemostasis has been achieved, or after 5 days,unless there is another indication for its use.
Offer prophylactic antibiotic therapy at presentation to patients with suspected or confirmed variceal bleeding.
Oesophageal varices:
Use band ligation in patients with upper gastrointestinal bleeding from oesophageal varices.
Consider transjugular intrahepatic portosystemic shunts (TIPS) if bleeding from oesophageal varices is not controlled by band ligation.
Gastric varices:
Offer endoscopic injection of N-butyl-2-cyanoacrylate to patients with upper gastrointestinal bleeding from gastric varices.
Offer TIPS if bleeding from gastric varices is not controlled by endoscopic injection of N-butyl-2-cyanoacrylate.
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