Anticoagulation Reversal


3-factor PCC

  • Factors II, IX, and X
  • Time to reversal: Minutes

4-factor PCC

  • Factors II, IX, X, and VII
  • Time to reversal: Minutes


  • Factors VIII, XIII, vWF
  • 10-20 mL total volume
  • 150-250 mg fibrinogen (greater concentration than FFP)
  • More expensive

Fresh Frozen Plasma (FFP)

  • All coagulation factors
  • 250-300 mL total volume
  • 700-800 mg of fibrinogen
  • Time to reversal: Generally within a couple hours

Vitamin K

  • Time to reversal:
    • Oral: 12-24 hours
    • IV: ~6 hours

Indications for patients with major/serious bleed

Warfarin reversal

  • Vitamin K
  • Add 4-Factor PCC for more rapid reversal
    • FFP can substitute if PCC not available

DOAC reversal

  • Unactivated PCC vs Activated PCC
    • Activated PCC: FEIBA (Factor Eight Bypassing Activity)
  • Specific reversal agents
    • Dabigatran – Idarucizumab
    • Factor Xa inhibitors (rivaroxaban, apixaban) – Andexanet alpha

Liver disease

  • Vitamin K
  • Cryoprecipitate if fibrinogen < 100 (or if awaiting results and bleeding uncontrolled)
  • Avoid FFP if possible due to large-volume nature and its negative effect on portal venous pressures. Can consider using if bleeding persists after fibrinogen repletion with Cryoprecipitate

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