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Reversing anticoagulation in the hemorrhaging patient

Treml, Benedikt; Oswald, Elgar; Schenk, Bettina

Current Opinion in Anesthesiology: April 2019 - Volume 32 - Issue 2 - p 206–212
doi: 10.1097/ACO.0000000000000697

Purpose of review Anticoagulants in general, but especially the relatively new direct oral anticoagulants and platelet inhibitors, pose a great challenge for physicians in the hemorrhaging patient. The aim of the present review is to provide an overview on recent studies dealing with the reversal of anticoagulation in the hemorrhaging patient and to describe our therapeutic emergency strategy for those patients.

Recent findings A specific antidote for dabigatran is already on the market and antidotes for the direct and indirect factor Xa inhibitors are in development. Moreover, bleeding under platelet inhibitors remains critical with very little evidence on effective reversal strategies.

Summary To reverse anticoagulation in the hemorrhaging patient, specific antidotes should be the first option if available, followed by four-factor prothrombin complex concentrate (PCC), activated PCC and recombinant activated factor seven as the emergency strategy. Fibrinogen concentrate, antifibrinolytics and oral charcoal, respectively, can be considered as an additional measure. Massive blood loss and thrombocytopenia should be treated independently according to the respective, local guidelines for (massive) transfusion of blood and blood products.

Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria

Correspondence to Bettina Schenk, Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria. Tel: +0043 (0)512 504 80604; e-mail:

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