Shock Syndromes II

ii.

Hemodynamic instability is defined as a mean arterial pressure (MAP) less than 65 mm Hg,

SBP less than 90 mm Hg, SBP decrease by at least 40 mm Hg, or orthostatic blood pressure

changes (SBP decrease of at least 20 mm Hg, diastolic blood pressure [DBP] decrease of at

least 10 mm Hg upon standing).

iii.

Overt bleeding, with a hemoglobin decrease of at least 2 g/dL within 24 hours, or requiring the

administration of at least 2 units of PRBCs, is associated with increased mortality, particularly

in patients with chronic cardiovascular disease.

iv.

Recommendations for managing a major bleed:

known or visualized, provide supportive care, assess and manage comorbidities that could

contribute to bleeding (e.g., thrombocytopenia, uremia, liver disease, antiplatelets), and

consider surgical or procedural management of the bleeding site.

hemodynamic instability. For overt bleeding, initial bleeding control procedures are

recommended, and reversal is indicated if the earlier measures fail to control the bleed.

correction of underlying coagulopathies (eg, liver dysfunction, platelet dysfunction)

Warfarin has a long physiologic half-life; thus, the reversal decision is usually based on the presence

of an elevated INR in a life-threatening hemorrhage or the need for urgent surgery or an invasive

procedure within 24 hours.

Phytonadione (vitamin K) administration is the definitive reversal of warfarin, promoting hepatic

production of vitamin K–dependent clotting factors depleted by warfarin.

In life-threatening hemorrhage, injectable phytonadione at a dose of 5–10 mg given

intravenously is preferred.

ii.

Previous reports of anaphylaxis are related to solubilizing agents no longer included in the

formulation.

iii.

Phytonadione has a delayed onset (6–12 hours); therefore, clotting factors are given concurrently

to expedite reversal.

Clotting factors can be given as either plasma or PCC.

Plasma has traditionally been used, but it requires large volumes, leads to incomplete INR

correction, requires compatibility testing, and requires an extended time to achieve hemostasis.

ii.

Evidence to support 4F-PCC over plasma:

reversal, is noninferior for clinical hemostasis, significantly reduces all-cause mortality,

and has a similar rate of thromboembolic events.

achievement of hemostasis.

suggests similar rates of thromboembolic events (4F-PCC 7.3% vs. fresh frozen plasma

7.1%), with fluid overload more common in the plasma group (4F-PCC 12.7% vs. fresh

frozen plasma 4.7%). Although nonactivated 4F-PCC has a black box warning for an

increased risk of arterial and venous thromboembolic events, this risk appears to be

similar to that of plasma.

analyses are investigating similar strategies for warfarin reversal to fully understand the

cost implications.

iii.

rFVIIa is no longer recommended for warfarin reversal because of incomplete correction of

factor concentrations inhibited by warfarin.