Multidisciplinary Expert Guidance for the Management of Severe Bleeding on Oral Anticoagulation: An Algorithm for Practicing Clinicians
Siraj Mithoowani 1), Tammy Bungard 2), Lana Castellucci 3), 4), Mark Crowther 1), Kerstin de Wit 5), Dar Dowlatshahi 3), 4), Nauzer Forbes 6), Katie Lin 6), Deborah M. Siegal 3), 4).
1) Department of Medicine, McMaster University, Hamilton, Canada
2) Department of Medicine, University of Alberta, Edmonton, Canada
3) Department of Medicine, University of Ottawa, Ottawa, Canada
4) Inflammation and Chronic Disease Program, Ottawa Hospital Research Institute, Ottawa, Canada
5) Department of Emergency Medicine, Queen’s University, Kingston, Canada
6) Department of Medicine, University of Calgary, Calgary, Canada
Abstract
Bleeding complications associated with oral anticoagulant (OAC) frequently lead to emergency department visits and hospitalization. Short-term all-cause mortality after severe bleeding is substantial ranging from approximately 10% for gastrointestinal bleeding (the most frequent single site) to approximately 50% for intracranial bleeding. A protocol for multidisciplinary approach to bleeding is needed to (i) ensure rapid identification of patients at risk of adverse outcomes, (ii) optimize delivery of supportive measures, (iii) treat the source of bleeding, and (iv) administer anticoagulant reversal or hemostatic therapies judiciously for patients most likely to benefit. We convened a multidisciplinary panel of experts (emergency medicine, gastroenterology, general internal medicine, hematology, neurology, pharmacy, thrombosis) to review the literature and provide practical guidance including a corresponding algorithm for use at the point of care to assist clinicians in the management of patients with acute severe OAC-related bleeding.