Reference:
“Initial Treatment Of Malignant Glioma In Older Adults”. Uptodate.com. 2017. Accessed 8 Mar. 2017.
for neurocritical care experts
“Initial Treatment Of Malignant Glioma In Older Adults”. Uptodate.com. 2017. Accessed 8 Mar. 2017.
Kovacs, Michael J. “Comparison Of 10-Mg And 5-Mg Warfarin Initiation Nomograms Together With Low-Molecular-Weight Heparin For Outpatient Treatment Of Acute Venous Thromboembolism”.Annals of Internal Medicine 138.9 (2003): 714.
Treatment:
DVT Prophylaxis:
REFERENCE:
Uptodate. “Anticoagulant and antiplatelet therapy in patients with brain tumors.” Accessed 08/12/2016.
Lyman GH, Khorana AA, Falanga A, et al. American Society of Clinical Oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol 2007; 25:5490.
VerifyNow for Clopidogrel:
VerifyNow for Aspirin:
ASA-specific VerifyNow uses arachidonic acid as an agonist for platelet aggregation onto fibrinogen-coated beads.
VerifyNow (P2Y12) uses adenosine diphosphate and is more commonly utilized to detect platelet dysfunction due to clopidogrel.
Degree of platelet aggregation is recorded as aspirin reaction units (ARUs) or P2Y12 reaction units (PRUs).
Abnormally functiong platelets are defined as ARU <550 or PRU 208 (U of Cincinnati lab normal value, cutoff not universally defined).
Clinical Value of the VerifyNow System
Click to access mvn0005_-_verifynow_pocket_guide_1.pdf
Click to access CLMA_Educ_Day_Presentation_-VerifyNow_2-18-14.pdf
Martin, G., Shah, D., Elson, N., Boudreau, R., Hanseman, D., Pritts, T., Makley, A., Foreman, B. and Goodman, M. (2018). Relationship of Coagulopathy and Platelet Dysfunction to Transfusion Needs After Traumatic Brain Injury. Neurocritical Care.
Checklist for hypercoagulable work-up
*Shani list, also add Lupus anticoagulant, Vit B12 levels
Rarer causes:
“Hypercoagulability Panel – Machaon Diagnostics”. Machaon Diagnostics. N.p., 2016. Web. 30 Mar. 2016.
“Hypercoagulable States”. Clevelandclinicmeded.com. N.p., 2016. Web. 30 Mar. 2016.
DESMOPRESSIN:
Mechanism of Action:
DOSAGE:
1. Uremic bleeding (off-label): 0.4 mcg/kg IV over 10 minutes
2. Prevention of surgical bleeding in uremia (off-label): 0.3 mcg/kg IV over 30 minutes
3. Diabetes insipidus:
4. Hemophilia A and von Willebrand disease (type 1):
5. Reversal of Aspirin in ICH: 0.4 ug/Kg x 1 dose (max dose 20 ug)
DDAVP (From NCS Guidelines)
“Because of the low risk of serious side effects, the relatively low cost, and the suggestion of benefit in the aforementioned studies, we suggest consideration of a single dose of DDAVP (0.4 mcg/kg) in intracranial hemorrhage patients exposed to antiplatelet agents. In patients deemed appropriate (e.g., those undergoing a neurosurgical procedure), DDAVP can be used in addition to platelet transfusion.” NSC Guidelines
Marino, Paul L, and Kenneth M Sutin. The ICU Book. Philadelphia: Lippincott Williams & Wilkins, 2007. Print.
Uptodate.
Frontera, J., Lewin, J., Rabinstein, A., Aisiku, I., Alexandrov, A., & Cook, A. et al. (2016). Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage. Critical Care Medicine, 44(12), 2251-2257. doi: 10.1097/ccm.0000000000002057
ADDENDUM: Max dose from UpToDate
#1
Kcentra: coumadin reversal in acute major bleeding or need for urgent surgery:
*Dosage expressed in units of factor IX activity
*give concurrent vitamin K
*Repeat dosing is not recommended (has not been studied).
#2
Life-threatening hemorrhage with DOACs: (off label)
Optimal dosing not established
European Heart Rhythm Association, 50 units/kg (+25 units/kg if clinically necessary) recommended based on limited evidence in healthy volunteers
ICH due to various antithrombotic agents (NCS/SCCM [Frontera 2016]):
FIXED vs. VARIABLE DOSE
Advantages of fixed dose KCentra:
Retrospective study from Netherlands – fixed dose 1000 IU fIX PCC, ffd by 500 IU if INR>1.5, used Cofact (Sanquin BV) which contains FII FVII FIX FX and PrC and PrS, no activated factors or heparin. CONCLUSION: that fixed dose required further dose/s to achieve target INR. Door-to-needle time shorter, but not significant. ?clinical outcome unknown.
Bottom line: For now, calculate dose based on weight and INR.
“Prothrombin complex concentrate, 4-factor, unactivated, from human plasma”. Uptodate.com. Accessed 13 Dec. 2016.
Kcentra product insert.
Abdoellakhan, Rahat Amadkhan et al. “Fixed Versus Variable Dosing Of Prothrombin Complex Concentrate In Vitamin K Antagonist-Related Intracranial Hemorrhage: A Retrospective Analysis”. Neurocritical Care 26.1 (2016): 64-69.
Disseminated Intravascular Coagulation Scoring System
TREATMENT:
Marino, Paul L, and Kenneth M Sutin. The ICU Book. Philadelphia: Lippincott Williams & Wilkins, 2007. Print.
Kiwon Lee. NeuroICU Book