In a an issue of Emergency Medicine News Dr. James Roberts comments on the section of the new ICH guidelines concerning coagulation and platelet defect reversal. Sometimes guidelines are little more than an acknowledgement that we don't really know what to do for the clinical problem in question but, given limited evidence, here's the authors' best shot. As Roberts points out that's particularly true in the case of ICH and accompanying hemostatic defects.
The 2010 guidelines offer few changes in this area. They are nicely summarized in the article. For coumadin reversal, alongside vitamin K IV, the guidelines recommend FFP or consideration for PCC as an alternative, and shy away form rFVIIa, saying it is “not routinely recommended.” Non-recommendation of rFVIIa for unselected patients in this setting is a change from the old guidelines. The guidelines do not recommend giving platelets to reverse the effects of antiplatelet agents in patients with normal counts, a new recommendation. Platelet transfusions for patients with severe thrombocytopenia are recommended, although the appropriate platelet count threshold is not defined. Dr. Roberts suggests maybe 50-100K, although this is certainly not defined by high level research evidence.
The article contains a lot of practical pearls on the nuances of giving plasma, IV vitamin K, and other issues.
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