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The headache over warfarin in British neurosurgical intensive care units: a national survey of current practice

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Abstract

Objective

To ascertain current British practice regarding the emergency medical management of patients who sustain a spontaneous intracerebral haemorrhage (ICH) whilst receiving warfarin therapy and to compare this with established national and international guidelines.

Design

Standardised, telephone based, questionnaire survey.

Setting

All 32 adult British neuroscience intensive care units (ICUs)

Participants

Duty consultant of each neuroscience ICU.

Results

Response rate was 100%. The international normalised ratio (INR) would be reversed by over 90% of ICU consultants treating patients on warfarin with an ICH, except patients with mechanical heart valves (MHV), when only 59.4% would reverse. Prothrombin complex concentrate (PCC) was used by 15 ICUs (46.9%); however, only six units (18.8%) apply reversal strategies with PCC and intravenous vitamin K in accordance with national guidelines. Fresh frozen plasma (FFP) continues to be used by 71.9% of the ICUs. A protocol for warfarin reversal in ICH was present in five ICUs, of which four followed national guidelines. None of the units that use FFP had a protocol. Following ICH, two-thirds of the ICUs (65.6%) would commence bridging heparinisation in the first 4 days for MHV patients and 25% would recommence warfarin before, and 64.5% after, 7 days.

Conclusion

There is considerable variation in practice amongst clinicians who regularly manage these patients and, in most cases (81.2%), practice is not in keeping with national or international guidelines. This study has demonstrated the need amongst senior ICU clinicians for a heightened awareness of current treatment recommendations and the availability of effective haemostatic therapies.

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Author information

Authors and Affiliations

  1. Department of Intensive Care Medicine, Derriford Hospital, Devon, PL6 8DH,, Plymouth, Devon, UK

    Rebecca Appelboam & Elfyn Owen Thomas

Authors
  1. Rebecca Appelboam
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  2. Elfyn Owen Thomas
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Corresponding author

Correspondence to Elfyn Owen Thomas.

Additional information

Dr E.O. Thomas acts as guarantor for this work and accepts full responsibility for the work and/or the conduct of the study, has access to all the original data, and controlled the decision to submit for publication. This work has not been published elsewhere.

E.O.T. was responsible for the concept and design of the study. R.A. and E.O.T. conducted the survey, analysed and interpreted the data and performed the literature search. R.A. drafted the article, which was then critically revised by E.O.T. R.A. and E.O.T. give final approval of the version to be submitted.

Funding: none

These results were presented in part as a poster at the 19th Annual Congress of the European Society of Intensive Care Medicine in Barcelona, Spain, 24 September 2006.

Appendix: Telephone survey of current practice in neurosurgical ICUs

Appendix: Telephone survey of current practice in neurosurgical ICUs

Date

Unit Name/ Hospital

Tel:........................

Type: stand alone NICU // GICU with ring fenced NICU beds // GICU

Number of Level 3 beds (NICU.......) (GICU........)

Consultant name

? Lead for NICU Y/N

? Lead GICU Y/N

Consent obtained Y/N

The following relate to the management of patients with significant but non-fatal spontaneous intracerebral haemorrhage who are taking oral anticoagulants:

Which, if any, of the following patients who were on therapeutic anticoagulants and suffered a significant but non-fatal spontaneous intracerebral haemorrhage would you reverse to a normal INR? (say < 1.5) (tick all that apply)

  1. a)

    Those with a previous history (more than 6 months) of DVT

  2. b)

    Those with a previous history (more than 1 year) of PE

  3. c)

    Those with chronic stable atrial fibrillation

  4. d)

    Those with paroxysmal AF

  5. e)

    Those with a metal aortic or mitral heart valve

What do you use/advise on your unit as optimal therapy for correcting the coagulopathy? (tick all, if any, that apply) (e. g. INR 3.2)

  1. a)

    FFP

  2. b)

    Vitamin K IV

  3. c)

    Vitamin K PO

  4. d)

    Prothrombin complex concentrate (PCC) e. g. Beriplex

  5. e)

    Factor VIIa

  6. f)

    Other.................................................

Does your unit have a protocol/policy for anticoagulation reversal in ICH? Y/ N

If Y how long for?........................

In which of the following patients, if any, would you usually commence intravenous heparin or therapeutic LMWH in the first 96 hours post ICH? (tick any that apply)

  1. a)

    Previous history of DVT (> 6 Mo)

  2. b)

    Previous history of PE (> 12 Mo)

  3. c)

    Atrial fibrillation (chronic stable)

  4. d)

    Paroxysmal AF

  5. e)

    Prosthetic heart valve

When, following ICH, would you restart oral anticoagulants?

  1. a)

    Within 48 hours

  2. b)

    Between 48 and 96 hours

  3. c)

    Between 96 hours and 1 week

  4. d)

    Between 1 and 2 weeks

  5. e)

    After 2 weeks

In which of the following patients, if any, would you restart oral anticoagulation once the acute event has passed? (tick all that apply)

  1. a)

    Previous history of DVT (> 6 Mo)

  2. b)

    Previous history of PE (> 12 Mo)

  3. c)

    Atrial fibrillation (chronic stable)

  4. d)

    Paroxysmal AF

  5. e)

    Prosthetic heart valve

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Appelboam, R., Thomas, E.O. The headache over warfarin in British neurosurgical intensive care units: a national survey of current practice. Intensive Care Med 33, 1946–1953 (2007). https://doi.org/10.1007/s00134-007-0765-1

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