2011ASH 成人抗凝剂量与出血处理.pdf

4. Reversal of Dabigatran Non-urgent: Hold further doses of dabigatran CrCl 50 ml/min: Hold 1-2 days CrCl 50 ml/min: Hold 3-5 days Consider longer times for major surgery, placement of spinal or epidural catheter or port Urgent: Abbreviations: PCC = prothrombin complex concentrates; rFVIIa = recombinant factor VIIa * Dabigatran primarily excreted in the urine, therefore maintain adequate diuresis ? Experimental evidence supports these agents but no clinical trial data available; PCC may not lower PTT C. Converting Anticoagulants to and from Dabigatran1 Current Anticoagulant Anticoagulant to be Converted to Procedure Warfarin (INR 2-3) Dabigatran Discontinue warfarin and start dabigatran when INR 2.0 Dabigatran Warfarin (INR 2-3) ? CrCl 50 ml/min: start warfarin 3 days before stopping dabigatran ? CrCl 31-50 ml/min: start warfarin 2 days before stopping dabigatran ? CrCl 15-30 ml/min: start warfarin 1 day before stopping dabigatran ? CrCl 15 ml/min: no recommendation LMWH, heparin Dabigatran Start dabigatran 0-2 hours before administration of last heparin/LMWH dose, or at same time as discontinuation of infusional heparin Dabigatran LMWH, heparin ? CrCl 30 ml/min: start 12 hours after last dose of dabigatran ? CrCl 30 ml/min: start 24 hours after last dose of dabigatran Abbreviations: CrCl = creatinine clearance; INR = international normalized ratio; LMWH = low- molecular-weight heparin 1 Pradaxa ? product monograph, 2010 2011 Clinical Practice Guide on Anticoagulant Dosing and Management of Anticoagulant- Associated Bleeding Complications in Adults Mary Cushman, MD, MSc 1 Wendy Lim, MD, MSc, FRCPC 2 Neil A Zakai, MD, MSc 1 1 University of Vermont 2 McMaster University Presented by the American Society of Hematology, adapted in part from the: American College of Chest Physicians Evidence- Based Clinical Practice Guideline on Antithrombotic and Thrombolytic Therapy (8th Edition).Q U IC K R EF ER EN C E American Society of Hematol