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Reversal of dabigatran in a patient with life-threatening intracranial haemorrhage

6AP3-11

Selvanambi, M.; Galvin, E.

European Journal of Anaesthesiology (EJA): June 2014 - Volume 31 - Issue - p 98–99
Transfusion and Haemostasis
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Beaumont Hospital, Dept of Anaesthesiology & Intensive Care, Dublin, Ireland

Background: Novel oral anticoagulant drugs are being used increasingly in clinical practice. As a result, patients who are taking these new anticoagulant drugs are presenting for both elective and emergency surgery.

Case report: A 64-year-old woman who taking Dabigatran 110 mg twice daily for non-valvular atrial fibrillation was transferred to our hospital with intracranial bleeding, increasing intracranial pressure and a reducing Glasgow coma scale score. CT brain showed a subarachnoid haemorrhage with evolving hydrocephalous. The neurosurgical team decided to insert an emergency External Ventricular drain (EVD) and refer the patient to the Interventional Neuroradiology team for coiling of a posterior communicating artery aneurysm. The time since the last dose of Dabigatran was less than 24 hours. FEIBA (Factor Eight Inhibitor Bypass Activity) 80 u/kg and Octaplex 30 u/kg were administered intravenously before the insertion of the External Ventricular Drain under general anaesthesia. There was minimal intraoperative blood loss. The patient was kept sedated and ventilated in the Neurosurgical ICU overnight and coil- ing of the intracranial aneurysm was performed successfully on the following day. The patient was extubated after the coiling and neurological evaluation did not show any significant deficits. There were no thromboembolic manifestations in the postoperative period.

Discussion: The use of Novel oral anticoagulants has increased several folds in recent years. Dabigatran, a direct thrombin inhibitor.Dabigatran does not have a specific reversal agent. For emergency surgery and in particular patients with intracranial bleeding no single clear reversal strategy has been described. FEIBA (Factor Eight Inhibitor Bypass Activity) and Octaplex could be beneficial in improving surgical haemostasis.

Conclusion: We assume that this is the first case report of successful management of intracranial haemorrhage in a patient who is using Dabigatran.Activated prothrombin complex concentrate (Octaplex) and FEIBA (Factor Eight Inhibitor Bypass Activity) are useful agents. Additional studies are warranted to confirm the findings of our observation.

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References:

1. NICE. Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation. 2012; http://guidance.nice.org.uk/TA/Wave21/10
    2. The acute management of haemorrhage, surgery and overdose in patients receiving Dabigatran Emerg Med J doi: 10.1136/emermed-2012-201976
      © 2014 European Society of Anaesthesiology