Annotations Warfarin Antidotes
If patient has significant bleeding:
Vitamin K (phytonadione)
- FFP (fresh frozen plasma)
- Activated Prothrombin Complex Concentrate (found as FEIBA VH
or anti-inhibitor coagulant complex in EMR)
- Recombinant Factor VIIa (NovoSeven RT®)
- Choice and dose is dependent on the clinical problem-no bleeding
vs. significant bleeding and need for future warfarin therapy.
- If patient requires rapid warfarin reversal but
has no bleeding, insignificant bleeding or bruising:
- Vitamin K 30 mcg/kg by slow IV infusion over
10-20 minutes (to avoid anaphylaxis). Max dose 2 mg.
- This weight adjusted regimen is safer for pediatric patients
than a universal dosage (i.e. 0.5-2mg) as recommended for adults. Even 0.5mg
(sufficient for many adults) is likely to be too high for most young children.
Seriously ill children with liver dysfunction may require more than a single
dose. Oral vitamin K is effective in adults but the INR fall is slower than IV
- The preferred route is IV, but in a child with poor or
no venous access, the PO or SQ route may be used, particularly if the INR
is 6-10. The PO route is preferred.
- The IM route is NOT recommended.
Safety of IV administration
- Not life threatening and will not cause morbidity:
K 30 mcg/kg by slow IV infusion over 10-20 minutes (to
avoid anaphylaxis). Max dose 2 mg.
FFP 20 mL/kg IV.
- Life threatening and will cause morbidity:
K 30 mcg/kg IV by slow IV infusion over 10-20 minutes (to
avoid anaphylaxis). Max dose 5mg.
- And FFP
20 mL/kg IV.
giving FEIBA VH 50 - 70 units/kg IV (first choice) or NovoSeven
RT 90 micrograms/kg IV (alternate choice).
- The standard product for IV administration of Vitamin K at CMH
is the 2mg/mL concentration, which is readily available in medication stations on
every inpatient unit.
- This dilute form (2mg/mL) along with slow IV infusion over 10 to
20 minutes may avoid anaphylaxis that has been associated with IV administration
of vitamin K.
- Where the concentrated 10mg/mL product is available, it must be
diluted to 2mg/mL with D5W or NS prior to administration.
These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time.
It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.