What is the management of hypovolemic shock due to intraabdominal bleeding secondary to warfarin (Coumadin)?

Management of Hypovolemic Shock due to Intraabdominal Bleeding Secondary to Warfarin

For patients with hypovolemic shock due to intraabdominal bleeding secondary to warfarin, immediate reversal with 4-factor prothrombin complex concentrate (PCC) plus intravenous vitamin K (5-10 mg) is recommended as the most effective and rapid approach to reverse anticoagulation and control bleeding. 1

Initial Assessment and Management

• Patients presenting with hemorrhagic shock and an identified source of bleeding should undergo immediate bleeding control procedures unless initial resuscitation measures are successful 2
• The extent of traumatic hemorrhage should be clinically assessed using an established grading system 2
• Early focused sonography (FAST) should be employed for the detection of free intraabdominal fluid 2
• Patients with significant free intraabdominal fluid and hemodynamic instability should undergo urgent surgery 2

Warfarin Reversal Strategy

First-Line Treatment

• Administer 4-factor PCC immediately as first-line therapy for life-threatening bleeding 1, 2
• Supplement with 5-10 mg of vitamin K by slow intravenous infusion (over 30 minutes) 1, 2
• Target INR should be <1.5 for emergency interventions 1

Advantages of PCC Over Fresh Frozen Plasma

• PCC has faster onset of action (5-15 minutes vs. hours for FFP) 1, 3
• No need for ABO blood type matching 1, 2
• Minimal risk of fluid overload, which is particularly important in hypovolemic shock 1, 3
• Lower risk of transmitting infections 1, 2
• Contains concentrated amounts of factors II, VII, IX, and X 1
• Associated with significant reduction in all-cause mortality compared to FFP (OR= 0.56,95% CI; 0.37-0.84) 3

Alternative if PCC Unavailable

• Fresh frozen plasma (FFP) should only be used if PCC is unavailable 1, 2
• If using FFP, a higher volume is required which may worsen hypovolemic shock 3

Fluid Resuscitation and Blood Pressure Management

• Implement a restricted volume replacement strategy with a target systolic blood pressure of 80-90 mmHg (MAP 50-60 mmHg) until major bleeding has been stopped 2
• Fluid therapy using 0.9% NaCl or balanced crystalloid solution should be initiated 2
• If erythrocyte transfusion is necessary, treatment should aim to achieve a target Hb of 70-90 g/L 2
• Noradrenaline should be administered in addition to fluids if a restricted volume strategy fails to maintain target arterial pressure 2

Surgical Management

• For ongoing intraabdominal bleeding, damage-control surgery should be performed in the severely injured patient presenting with hemorrhagic shock 2
• When bleeding is ongoing and/or angioembolization cannot be achieved in a timely manner, temporary extra-peritoneal packing should be applied 2
• Topical hemostatic agents should be employed in combination with other surgical measures 2

Additional Hemostatic Measures

• Tranexamic acid should be administered to the trauma patient who is bleeding or at risk of significant bleeding as soon as possible 2
• The recommended dose is 1g over 10 min, followed by an intravenous infusion of 1g over 8 hours 2
• Early measures to reduce heat loss and warm the hypothermic patient should be employed to maintain normothermia, as hypothermia worsens coagulopathy 2, 4

Monitoring and Follow-up

• Serum lactate should be employed to estimate and monitor the extent of bleeding and shock 2
• Base deficit should be employed to estimate and monitor the extent of bleeding and shock 2
• Single hematocrit measurements should not be employed as an isolated laboratory marker for bleeding 2

Considerations for Restarting Anticoagulation

• The decision to restart warfarin after bleeding control should balance the prevention of ischemic stroke and the risk of recurrent bleeding 2
• For patients with prosthetic heart valves or chronic AF, reversal of anticoagulation with PCC or FFP is associated with a low frequency of embolic events over periods of 7 to 10 days 2
• Reinstitution of warfarin anticoagulation appears to be safe after this period 2

Common Pitfalls and Caveats

• Delayed reversal of anticoagulation can lead to continued bleeding and worsening shock 2
• Excessive vitamin K administration can lead to warfarin resistance when anticoagulation needs to be restarted 1, 5
• Resumption of warfarin after high-dose vitamin K may require bridging with heparin until the effects of vitamin K have been reversed 1
• PCC carries a small risk of thromboembolic complications, but this risk is similar to that of FFP and is outweighed by the benefits in life-threatening bleeding 3, 6