The headache over warfarin in British neurosurgical intensive care units: a national survey of current practice.

OBJECTIVE

To ascertain current British practice regarding the emergency medical management of patients who sustain a spontaneous intracerebral haemorrhage (ICH) whilst receiving warfarin therapy and to compare this with established national and international guidelines.

DESIGN

Standardised, telephone based, questionnaire survey.

SETTING

All 32 adult British neuroscience intensive care units (ICUs)

PARTICIPANTS

Duty consultant of each neuroscience ICU.

RESULTS

Response rate was 100%. The international normalised ratio (INR) would be reversed by over 90% of ICU consultants treating patients on warfarin with an ICH, except patients with mechanical heart valves (MHV), when only 59.4% would reverse. Prothrombin complex concentrate (PCC) was used by 15 ICUs (46.9%); however, only six units (18.8%) apply reversal strategies with PCC and intravenous vitamin K in accordance with national guidelines. Fresh frozen plasma (FFP) continues to be used by 71.9% of the ICUs. A protocol for warfarin reversal in ICH was present in five ICUs, of which four followed national guidelines. None of the units that use FFP had a protocol. Following ICH, two-thirds of the ICUs (65.6%) would commence bridging heparinisation in the first 4 days for MHV patients and 25% would recommence warfarin before, and 64.5% after, 7 days.

CONCLUSION

There is considerable variation in practice amongst clinicians who regularly manage these patients and, in most cases (81.2%), practice is not in keeping with national or international guidelines. This study has demonstrated the need amongst senior ICU clinicians for a heightened awareness of current treatment recommendations and the availability of effective haemostatic therapies.