In this section : Haematology and Thrombosis
Myeloma
Warfarin
Anticoagulation for AF, DVT and PE
Orthopaedic VTE Risk Assessment
Haemolytic Anaemia
Platelet Transfusion
Parenteral Iron in Adults >18 Years
Pulmonary Embolism
Deep Vein Thrombosis of Lower Extremities
Bleeding with Other Antithrombotics
Low Molecular Weight Heparin
Haematinic Testing
Thromboprophylaxis for Non-Covid Patients
Thrombophilia Screening
Antithrombotics in Hip Fracture
Reversal of Warfarin
Lumbar Puncture, Antiplatelet & Anticoagulant Drugs
Antithrombotics & Surgery
Iron Deficiency Anaemia
Unfractionated Heparin Infusion
Massive Pulmonary Embolism
Bleeding with Other Antithrombotics
Last updated 11th March 2022
Aspirin, Clopidogrel, Dipyridamole Prasugrel, Ticagrelor and Dual Therapies
- Stop administration of drug(s)
- Consider 1g Tranexamic acid IV
- If life threatening, give 2-3 units platelets
Alteplase, Tenecteplase, Reteplase, Streptokinase and Urokinase
- Stop infusion of fibrinolytic drugs and other antithrombotics
- Administer FFP 12ml/kg
- Administer tranexamic acid 1g tds IV
- Check fibrinogen – if there is depletion of fibrinogen, administer cryoprecipitate or fibrinogen concentrate
Apixaban, Edoxaban & Rivaroxaban
- Stop all antithrombotic drugs
- Check drug level, if <25ng/ml bleeding unlikely to be related to drug
- For trivial/local bleeding – use local measures to control
- Moderate bleeding – Tranexamic acid 1g IV and blood product support
- Major life/limb/sight threatening – Tranexamic acid 1g IV, blood product support and Andexanet (discuss with Haematology)
Dabigatran
- Stop all antithrombotic drugs
- Check drug level, if <25ng/ml bleeding unlikely to be related to drug
- For trivial/local bleeding – use local measures to control
- Moderate bleeding – Tranexamic acid 1g IV and blood product support
- Major life/limb/sight threatening – Tranexamic acid 1g IV and blood product support and Idarucizumab (discuss with Haematology)
Unfractionated Intravenous Heparin
- Stop all antithrombotic drugs
- Not major bleeding (where reversal can wait 2 hours) – stop infusion and support patient
- Major or life/limb/sight threatening – stop infusion and give IV protamine 1mg per 80-110 units UFH administered in the previous two hours, max 50mg and no faster than 5mg/min
Low Molecular Weight Heparin (LMWH)
- Stop all antithrombotic drugs
- Not major bleeding – support patient
- Major or life/limb/sight threatening
- Give 1g Tranexamic acid IV
- Check anti-Xa level. If <0.1U/ml unlikely to be significant anticoagulation
- < 8 hours give 1mg IV protamine per 100 anti-Xa units of LMWH at infusion rate of 5mg/min with maximum dose of 50mg
- > 8 hours – give 0.5mg IV protamine per 100 anti-Xa units of LMWH at infusion rate of 5mg/min with maximum dose of 50mg
- Consider further doses of protamine if further bleeding
- Consider 90 microgrammes/kg recombinant FVIIa (NovoSeven) if life-threatening haemorrhage (discuss with Haematology)
Fondaparinux
- Stop all antithrombotic drugs
- Non-major bleeding – support patient
- Major or life /limb/sight threatening
- Give 1g tranexamic acid IV
- Check anti-Xa level – if <0.1U/ml unlikely to be significant anticoagulation present
- Consider 90 microgrammes/kg recombinant FVIIa (NovoSeven) if life-threatening haemorrhage (discuss with Haematology).
Andexanet
- Andexanet is a recombinant inactive factor X molecule. It is licensed for the reversal of Apixaban and Rivaroxaban in life-threatening bleeding. It is also likely to be effective in the reversal of Edoxaban.
- It is located in the ED drug cabinet in both DGRI and GCH. It can only be used after discussion with a Consultant Haematologist. Instructions for its administration are included with the drug.
Drug | Last dose | Timing of last dose | |
---|---|---|---|
<8 hours or unknown | ≥8 hours | ||
Apixaban | ≤5mg | Low dose | Low dose |
>5mg or unknown | High dose | ||
Rivaroxaban | ≤10mg | Low dose | |
>10mg or unknown | HIgh dose | ||
Edoxaban | Any dose | High dose |
Initial IV bolus | Continuous IV infusion | Total number of 200mg vials needed | |
---|---|---|---|
Low dose | 400mg at 30mg/min | 4mg/min for 120 minutes | 5 |
High dose | 800mg at 30mg/min | 8mg/min for 120 minutes | 9 |
Idarucizumab
- Idarucizumab is a specific reversal agent for Dabigatran.
- It is located in the ED drug cabinet in both DGRI and GCH. It can only be used after discussion with a Consultant Haematologist. Instructions for its administration are included with the drug.
- The dose is 5g IV infusion given as two separate 2.5g doses each over 5-10 minutes.
- A further dose of 5g may be required if:
- Recurrence of clinically relevant bleeding together with detectable Dabigatran levels, or
- If potential re-bleeding would be life-threatening with detectable Dabigatran levels, or
- Patients require a second emergency surgery/urgent procedure and have detectable Dabigatran levels.
Content by Dr Mark Crowther