Anticoagulation in the intensive care unit
Intensive care unit (ICU) patients are often anticoagulated for indications that include thromboprophylaxis, ischemic and other cardiovascular thrombotic states, and extracorporeal circulation. The non-vitamin K direct oral anticoagulation agents (DOACs) include the factor Xa inhibitors apixaban, edoxaban, rivaroxaban and the direct thrombin inhibitor dabigatran. If bleeding occurs in patients receiving DOACs, standard principles of bleeding management should be considered, but specific reversal agents are available, including andexanet for Xa inhibitors and idarucizumab for dabigatran. For emergency reversal of warfarin or other vitamin K antagonists, prothrombin complex concentrates are the standard of care. One of the complications of heparin administration is heparin-induced thrombocytopenia, necessitating the use of alternative anticoagulants that are direct thrombin inhibitors, either argatroban or bivalirudin. For patients requiring dialysis, citrate anticoagulation can also be used. Prothrombin complex concentrates are increasingly used off-label for DOAC bleeding and as part of multimodal strategies to treat anticoagulant-related bleeding. Antiplatelet therapy includes aspirin, but also the P2Y12 receptor antagonist clopidogrel, prasugrel, and ticagrelor, which are often used in ischemic cardiovascular disease treatment. New bridging strategies have emerged for most of the anticoagulants, including cangrelor, a short-acting intravenous antiplatelet agent.
