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VitKguidelines

VitKguidelines

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Published by Mayer Rosenberg

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Published by: Mayer Rosenberg on Feb 22, 2008
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06/16/2009

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Guidelines for the Administration of Vitamin K
Drug Information Center
C-113 Chandler Medical Center, (859) 323-5320
 
Introduction
In 2001, the American College of Chest Physicians (ACCP) Task Force on Antithrombotic Therapy published theproceedings of their Sixth Consensus Conference on antithrombotic therapy. These recommendations, publishedin
CHEST 
, address the management of patients receiving oral anticoagulation therapy.Warfarin-associated coagulopathy, or excessive prolongation of the INR, places patients at an increased risk forsevere bleeding complications. In addition, therapeutic INRs (usually values of 2-3) place patients at an increasedrisk for bleeding during invasive procedures. The
CHEST 
Guidelines outline specific recommendations for themanagement of supratherapeutic INRs and for reversal of anticoagulation for invasive procedures. Theserecommendations are summarized in Table 1.
WHAT’S THE PROBLEM? 
Complications associated with vitamin K
1
:
 
Subcutaneous:
response to vitamin K
1
may be unpredictable and delayed, allowing the patient to remain at anincreased risk for bleeding.
 
High Doses:
(via any route) can result in overcorrection of the INR with a subsequent increase in clotting risk,and
warfarin resistance 
for up to a week.
 
Warfarin Resistance 
:
can prolong hospital length of stay (if the patient is receiving a heparin drip) or increasethe number of doses of low molecular weight heparin while waiting for a therapeutic INR on warfarin.
 
Intramuscular:
never shown to be effective; associated with skin lesions and delayed cutaneous reactions (4to 5 days after exposure).
 
Intravenous:
doses of 5-20mg can cause hypersensitivity reactions or anaphylaxis
WHAT SHOULD WE DO? 
 
When INR is <5, holding the warfarin dose is the safest option.
 
Oral vitamin K
1
is the treatment of choice in many cases, especially when the patient is at increased risk forbleeding (
history of bleeding or stroke, or serious comorbid conditions 
).
 
Because of the serious risk of anaphylaxis, the IV route should be reserved for patients who meet criteriaindicated in
CHEST 
Guidelines (see Table 1); it should be diluted (NSS or D5W) and administered at amaximum rate of 1mg/min.
 
Clinicians should become familiar with current recommendations for the administration of vitamin K
1
. Untillarger, randomized trials are conducted, the current
CHEST 
Guidelines are the most widely acceptedrecommendations available.
 
Table 1: Modified ACCP Consensus for Managing Patients with High INR Values
*
 
INR Action / RecommendationGreater than therapeutic,but < 5 with nosignificant bleeding
+
 
Lower warfarin dose,
OR
omit a dose and resume therapy at a lower dose when theINR is within therapeutic range.
5 – 9(No significantbleeding+)
Omit 1 or 2 doses (monitoring INR more frequently), and resume therapy at a lowerdose when INR therapeutic,
OR
Omit a dose and administer vitamin K
1
1.25 to 2.5mg PO if patient at increased risk of bleeding.
5 – 9(Rapid reversal requiredfor urgent surgery)
Administer vitamin K
1
2.5 to 5 mg PO (INR to normalize in 24 hours); If INR still high,administer additional 1.25 to 2.5 mg vitamin K
1
PO.
>9(No significantbleeding+)
Hold warfarin therapy
AND
administer vitamin K
1
3.75 to 5 mg PO (monitor INRmore frequently, and administer additional vitamin K
1
in 24 to 48 hours if necessary);resume therapy at a lower dose when INR therapeutic.
>20OR significant bleeding+
Hold warfarin therapy
AND
administer vitamin K
1
10mg by slow IV
 
infusion(1mg/min); may repeat every 12 hours if needed.(Supplement with fresh plasma, depending on urgency.)

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