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Major Recommendations

General Care for All Patients

• Hold dabigatran (van Ryn et al., 2010; Hankey & Eikelboom, 2011) [R]
• Obtain laboratory studies including complete blood count (CBC), activated partial thromboplastin time (aPTT), creatinine, liver function tests (LFTs), international normalized ratio (INR), thrombin clotting time, fibrinogen activity (van Ryn et al., 2010; Hankey & Eikelboom, 2011; Institute for Clinical Systems Improvement [ICSI], "Dabigatran," 2011) [R]
• Evaluate for anatomic defects explaining hemorrhage (van Ryn et al., 2010; Hankey & Eikelboom, 2011) [R]
• Use local measures to control bleeding (van Ryn et al., 2010; Hankey & Eikelboom, 2011) [R]
• Consider the need for surgical intervention, embolization to control bleeding (van Ryn, et al., 2010; Hankey & Eikelboom, 2011) [R]
• Consider the need for Hematology/Nephrology consults (van Ryn et al., 2010; Hankey & Eikelboom, 2011) [R]

For Patients with Mild Bleeding

• Continue "General Care for All Patients" listed above, and:
• Delay next dabigatran dose (van Ryn et al., 2010; Hankey & Eikelboom, 2011) [R]
• Discontinue dabigatran treatment if appropriate (van Ryn et al., 2010; Hankey & Eikelboom, 2011) [R]
• Supportive care/symptomatic treatment (van Ryn et al., 2010; Hankey & Eikelboom, 2011) [R]

For Patients with Moderate to Severe Bleeding

• Discontinue dabigatran (van Ryn et al., 2010; Hankey & Eikelboom, 2011) [R]
• Supportive care/symptomatic treatment (van Ryn et al., 2010; Hankey & Eikelboom, 2011) [R]
• Activated charcoal at standard doses if last dose of dabigatran etexilate within 2 hours (van Ryn et al., 2010; Hankey & Eikelboom, 2010; van Ryn et al., 2009) [R]
• Maintain adequate diuresis with fluid replacement and hemodynamic support as needed (van Ryn et al., 2010; Hankey & Eikelboom, 2011; van Ryn et al., 2009; Stangier, 2008; Stangier et al., 2010) [B]
• Transfuse red blood cells (RBCs) as needed to maintain hemoglobin (HgB) above 8 gm/dL (Hankey & Eikelboom, 2011; ICSI, "Antithrombotic," 2011) [R]
• If more than 4 units of RBCs are required, transfuse RBCs/plasma 1:1 to avoid a dilutional coagulopathy (Stangier et al., 2008) [B]
• See also Maine Medical Center Massive Transfusion Protocol.
• Consultation with nephrology for consideration of dialysis (van Ryn et al., 2010; Stangier et al., 2010; Stangier et al., 2008) [B]

For Patients with Severe/Life Threatening Bleeding

• Continue "General Care," and "Moderate to Severe Bleeding" measures above, and:
• Consider recombinant activated Factor VII (40 mcg/kg) or (van Ryn et al., 2008; Eerenberg et al., 2011) [R]
• As a last resort, consider prothrombin complex concentrate (PCC) (25 units/kg) to help with clot formation at the site of bleeding (van Ryn et al., 2008; Eerenberg et al., 2011) [R]
• NOTE: The strength of the evidence for these interventions is weak and limited.

[Definitions:  Level of Evidence Grading available online]

[Link to free full-text guideline: PDF | NGC version online]