Principles of management

1. An International Normalised Ratio (INR) between 1.5-2.5 and/or platelet count of (20-40) x 109/l do not usually require correction if the patient is not bleeding or at high risk e.g. active peptic ulcer, recent cerebral haemorrhage, undergoing an invasive procedure. 5-10 units of platelets will raise the count by only 10-20 x 109/l. The effect is often transient (<24 h) and the increment reduces with repetitive dosing. Treatment of symptomatic thrombocytopenia aims to increase the count >50 x 109/l. A target INR <1.5 is acceptable. Vitamin K is given for liver failure and considered for warfarin overdosage. 1 mg Vitamin K will reverse warfarin effects within 12 h while 10 mg will saturate liver stores, preventing warfarin activity for some weeks. Fresh frozen plasma (FFP) is given for short term control.

2. If bleeding and INR = 1.5-2, give 2-3 units FFP. If INR >2, give 4-6 units FFP. If not bleeding (or high risk), generally only correct if INR >2.5-3. Repeat clotting screen 30-60 min after FFP infused. Give more FFP if bleeding continues and/or INR >3.

3. For bleeding related to thrombolysis, (i) stop the drug infusion, (ii) give either aprotinin 500,000 units over 10 min, then 200,000 units over 4 h or tranexamic acid 10 mg/kg repeated 6-8-hrly (iii) give 4 units FFP.

4. Cryoprecipitate is rarely needed. Consider when the thrombin time is elevated, e.g. with DIC. Similarly, factor VIII is generally used for haemophiliacs only.

5. If aspirin has been taken within the past 1-2 weeks, platelet function may be deranged. Give fresh platelets, even though count may be adequate.

6. Factor VIIa may be useful for severe, intractable bleeding but more studies are needed to confirm its efficacy.

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