Chris Giordano, MD

1. Bringing the Anti-Coagulated
Patient to the OR
Chris Giordano, MD
Assistant Professor
University of Florida
June 11, 2014

2. Disclosures
None

3. Objectives
• Prothrombin Concentrate Complex (PCC)
• Dabigatran (Pradaxa)
• Rivaroxaban (Xeralta) and Apixaban (eliquis)

4. The Classic Cascade

5. Changing Paradigm

6. Tissue Factor Pathway

7. Amplification Pathway

8. Target for NOAC

9. Patient: Aaron Burr
• 75yo Male
• Branch struck head
• Surgery posted:
• Burr holes SDH
• Coumadin for Afib
• INR 3.1

10. Coumadin

11. Factors II, VII, IX, X, C, S

12. INR 3.1—options?
• Vitamin K
• 24 hours to normalization
• FFP
• 1cc/ kg / 1%
• INR 1.5 = 30% enzymatic activity
• 1500cc on average (4-6units)
• PCC?

13. PCC
• Prothrombin complex concentrate
• Profilnine = 3 factor complex
• Kcentra = 4 factor complex

14. Profilnine—UF Guidelines
• FDA approval : Hemophilia
• Factors II, IX, X (NOT VII)
• Dosing 25units/kg independent if INR
• FFP requirements : 2 concomitant FFP units
• Vitamin K 10mg IV
• Cost of Therapy = 0.88$/ unit (ave. cost $1760)

15. Kcentra—UF Guidelines
• FDA approval : Reversal of Vit K antagonists
• Factors II, VII, IX, X, C, S
• INR dependent dosing
• Actual body weight with 100kg max
• NO Concomitant FFP
• Vit K 10mg IV Concomitant
• Cost = $1.27unit (avg. $3055)

16. Patient: Aaron Burr
• INR 3.1
• Vit K = timing?
• FFP = volume ?
• Kcentra = yes
• INR 1.7 - 3.9
• 25units/kg

17. Patient: Debbie Gatran
• 55yo Female ruptured AAA
• Contained rupture
• EVAR
• Pradaxa (Dabigatran)
• Afib

18. Dabigatran (Pradaxa)

19. Dabigatran (Pradaxa)

20. Thrombin inhibition

21. Dabigatran (Pradaxa)

22. Dabigatran (Pradaxa)
• Thrombin time
• Hemoclot assay
• Ecarin clotting time
• aPTT

23. Dabigatran (Pradaxa)
• Emergency v. Urgency
• Activated charcoal if 1-2 hours
• Hemodialysis
• aPTT
• PCC v. FFP
• FVIIa

24. Patient: Debbie Gatran
• 55yo Female ruptured AAA
• EVAR
• Pradaxa (Dabigatran)
• Profilnine –sent back
• 50cc EBL

25. Rivaroxaban
( Xeralta )
Apixaban
( Eliquis )

26. Xa Inhibitors

27. Xa Inhibitors

28. Rivaroxaban ( Xeralta )
Apixaban ( Eliquis )
• PT
• aPTT
• TEG
• Specific Xa

29. Rivaroxaban ( Xeralta )
Apixaban ( Eliquis )
• Emergency v. Urgency
• Activated charcoal if 1-2 hours
• PCC v. FFP
• FVIIa

30. NOAC

31. NOAC

32. NOAC

33. Summation
• PCC (Profilnine & Kcentra)
• Dabagatran (IIa)
• Xeralta and Eliquis (Xa)