Top

Intensive Care Medicine

Published in:

01-11-2007 | Original

The headache over warfarin in British neurosurgical intensive care units: a national survey of current practice

Authors: Rebecca Appelboam, Elfyn Owen Thomas

Published in: Intensive Care Medicine | Issue 11/2007

Abstract

Objective

To ascertain current British practice regarding the emergency medical management of patients who sustain a spontaneous intracerebral haemorrhage (ICH) whilst receiving warfarin therapy and to compare this with established national and international guidelines.

Design

Standardised, telephone based, questionnaire survey.

Setting

All 32 adult British neuroscience intensive care units (ICUs)

Participants

Duty consultant of each neuroscience ICU.

Results

Response rate was 100%. The international normalised ratio (INR) would be reversed by over 90% of ICU consultants treating patients on warfarin with an ICH, except patients with mechanical heart valves (MHV), when only 59.4% would reverse. Prothrombin complex concentrate (PCC) was used by 15 ICUs (46.9%); however, only six units (18.8%) apply reversal strategies with PCC and intravenous vitamin K in accordance with national guidelines. Fresh frozen plasma (FFP) continues to be used by 71.9% of the ICUs. A protocol for warfarin reversal in ICH was present in five ICUs, of which four followed national guidelines. None of the units that use FFP had a protocol. Following ICH, two-thirds of the ICUs (65.6%) would commence bridging heparinisation in the first 4 days for MHV patients and 25% would recommence warfarin before, and 64.5% after, 7 days.

Conclusion

There is considerable variation in practice amongst clinicians who regularly manage these patients and, in most cases (81.2%), practice is not in keeping with national or international guidelines. This study has demonstrated the need amongst senior ICU clinicians for a heightened awareness of current treatment recommendations and the availability of effective haemostatic therapies.

Available only for authorised users

[No authors named] (1998) Guidelines on oral anticoagulation: third edition. Br J Haematol 101:374–387

Baglin TP, Keeling DM, Watson HG for the British Committee for Standards in Haematology. (2006) Guidelines on oral anticoagulation (warfarin): third edition – 2005 update. Br J Haematol 132:277–285PubMedCrossRef

Buller HR, Agnelli G, Hull RD, Hyers TM, Prins MH, Raskob GE (2004) Antithrombotic therapy for venous thromboembolic disease: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 126:401S–428SPubMedCrossRef

Singer DE, Albers GW, Dalen JE, Go AS, Halperin JL, Manning WJ (2004) Antithrombotic therapy in atrial fibrillation: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 126:429S–456SPubMedCrossRef

Salem DN, Stein PD, Al-Ahmad A, Bussey HI, Horstkotte D, Miller N, Pauker SG (2004) Antithrombotic therapy in valvular heart disease – native and prosthetic: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 126:457S–482SPubMedCrossRef

The British Thoracic Society Standards of Care Committee, Pulmonary Embolism Guideline Development Group (2003) BTS guidelines for the management of suspected acute pulmonary embolism. Thorax 48:470–484

Butchart EG, Gohlke-Bärwolf C, Antunes MJ, Tornos P, De Catarina R, Cormier B, Prendergast B, Iung B, Bjornstad H, Leport C, Hall RJC, Vahanian A on behalf of European Society of Cardiology (2005) Recommendations for the management of patients after heart valve surgery. Eur Heart J 26:2463–2471PubMedCrossRef

Cannegieter SC, Rosendaal FR, Briet E (1994) Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation 89:635–641PubMed

Levine MN, Beyth RJ, Kearon C, Schulman S (2004) Hemorrhagic complications of anticoagulant treatment: The seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 126:287–310CrossRef

10.

Franke CL, de Jonge J, van Swieten JC, Op de Coul AA, Van Gijn J (1990) Intracerebral haematomas during anticoagulant treatment. Stroke 21:726–730PubMed

11.

Rosand J, Eckman MH, Knudsen KA, Singer DE, Greenberg SM (2004) The effect of warfarin and intensity of anticoagulation on outcome of intracerebral hemorrhage. Arch Int Med 164:880–884CrossRef

12.

Rådberg JA, Olsson JE, Rådberg CT (1991) Prognostic parameters in spontaneous intracerebral hematomas with special reference to anticoagulant treatment. Stroke 22:571–576PubMed

13.

Flibotte JJ, Hagan BA, O'Donnell J, Greenberg SM, Rosand J (2004) Warfarin, hematoma expansion, and outcome of intracerebral hemorrhage. Neurology 63:1059–1064PubMed

14.

Davis SM, Broderick J, Hennerici M, Brun NC, Diringer MN, Mayer SA, Begtrup K, Steiner T for the Recombinant Activated Factor VII Intracerebral Hemorrhage Trial Investigators (2006) Hematoma growth is a determinant of mortality and poor outcome after intracerebral hemorrhage. Neurology 66:1175–1181PubMedCrossRef

15.

Mayer SA, Rincon F (2006) Ultra-early hemostatic therapy for acute intracerebral hemorrhage. Semin Hematol 43:S70–76PubMedCrossRef

16.

Mayer SA, Brun NC, Begtrup K, Broderick J, Davis S, Diringer MN, Skolnick BE, Steiner T for the Recombinant Activated Factor VII Intracerebral Hemorrhage Trial Investigators (2005) Recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med 352:777–785PubMedCrossRef

17.

Sjöblom L, Hårdemark HG, Lindgreen A, Norrving B, Fahlén M, Samuelsson M, Stigendal L, Stockelberg D, Taghavi A, Wallrup L, Wallvik J (2001) Management and prognostic features of intracerebral hemorrhage during anticoagulant therapy: a Swedish multicenter study. Stroke 32:2567–2574PubMedCrossRef

18.

The European Stroke Initiative Writing Committee and the Writing Committee for the EUSI Executive Committee (2006) Recommendations for the management of intracranial haemorrhage. 1. Spontaneous intracerebral haemorrhage. Cerebrovasc Dis 22:294–316CrossRef

19.

Butler AC, Tait RC (1998) Management of oral anticoagulant-induced intracranial haemorrhage. Blood Rev 12:35–44PubMedCrossRef

20.

Steiner T, Rosand J, Diringer M (2006) Intracerebral hemorrhage associated with oral anticoagulant therapy: Current practices and unresolved questions. Stroke 37:256–262PubMedCrossRef

21.

Crawley F, Bevan D, Wren D (2000) Management of intracranial bleeding associated with anticoagulation: balancing the risk of further bleeding against thromboembolism from prosthetic heart valves. J Neurol Neurosurg Psychiatry 69:396–398PubMedCrossRef

22.

Hanley JP (2004) Warfarin reversal. J Clin Pathol 54:1132–1139CrossRef

23.

Baker RI, Coughlin PB, Gallus AS, Harper PL, Salem HH, Wood EM, Warfarin Reversal Consensus Group (2004) Warfarin reversal: consensus guidelines, on behalf of the Australasian Society of Thromb Haemostat. Med J Aust 181:492–497PubMed

24.

Ansell J, Hirsch J, Dalen J, Bussey H, Anderson D, Poller L, Jacobson A, Deykin D, Matchar D (2001) Managing oral anticoagulant therapy. Chest 119:22S–38SPubMedCrossRef

25.

Baldi G, Altomonte F, Altomonte M, Ghirarduzzi A, Brusasco C, Parodi RC, Ricciardi A, Remollino V, Spisni V, Saporito A, Caiazza A, Musso G, Cervellin G, Lamberti S, Buzzalino M, De Giorgi F, Del Prato C, Golinelli MP, Gai V, Monsu R, Gioffre M, Giovanardi D, Cattaneo S, Frumento F, Caporrella A, Re G, De Iaco F, Bologna G, Nocenti F, Lorenzi C, Zoratti R, Sciolla A, Tiscione V, Pastorello M, Vandelli A, Villa A, Zanna M, De Palma A, Iorio A (2006) Intracranial haemorrhage in patients on antithrombotics: clinical presentation and determinants of outcome in a prospective multicentre study in Italian emergency departments. Cerebrovasc Dis 22:286–293PubMedCrossRef

26.

Appelboam R, Thomas EO (2006) The headache and heartache over warfarin in British neuro intensive care units. Intensive Care Med 32:S29

27.

Diringer MN, Edwards DF (2001) Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit Care Med 29:635–640PubMedCrossRef

28.

Huttner HB, Schellinger PD, Hartmann M, Köhrmann M, Juettler E, Wikner J, Mueller S, Meyding-Lamade U, Strobl R, Mansmann U, Schwab S, Steiner T (2006) Hematoma growth and outcome in treated neurocritical care patients with intracerebral hemorrhage related to oral anticoagulant therapy. Stroke 37:1465–1470PubMedCrossRef

29.

Goldstein JN, Thomas SH, Frontiero V, Joseph A, Engel C, Snider R, Smith EE, Greenberg SM, Rosand J (2006) Timing of fresh frozen plasma administration and rapid correction of coagulopathy in warfarin-related intracerebral hemorrhage. Stroke 37:151–155PubMedCrossRef

30.

Preston FE, Laidlow ST, Sampson B, Kitchen S (2002) Rapid reversal of oral anticoagulation with warfarin by a prothrombin complex concentrate (Beriplex): efficacy and safety in 42 patients. Br J Haematol 116:619–624PubMedCrossRef

31.

Yasaka M, Minematsu K, Naritomi H, Sakata T, Yamaguchi T (2003) Predisposing factors for enlargement of intracerebral hemorrhage in patients treated with warfarin. Thromb Haemost 89:278–283PubMed

32.

Yasaka M, Sakata T, Minematsu K, Naritomi H (2003) Correction of INR by prothrombin complex concentrate and vitamin K in patients with warfarin related hemorrhagic complication. Thrombosis Res 108:25–30CrossRef

33.

Kenet G, Walden R, Eldad A, Martinowitz U (1999) Treatment of traumatic bleeding with recombinant factor VIIa. Lancet 354:1879PubMedCrossRef

34.

Sørensen B, Johansen P, Nielsen G, Sørensen JC, Ingerslev J (2003) Reversal of the international normalized ratio with recombinant activated factor VII in central nervous system bleeding during warfarin thromboprophylaxis: clinical and biochemical aspects. Blood Coagulation Fibrinolysis 14:469–477PubMedCrossRef

35.

Conti S, La Torre D, Gambelunghe G, Ciorba E, Iorio A (2005) Successful treatment with rFVIIa of spontaneous intracerebral hemorrhage in a patient with mechanical prosthetic heart valves. Clin Lab Haem 27:283–285CrossRef

36.

Fewel ME, Park P (2004) The emerging role of recombinant activated factor VII in neurocritical care. Neurocrit Care 1:19–30PubMedCrossRef

37.

Lubetsky A, Hoffman R, Zimlichman R, Eldor A, Zvi J, Kostenko V, Brenner B (2004) Efficacy and safety of a prothrombin complex concentrate (Octaplex^®) for rapid reversal of oral anticoagulation. Thrombosis Res 113:371–378CrossRef

38.

Punthakee X, Doobay J, Anand SS (2003) Oral-anticoagulant-related intracerebral hemorrhage. Thrombosis Res 108:31–36CrossRef

39.

Wijdicks EF, Schievink WI, Brown RD, Mullany CJ (1998) The dilemma of discontinuation of anticoagulation therapy for patients with intracranial hemorrhage and mechanical heart valves. Neurosurgery 42:769–773PubMedCrossRef

40.

Phan TG, Koh M, Wijdicks EF (2000) Safety of discontinuation of anticoagulation in patients with intracranial hemorrhage at high thromboembolic risk. Arch Neurol 57:1710–1713PubMedCrossRef

41.

Bertram M, Bonsato M, Hacke W, Schwab S (2000) Managing the therapeutic dilemma: patients with spontaneous intracerebral hemorrhage and urgent need for anticoagulation. J Neurol 247:209–214PubMedCrossRef

42.

Butler AC, Tait RC (1998) Restarting anticoagulation in prosthetic heart valve patients after intracranial haemorrhage: a 2 year follow up. Br J Haematol 103:1064–1066PubMedCrossRef

43.

Kawamata T, Takeshita M, Kubo O, Izawa M, Kagawa M, Takakura K (1995) Management of intracranial hemorrhage associated with anticoagulant therapy. Surg Neurol 44:438–443PubMedCrossRef

44.

Leker RR, Abramsky O (1998) Early anticoagulation in patients with prosthetic heart valves and intracerebral hematoma. Neurology 50:1489–1491PubMed

45.

Ananthasubramaniam K, Beattie J Rosman H, Jamam V, Borzak S (2001) How safely and for how long can warfarin therapy be withheld in prosthetic heart valve patients hospitalized with a major hemorrhage? Chest 119:478–484PubMedCrossRef

46.

Babikian VL, Kase CS, Pessin MS, Caplan LR, Gorelick PB (1988) Resumption of anticoagulation after intracranial bleeding in patients with prosthetic heart valves. Stroke 19:407–408PubMed

47.

Eckman MH, Rosand J, Knudsen KA, Singer DE, Greenberg SM (2003) Can patients be anticoagulated after intracerebral hemorrhage? A decision analysis. Stroke 34:1710–1716PubMedCrossRef

Title: The headache over warfarin in British neurosurgical intensive care units: a national survey of current practice
Authors: Rebecca Appelboam
Elfyn Owen Thomas
Publication date: 01-11-2007
Publisher: Springer-Verlag
Published in: Intensive Care Medicine / Issue 11/2007
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-007-0765-1

At a glance: The STEP trials

Springer Medicine

The headache over warfarin in British neurosurgical intensive care units: a national survey of current practice

Abstract

Objective

Design

Setting

Participants

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Objective

Design

Setting

Participants

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 11/2007

Outcomes and prognostic factors in patients with head and neck cancer and severe acute illnesses

The first demonstration of lactic acid in human blood in shock by Johann Joseph Scherer (1814–1869) in January 1843

Relative safety of hyperinsulinaemia/euglycaemia therapy in the management of calcium channel blocker overdose: a prospective observational study

Don't take vitals, take a lactate

Announcement

The views of patients and relatives of what makes a good intensivist: a European survey