Abstract
Objective
To assess compliance and impact of a teaching program on guidelines for the management of severe bleeding under oral anticoagulation therapy in emergency departments (EDs).
Design and setting
Multicenter, before–after observational studies in six French EDs.
Patients
Forty-five patients in 2003 and 54 patients in 2005 consecutively admitted with severe bleeding under oral anticoagulation therapy.
Interventions
A specific teaching program on management of severe bleeding under oral anticoagulation therapy, performed by an expert physician.
Measurements and results
Primary end-point was the use of prothrombin complex concentrate–vitamin K association between the two study periods. Nine patients (20%) in 2003 and 29 patients (54%) in 2005 received this association (P < 0.01). Almost one-third of patients had only withholding oral anticoagulation therapy. Adverse events and mortality rate did not differ between the two phases.
Conclusions
Compliance with guidelines on the management of severe bleeding under oral anticoagulation remains poor and might be improved by specific teaching program.
References
Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, Singer DE (2001) Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. bénéfice AVK 285:2370–2375
Pirmohamed M, James S, Meakin S, Green C, Scott AK, Walley TJ, Farrar K, Park BK, Breckenridge AM (2004) Adverse drug reactions as cause of admission to hospital: prospective analysis of 18,820 patients. BMJ 329:15–19
Fitzmaurice DA, Blann AD, Lip GY (2002) Bleeding risks of antithrombotic therapy. BMJ 325:828–831
Huttner HB, Schellinger PD, Hartmann M, Kohrmann M, Juettler E, Wikner J, Mueller S, Meyding-Lamade U, Strobl R, Mansmann U, Schwab S, Steiner T (2006) Hematoma growth and outcome in treated neurocritical care patients with intracerebral hemorrhage related to oral anticoagulant therapy: comparison of acute treatment strategies using vitamin K, fresh frozen plasma, and prothrombin complex concentrates. Stroke 37:1465–1470
Vigue B, Ract C, Tremey B, Engrand N, Leblanc PE, Decaux A, Martin L, Benhamou D (2007) Ultra-rapid management of oral anticoagulant therapy-related surgical intracranial hemorrhage. Intensive Care Med 33:721–725
Ansell J, Hirsh J, Hylek E, Jacobson A, Crowther M, Palareti G (2008) Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 133:160S–198S
Baglin TP, Keeling DM, Watson HG (2006) Guidelines on oral anticoagulation (warfarin): third edition-2005 update. Br J Haematol 132:277–285
HAS (2008) Prise en charge des surdosages, des accidents hémorragiques et des situations à risque hémorragiques, chez les patients traités par antivitamines K en ville et en milieu hospitalier. STV 20:69–83
Haverkamp D, Hutten BA, Buller HR, Gallus AS, Lensing AW, Prins MH (2003) The use of specific antidotes as a response to bleeding complications during anticoagulant therapy for venous thromboembolism. J Thromb Haemost 1:69–73
Sjoblom L, Hardemark HG, Lindgren A, Norrving B, Fahlen M, Samuelsson M, Stigendal L, Stockelberg D, Taghavi A, Wallrup L, Wallvik J (2001) Management and prognostic features of intracerebral hemorrhage during anticoagulant therapy: a Swedish multicenter study. Stroke 32:2567–2574
Appelboam R, Thomas EO (2007) The headache over warfarin in British neurosurgical intensive care units: a national survey of current practice. Intensive Care Med 33:1946–1953
Evans SJ, Biss TT, Wells RH, Hanley JP (2008) Emergency warfarin reversal with prothrombin complex concentrates: UK wide study. Br J Haematol 141:268–269
Pabinger I, Brenner B, Kalina U, Knaub S, Nagy A, Ostermann H (2008) Prothrombin complex concentrate (Beriplex P/N) for emergency anticoagulation reversal: a prospective multinational clinical trial. J Thromb Haemost 6:622–631
Cannegieter SC, Rosendaal FR, Briet E (1994) Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation 89:635–641
Kearon C, Hirsh J (1997) Management of anticoagulation before and after elective surgery. N Engl J Med 336:1506–1511
Ashton A, Bhati R (2007) The use of an asynchronous learning network for senior house officers in emergency medicine. Emerg Med J 24:427–428
Hylek EM, Evans-Molina C, Shea C, Henault LE, Regan S (2007) Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation 115:2689–2696
Flaherty ML, Haverbusch M, Sekar P, Kissela BM, Kleindorfer D, Moomaw CJ, Broderick JP, Woo D (2006) Location and outcome of anticoagulant-associated intracerebral hemorrhage. Neurocrit Care 5:197–201
Fang MC, Chang Y, Hylek EM, Rosand J, Greenberg SM, Go AS, Singer DE (2004) Advanced age, anticoagulation intensity, and risk for intracranial hemorrhage among patients taking warfarin for atrial fibrillation. Ann Intern Med 141:745–752
Koo S, Kucher N, Nguyen PL, Fanikos J, Marks PW, Goldhaber SZ (2004) The effect of excessive anticoagulation on mortality and morbidity in hospitalized patients with anticoagulant-related major hemorrhage. Arch Intern Med 164:1557–1560
Acknowledgements
The authors would like to thank the LFB company (Courtaboeuf, France) for financial support. Research assistant sponsoring by LFB society helped physicians in each center to collect data.
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Tremey, B., Tazarourte, K., Ract, C. et al. Teaching improves adherence to clinical guidelines in the treatment of oral anticoagulation-related severe bleeding in the emergency department. Intensive Care Med 35, 1444–1448 (2009). https://doi.org/10.1007/s00134-009-1465-9
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DOI: https://doi.org/10.1007/s00134-009-1465-9