case presentation ich & prosthetic mv

Case presentationCase presentation

Kamal Osman Mirghani,MD,FSCCMKamal Osman Mirghani,MD,FSCCMInternal Medicine & Critical Care ConsultantInternal Medicine & Critical Care Consultant

Clinical Director of ICU departmentClinical Director of ICU department Omdurman military HospitalOmdurman military Hospital kamalmergani@gmail.comkamalmergani@gmail.com

HISTORYHISTORY

• 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

HISTORYHISTORY• The patient sustained

RTA ,brought the accidents and emergency

• Complaining of sever head ache .

ExaminationExamination

• O\E

• Conscious communicating

• GCS 15\15

• Pulse 95 beat\min

• Bp 120\85

• O2 sat 97% on room air.

• Chest and abdomen NAD

ExaminationExamination

• What is the most important examination to be done in this patient ??

CVSCVS• There is audible Clik

• What is next?

CT SCAN DiagnosisCT SCAN Diagnosis

• EXTRADURAL HEMATOMA

InvestigationInvestigation• HB 10 gm• TWBCs 5000• Plalet 350,000• INR 1.5• PTT 36 sec• LFT Normal• Scr 0.5mg • S. urea 20mg

Problem listsProblem lists

• 30 year mal wit prosthetic MV

• Was on warrfarin 5mg

• Extradural hematoma

• INR 1.5

What will you doWhat will you do??

• Stop anticoagulation? …. Danger !

• Is he for reversal? What to use ? …..Danger!

• If stop ? … For how long?

Or continue warfarin ?

Basic ICU managementBasic ICU management

• HOLD warfarrin

• Neurosurgical consolation

• Follow up coagulation profiles 6 hourly

• For possible evacuation

ContiueContiue

• Patient operated and the hematoma evacuated ,patient return back to ICU .

• OE conscious communicating GCS 15\15

• Hemodynamic stable

• O2 sat 98% on room air

2days later2days later

• HB 10 gm

• INR 1.2

• platelet 350.000

NOTENOTE

• To restart anticoagulation ( warfarrin) danger

• NOT to restart warfarrin danger

What to doWhat 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.

IV heparin infusion protocolIV 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.

IV heparin infusion protocolIV heparin infusion protocol

• PTTHeparin rate/dose change

Repeat PTT

Less than 50 sec5000 iu bolus and increase rate by

150 iu /hr

In 6 hrs

50- 59 secIncrease infusion rate by

100unit/hr

In 6 hrs

60 -- 85 secNO CHANGENext day Am

IV heparin infusion protocolIV heparin infusion protocol

• PTTHeparin rate/dose change

Repeat PTT

86 –95 secDecrease infusion rate by 50units/hr

Next day in Am

96 –150secStop 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)

Case ContinueCase Continue

• 7 days late the PTT was 69se persistent for 2 consecutive days.

• .

CT 7 days postoperativeCT 7 days postoperative

Case ContinueCase Continue

• Warfarin was started at 3 mg daily with daily Pt & INR adjusting to the target INR for prosthetic MV 2.5 -3.0

Case ContinueCase Continue

• Later INR was 2.9 .

• Heparin infusion was stopped

• Patient discharged from ICU to cardiology word.

Questions to be answeredQuestions 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???

Topics Review

WLC March 2012WLC March 2012

Treatment strategies in patients with MHV and Treatment strategies in patients with MHV and

warfarin-induced major bleedingwarfarin-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;

Treatment strategies in patients with MHV and Treatment strategies in patients with MHV and

warfarin-induced major bleedingwarfarin-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.

Treatment strategies in patients with MHV Treatment strategies in patients with MHV and warfarin-induced major bleedingand 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.

Treatment strategies in patients with MHV and Treatment strategies in patients with MHV and

warfarin-induced major bleedingwarfarin-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;

Treatment strategies in patients with MHV and Treatment strategies in patients with MHV and

warfarin-induced major bleedingwarfarin-induced major bleeding::

• (4) Recombinant F a should Ⅶ 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.

Treatment strategies in patients with MHV and Treatment strategies in patients with MHV and

warfarin-induced major bleedingwarfarin-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

2013

BLEEDING AND CORRECTION OF BLEEDING AND CORRECTION OF

OVERANTICOAGULATIONOVERANTICOAGULATION

• 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 :

BLEEDING AND CORRECTION OF BLEEDING AND CORRECTION OF

OVERANTICOAGULATIONOVERANTICOAGULATION    

• 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

BLEEDING AND CORRECTION OF BLEEDING AND CORRECTION OF OVERANTICOAGULATIONOVERANTICOAGULATION

• 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 (

BLEEDING AND CORRECTION OF BLEEDING AND CORRECTION OF OVERANTICOAGULATIONOVERANTICOAGULATION

• Bleeding in patients who are therapeutically anticoagulated or over-anticoagulated often comes from a pathologic cause that should be identified and treated.

BLEEDING AND CORRECTION OF BLEEDING AND CORRECTION OF OVERANTICOAGULATIONOVERANTICOAGULATION

• 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.

High-risk features for thromboembolismHigh-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.

BLEEDING AND CORRECTION OF BLEEDING AND CORRECTION OF OVERANTICOAGULATIONOVERANTICOAGULATION

• 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.

BLEEDING AND CORRECTION OF BLEEDING AND CORRECTION OF OVERANTICOAGULATIONOVERANTICOAGULATION

• 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.

BLEEDING AND CORRECTION OF BLEEDING AND CORRECTION OF OVERANTICOAGULATIONOVERANTICOAGULATION

• 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.

Observational cohort studies: baseline Observational cohort studies: baseline characteristicscharacteristics

Observational cohort studies:restarting Observational cohort studies:restarting anticoagulation therapyanticoagulation therapy

Case Report : Case Report : baseline characteristicsbaseline characteristics

Case report:

hemorragic events

Case report :restarting anticoagulation

ConclusionConclusion• 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

ConclusionConclusion

• 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.

•The Management of Patients With The Management of Patients With Mechanical Heart Valves and Mechanical Heart Valves and

Intracerebral HemorrhageIntracerebral Hemorrhage

Daniel B McKenzie; Kelvin Wong; Timothy Edwards •Br J Cardiol.  2008;15(3):145-148  .•

Conclusion#1Conclusion#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.

Conclusion#2Conclusion#2

The author recommend a multi-

disciplinary team approach involving

haematologists, cardiothoracic surgeons

,neurosurgeons, neurologists and

cardiologists.

The risks of further hemorrhage need to

be weighed against thromboembolism.