Case presentation ICH & Prosthetic MV

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  • 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?
  • 8. CT SCAN Diagnosis • EXTRADURAL HEMATOMA
  • 9. Investigation • • • • • • • • HB 10 gm TWBCs 5000 Plalet 350,000 INR 1.5 PTT 36 sec LFT Normal Scr 0.5mg S. urea 20mg
  • 10. Problem lists • • • • 30 year mal wit prosthetic MV Was on warrfarin 5mg Extradural hematoma INR 1.5
  • 11. ?What will you do • Stop anticoagulation? …. Danger ! • Is he for reversal? What to use ? …..Danger! • If stop ? … For how long? Or continue warfarin ?
  • 12. Basic ICU management • • • • HOLD warfarrin Neurosurgical consolation Follow up coagulation profiles 6 hourly For possible evacuation
  • 13. 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
  • 14. 2days later • HB 10 gm • INR 1.2 • platelet 350.000
  • 15. NOTE • To restart anticoagulation ( warfarrin) danger • NOT to restart warfarrin danger
  • 16. ???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.
  • 17. 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.
  • 18. 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
  • 19. 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)
  • 20. Case Continue • 7 days late the PTT was 69se persistent for 2 consecutive days. • .
  • 21. CT 7 days postoperative
  • 22. 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
  • 23. Case Continue • Later INR was 2.9 . • Heparin infusion was stopped • Patient discharged from ICU to cardiology word.
  • 24. ????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??? •
  • 25. Topics Review
  • 26. WLC March 2012
  • 27. 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;
  • 28. 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.
  • 29. 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.
  • 30. 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;
  • 31. 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.
  • 32. 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
  • 33. 2013
  • 34. 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 :
  • 35. 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
  • 36. 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 (
  • 37. 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.
  • 38. 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.
  • 39. 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.
  • 40. 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.
  • 41. 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.
  • 42. 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.
  • 43. Observational cohort studies: baseline characteristics
  • 44. Observational cohort studies:restarting anticoagulation therapy
  • 45. Case Report : baseline characteristics
  • 46. rt: Case repo ic hemorrag events
  • 47. Case report :restarting anticoagulation
  • 48. 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
  • 49. 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.
  • 50. 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 •
  • 51. 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.
  • 52. 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.