Upper Gastrointestinal Bleed — Anticoagulation Management — Clinical Pathway: Emergency Department, ICU and Inpatient

Upper Gastrointestinal Bleed Clinical Pathway — Emergency Department, ICU and Inpatient

Anticoagulation Management

Anticoagulants

  • Determine when the last dose was received
  • Consult Hematology for guidance on anticoagulation and reversal
  • Reference Clinical Practice Guidelines
Medication Clinical Practice Guidelines
Apixaban Initiation and Maintenance of Apixaban
Bivalirudin Initiation and Maintenance of Bivalirudin Infusion
Enoxaparin Initiation and Maintenance of Enoxaparin
Heparin Initiation and Maintenance of Heparin Infusion
Rivaroxaban Initiation and Maintenance of Rivaroxaban
Warfarin Initiation and Maintenance of Warfarin in Patients ≥ 10 kg

Antiplatelets

  • Consider holding antiplatelet medications if clinically appropriate and ongoing GI bleeding
  • Determine when last dose of antiplatelet drug was administered
  • Based on the specific drug’s duration of effect, determine if platelet function is inhibited
  • Consider platelet transfusions for children with significant blood loss and/or hemorrhagic shock who are on antiplatelet therapy
Medication Mechanism of Action Approximate Duration of
Increased Bleeding Risk
Aspirin Irreversibly inhibits cyclooxygenase-1 and 2 enzymes 5-7 days
Clopidogrel Thienopyridine, irreversibly inhibits P2Y12 receptors 7 days
Dipyridamole Reversibly inhibits adenosine deaminase and phosphodiesterase, causing accumulation of mediators that inhibit platelet aggregation (adenosine, adenine nucleotides, and cyclic AMP) Minimal to no risk
with procedures
NSAIDs
Ibuprofen, ketorolac, indomethacin and naproxen		 Reversibly inhibits both cyclooxygenase-1 and 2 enzymes 24 hrs

References

  1. Risk of Colonoscopic Polypectomy Bleeding with Anticoagulants and Antiplatelet Agents: Analysis of 1657 Cases  
  2. Reversal of Drug-induced Anticoagulation: Old Solutions and New Problems  
  3. Updated European Heart Rhythm Association Practical Guide on the Use of Non-vitamin K Antagonist Anticoagulants in Patients with Non-valvular Atrial Fibrillation  
  4. The Management of Antithrombotic Agents for Patients Undergoing GI Endoscopy  
  5. Acquired Disorders of Platelet Function