Mao Gordon, King Lauren, Young Sarah, Kaplan Richard
Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania.
Department of Pharmacy, Allegheny General Hospital, Pittsburgh, Pennsylvania.
J Emerg Med. 2017 May;52(5):731-737. doi: 10.1016/j.jemermed.2016.11.011. Epub 2016 Dec 19.
As increasing number of patients present to emergency departments with life threatening hemorrhages, particularly intracranial hemorrhage on anticoagulation physicians must be cognizant of the limitations of the available reversal options. Based upon the available literature, our institution formulated a reversal algorithm for patients with life-threatening bleeding on factor Xa inhibitors by administering factor eight inhibitor bypassing agent (FEIBA) 20 units/kg.
A retrospective chart review was performed to include all patients who received FEIBA per institutional protocol. This case series excluded patients who received FEIBA for reversal of dabigatran. Pre and post FEIBA CT scans were compared for changes. Finally, patients were stratified by estimated mortality rates calculated based on pre-intervention characteristics via published risk models.
Thirteen patients were initially included in this study yet two patients were excluded because they were on dabigatran. Fifty-five percent of patients demonstrated stable ICH on CT scan after FEIBA administration while thirty-six percent showed worsening scans. Two patients developed thrombotic events after FEIBA administration.
FEIBA is a treatment option in patients on a TSOA with acute intracranial hemorrhage with evidence of at least partial pharmacologic reversal of their anticoagulation status. There does not appear to be any major risk of thromboembolic complications associated with FEIBA. Much larger study sizes will be necessary to establish statically significant clinical efficacy for FEIBA use in this patient population. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency medicine physicians are first-line caretakers for patients with life threatening intracranial hemorrhages whether spontaneous or traumatic. FEIBA is a potentially safe option to reverse TSOA in this patient population.
随着越来越多有危及生命出血情况的患者前往急诊科就诊，尤其是正在接受抗凝治疗的颅内出血患者，医生必须认识到现有逆转治疗方法的局限性。基于现有文献，我们机构针对服用Xa因子抑制剂且有危及生命出血情况的患者制定了一种逆转算法，即给予20单位/千克的凝血因子VIII抑制物旁路制剂（FEIBA）。
进行了一项回顾性病历审查，纳入所有按照机构方案接受FEIBA治疗的患者。该病例系列排除了因达比加群逆转而接受FEIBA治疗的患者。比较FEIBA治疗前后的CT扫描变化。最后，根据通过已发表的风险模型基于干预前特征计算出的估计死亡率对患者进行分层。
本研究最初纳入了13名患者，但有2名患者因正在服用达比加群而被排除。55%的患者在接受FEIBA治疗后CT扫描显示颅内出血稳定，而36%的患者扫描结果显示病情恶化。2名患者在接受FEIBA治疗后发生了血栓事件。
FEIBA是正在接受凝血酶原复合物浓缩物治疗且发生急性颅内出血的患者的一种治疗选择，有证据表明其抗凝状态至少部分得到了药物逆转。似乎没有与FEIBA相关的血栓栓塞并发症的重大风险。需要更大规模的研究来确定FEIBA在该患者群体中的使用具有统计学意义的临床疗效。急诊科医生为何应了解这一点？：急诊科医生是患有危及生命的颅内出血（无论是自发性还是外伤性）患者的一线护理人员。FEIBA是逆转该患者群体中凝血酶原复合物浓缩物的一种潜在安全选择。
