Fast point-of-care coagulometer guided reversal of oral anticoagulation at the bedside hastens management of acute subdural hemorrhage.

BACKGROUND: Emergency reversal of the international normalized ratio (INR) in patients who develop nontraumatic subdural hemorrhage (SDH) due to oral anticoagulants (OAC) represents a primary treatment strategy but it is difficult to predict the amount of prothrombin complex concentrate (PCC) needed for reversal treatment. Moreover, repeated INR testings in central laboratories (CL) are time consuming. The usefulness of point-of-care INR coagulometers (POC) to test the success of INR reversal in OAC-SDH has not yet been investigated.

METHODS: Prospectively, INR reversal was performed by administering PCC to patients suffering from acute SDH-OAC using a predefined dosing schedule. Accuracy and time gained by using POC were assessed and compared with CL measurements.

RESULTS: A total of 10 patients were treated according to the protocol (male: 5). Bland-Altman analysis between POC and CL revealed a mean INR deviation of 0.013 for initial INR values and of 0.081 during reversal treatment. Using POC, the median initial net time gain (accounting for clinical examination and CT) for the start of PCC was 21 min. Median total time for POC-documented reversal was 27 min, as compared to 70 min for CL. The shortest interval between head CT and start of emergency SDH evacuation surgery was 37 min. By employing stepwise POC-guided reversal of the anticoagulatory effect of OAC, the calculated PCC dose could be reduced by 25% in the median.

CONCLUSIONS: Using POC to measure INR values and patient-adapted PCC administration is a fast and economic method to reverse anticoagulation in patients with acute OAC-SDH.