Warfarin (INR) Reversal

🚨 1. Major Bleeding OR Emergent Surgery (≤6 hrs)

👉 Bleeding = YES

Treatment:

• Vitamin K 10 mg IV x1 (over 30 min)

• PCC (Kcentra/Balfaxar):

  • Non-ICH / surgery:

    • <100 kg → 1500 units

    • ≥100 kg or INR ≥7.5 → 2000 units

  • Suspected ICH:

    • <100 kg → 2000 units

    • ≥100 kg → 2500 units

• Redose PCC:

  • +500 units if INR >1.5 or bleeding persists (after 15–30 min)

Monitoring:

• Do NOT delay PCC for INR result

• Check INR:

  • 30 min after PCC

  • Then q6h x24h

⚠️ 2. Non-Major Bleeding + INR >10

👉 Bleeding = YES

Treatment:

• Vitamin K 2.5–5 mg PO x1

• If cannot take PO → Vitamin K 1–5 mg IV

Monitoring:

• Recheck INR in 24 hrs

• Repeat 2.5 mg PO if still elevated

⚠️ 3. No Bleeding + INR >10

👉 Bleeding = NO

Treatment:

• Vitamin K 2.5–5 mg PO x1

• If no PO → 1–5 mg IV

Monitoring:

• Recheck INR in 24 hrs

• Repeat dose if needed

⚠️ 4. Non-Major Bleeding + INR 4.5–10

👉 Bleeding = YES

Treatment:

• Hold warfarin

• Vitamin K 1–2.5 mg PO

Monitoring:

• Recheck INR in 24 hrs

⚠️ 5. No Bleeding + INR 4.5–10

👉 Bleeding = NO

Treatment:

• Hold 1–2 doses of warfarin

• Consider Vitamin K 1.25–2.5 mg PO ONLY if high bleeding risk

⚠️ Special situations:

• Mechanical valve / LVAD → avoid Vitamin K (unless necessary)

• Low bleeding risk → just hold warfarin

Monitoring:

• Recheck INR next day