1. Case presentation
Kamal Osman Mirghani,MD,FSCCM
Internal Medicine & Critical Care Consultant
Clinical Director of ICU department
Omdurman military Hospital
kamalmergani@gmail.com

2. HISTORY
• A 30 years male known case of
mechanical MV replacement
since 2009
• On warfarin 5 mg
• Digosin 0.25 mg
• Lasix 20 mg
• ON REGULAR FOLLOW UP

3. HISTORY
• The patient sustained RTA
,brought the accidents and
emergency
• Complaining of sever head
ache .

4. Examination
•
•
•
•
•
•
•
OE
Conscious communicating
GCS 1515
Pulse 95 beatmin
Bp 12085
O2 sat 97% on room air.
Chest and abdomen NAD

5. Examination
• What is the most
important examination to
be done in this patient ??

6. CVS
• There is audible Clik

7. • What is next?

9. CT SCAN Diagnosis
• EXTRADURAL HEMATOMA

10. Investigation
•
•
•
•
•
•
•
•
HB
10 gm
TWBCs 5000
Plalet 350,000
INR
1.5
PTT
36 sec
LFT
Normal
Scr
0.5mg
S. urea 20mg

11. Problem lists
•
•
•
•
30 year mal wit prosthetic MV
Was on warrfarin 5mg
Extradural hematoma
INR 1.5

12. ?What will you do
• Stop anticoagulation? …. Danger !
• Is he for reversal? What to use ?
…..Danger!
• If stop ? … For how long?
Or continue warfarin ?

13. Basic ICU management
•
•
•
•
HOLD warfarrin
Neurosurgical consolation
Follow up coagulation profiles 6 hourly
For possible evacuation

14. Contiue
• Patient operated and the hematoma
evacuated ,patient return back to ICU .
• OE conscious communicating GCS 1515
• Hemodynamic stable
• O2 sat 98% on room air

15. 2days later
• HB
10 gm
• INR
1.2
• platelet 350.000

16. NOTE
• To restart anticoagulation ( warfarrin) danger
• NOT to restart warfarrin danger

17. ???What to do
• ICU team discussed the need for
restarting the anticoagulation with the
neurosurgeon and Cardiology.
• The patient was Started on short acting
heparin intravenous infusion according the
following protocol.

19. IV heparin infusion protocol
• Dilute 25.000 iu of heparin in 500 ml of
Dw and start the infusion at a rate of 1000
iu of heparin per min (20ml/ min)
• Take sample for base line PTT
• Adjust the infusion rate according to the
following protocol.

20. IV heparin infusion protocol
PTT
Heparin rate/dose
•
change
Repeat PTT
Less than 50 sec
iu bolus and 5000
increase rate by
150 iu /hr
In 6 hrs
sec 59 -50
Increase
infusion rate by
100unit/hr
In 6 hrs
NO CHANGE
Next day Am
sec 85 -- 60

21. IV heparin infusion protocol
PTT
Heparin rate/dose
•
change
Repeat PTT
86 –95 sec
Decrease infusion Next day in Am
rate by 50units/hr
96 –150sec
Stop infusion for 30
mints then decrease
the rate by
100units/hrs
In 6 hrs( from
restart time)
More than 150
sec
Stop infusion for 60
mints then decrease
rate by 150units/hr
In 6 hrs( from
restart time)

22. Case Continue
• 7 days late the PTT was 69se persistent
for 2 consecutive days.
• .

23. CT 7 days postoperative

24. Case Continue
• Warfarin was started at 3 mg daily with
daily Pt & INR adjusting to the target INR
for prosthetic MV 2.5 -3.0

26. Case Continue
• Later INR was 2.9 .
• Heparin infusion was stopped
• Patient discharged from ICU to cardiology
word.

27. ????Questions to be answered
For how long we can withhold
anticoagulation????
• when to restart anticoagulation after
warfarin-induced major bleed??
• What the Current treatments
available to reverse warfarin-induced
bleeding???
•

28. Topics Review

29. WLC March 2012

30. Treatment strategies in patients with MHV and
:warfarin-induced major bleeding
•
(1) high dose vitamin K therapy (5-10
mg) should be administered immediately
by slow intravenous infusion over 10-30
min, and a repeat dose should be
considered at 12 h;

31. Treatment strategies in patients with MHV and
:warfarin-induced major bleeding
• (2) large volume of type-specific FFP
(initially, emergency-released AB plasma
= universal plasma donors, maximum 4
units) should be infused as tolerated
according to desired INR levels as well as
to stop bleeding.

32. Treatment strategies in patients with MHV
and warfarin-induced major bleeding
• 2)Caution is needed during large volume
FFP infusion and diuretic therapy should
be used when needed.
• Four hourly INR needs to be checked for
the first 24 h, if INR is not to the desired
level, repeat FFP infusion.

33. Treatment strategies in patients with MHV and
:warfarin-induced major bleeding
• (3) PCC should be reserved for patients
who are allergic or intolerant to FFP and in
those who cannot tolerate a large volume
of FFP such as patients with heart failure
in view of its potential thrombotic
complications till further data prove that it
is safe to be used routinely in MHV
patients;

34. Treatment strategies in patients with MHV and
:warfarin-induced major bleeding
• (4) Recombinant FⅦa should not be used
in patients with MHV in view of its high
incidence of thrombotic complications till
further studies prove its safety in MHV
patients; and bleed.

35. Treatment strategies in patients with MHV and
:warfarin-induced major bleeding
• (5) with regard to restarting any anticoagulation
in patients with warfarin-induced major bleeding
and MHV (especially in patients with high risk
MHV = mitral MHV, multiple MHVs, MHV with
prior stroke or atrial fibrillation, and MHV
implanted within 6 mo), any anticoagulation
should be withheld (or safe to re-start)
• for7-14 d in patients with intracranial bleed and
48-72 h for patients with extra cranial

36. 2013

37. BLEEDING AND CORRECTION OF
OVERANTICOAGULATION
• The management of overanticoagulation
is complicated in patients with prosthetic
heart valves because overcorrection
carries a risk of valve thrombosis.
Because of these concerns, the 2005 ESC
guideline recommendations vary with the
clinical setting :

38. BLEEDING AND CORRECTION OF
OVERANTICOAGULATION
• Among patients who are not bleeding,
those with an INR ≥6.0 should be admitted
to the hospital and warfarin should be
temporarily discontinued to permit a
gradual reduction in INR.
• Intravenous vitamin K should not be given
because of the risk of valve thrombosis if
the INR falls too quickly

39. BLEEDING AND CORRECTION OF
OVERANTICOAGULATION
• If the INR is >9 and there is no bleeding,
warfarin should be discontinued and 1 to 2.5 mg
of oral vitamin K should be administered.
• The 2006 ACC/AHA guidelines and others note
that, in contrast to the risk of high-dose
intravenous vitamin K, low-dose (1 to 2.5 mg
oral vitamin K safely corrects the excessive
degree of anticoagulation more rapidly than
simple withholding of warfarin, without making
the patient temporarily resistant to further
therapy with warfarin (

40. BLEEDING AND CORRECTION OF
OVERANTICOAGULATION
• Bleeding in patients who are
therapeutically anticoagulated or
over-anticoagulated often comes from
a pathologic cause that should be
identified and treated.

41. BLEEDING AND CORRECTION OF
OVERANTICOAGULATION
• In patients who are bleeding with a
therapeutic or high INR, the risk of major
bleeding (eg, intracranial or hemodynamically
significant gastrointestinal bleeding) must be
weighed against the risk of valve thrombosis.

42. High-risk features for thromboembolism
• Atrial fibrillation
• Prior thromboembolism
• severe left ventricular systolic dysfunction
(EF <30 percent),
• The presence of a hypercoagulable state.
• Patients with a mechanical mitral or tricuspid
valve, two or more mechanical valves, or
older aortic caged-ball or tilting disc valves
• Surgery for malignancy or infection, which is
associated with hypercoagulability.

43. BLEEDING AND CORRECTION OF
OVERANTICOAGULATION
• If the risk from major continued bleeding
that is inaccessible to local control
(particularly intracerebral bleeding) is
considered greater than the risk of valve
thrombosis, cessation of anticoagulation
should be accomplished by the use of
fresh frozen plasma (FFP)
and intravenous vitamin K at a dose of
2.5 to 5 mg.

44. BLEEDING AND CORRECTION OF
OVERANTICOAGULATION
• For urgent situations, either prothrombin
complex concentrate (PCC) or recombinant
human factor VIIa may be employed.
• The INR should be monitored frequently.
• Doses of vitamin K may be repeated at 12 hour
intervals, if needed.
• FFP, PCC, or recombinant human factor VIIa
can be repeated if necessary, depending upon
the INR response.

45. BLEEDING AND CORRECTION OF
OVERANTICOAGULATION
• The optimal time to resume
warfarrin therapy after a major bleeding
episode is uncertain.
• But the ESC guidelines recommended
resumption of warfarin at one week.
• It was presumed that, at this interval, the
long-term risk of further intracranial
bleeding was less than the risk of valve
thrombosis.

47. Observational cohort studies: baseline
characteristics

48. Observational cohort studies:restarting
anticoagulation therapy

49. Case Report : baseline characteristics

50. rt:
Case repo
ic
hemorrag
events

51. Case report
:restarting
anticoagulation

52. Conclusion
• Available evidence ( even if of low quality )suggests
that:
• Restarting oral anticoagulant after few days
and, stopping oral anticoagulant therapy for
few days(7–14 days) are apparently safe.
• The risk of severe organs damage due to
bleeding when anticoagulation is not fully
interrupted is much higher in these situations

53. Conclusion
• In the worst-clinical-case scenario, the
incidence of thromboembolic events in the
absence of anticoagulant therapy in patients
with a mechanical bileaflet valve is 22 per 100
patient-years
• This is a high risk on a yearly basis, this
corresponds to a 0.06% daily risk (i.e. 6 in
10,000 patients). Therefore, short interruption
of anticoagulation may not be as dangerous as
is often presumed.

54. The Management of Patients With •
Mechanical Heart Valves and
Intracerebral Hemorrhage
Daniel B McKenzie; Kelvin Wong; Timothy Edwards
•
. Br J Cardiol. 2008;15(3):145-148
•

55. Conclusion#1
In view of the lack of data regarding
patients with mechanical heart valves
and ICH, each case must be assessed on
an individual basis.

56. Conclusion#2
The author recommend a multidisciplinary team approach involving
haematologists, cardiothoracic surgeons
,neurosurgeons, neurologists and
cardiologists.
The risks of further hemorrhage need to
be weighed against thromboembolism.