My patient is taking warfarin and has a major bleed. What should I do?

By William Aird

  • Stop anticoagulant.
  • Assess for and manage comorbidities that might contribute to bleeding, such as, thrombocytopenia, uremia, or liver disease.
  • Provide supportive care with volume resuscitation (IV fluids) and hemodynamic support (inotropes, monitoring) as needed.
  • Initiate local or surgical hemostatic measures to control bleeding.
  • Red blood cell transfusion as needed.
  • Administer vitamin K 5-10 mg IV
  • Consider administering 4-factor prothrombin complex concentrate (PCC):
    • 25 units/kg for INR 2-4
    • 35 units/kg for INR 4-6
    • 50 units/kg for INR > 6
  • Recombinant factor VIIa (rFVIIa) is not recommended.

Guideline recommendations:

American Society of Hematology 2018 guidelines:

Administration of oral vitamin K might be considered for patients at high risk of developing bleeding complications (eg, those who have undergone recent surgical procedures) or in situations where the INR is expected to be prolonged for a longer period of time (eg, intentional overdose, presence of interacting drugs, or very low weekly VKA dose.

2012  American College of Chest Physicians Evidence-Based Clinical Practice Guidelines:

We suggest the additional use of vitamin K 5 to 10 mg administered by slow IV injection rather than reversal with coagulation factors alone.