Significant Bleeding

  • Vitamin K 10mg
  • Slow IV infusion +
  • FFP (Fresh Frozen Plasma) 4-6 units or PCC (Prothrombin Complex Concentrate) (Kcentra) 15-50 units / kg
  • Recheck INR in 30 minutes—1 hour after FFP (Fresh Frozen Plasma) or PCC (Prothrombin Complex Concentrate) or in 12 hours with Vit K alone
  • INR Still Elevated
  • Repeat Vitamin K and FFP depending on patient condition and INR

PT / INR elevated Due to Warfarin?

  • Yes
  • Is Patient Bleeding Significantly?
  • Caution:  Before giving Vitamin K, the patient’s risk of thrombosis should always be considered.
    • Use caution in patients with a mechanical heart valve.  Consider using fresh frozen plasma to correct an elevated INR in this population.
      • Note:  Vitamin K should be given by mouth if possible.  If a quicker onset is desired or if the patient cannot take oral medications, IV Vitamin K should be used.  Subcutaneous Vitamin K is unpredictable and should be avoided.
  • Urgent surgery required

No Significant Bleeding

  • Does patient require urgent surgery ? (within 12 hours)
  • Yes
  • Recheck INR to confirm
  • Vitamin K 2.5 -5mg PO or slow IV  infusion + FFP or PCC

No Significant Bleeding

  • Does patient require urgent surgery ? (within 12 hours)
  • No
  • Recheck INR If INR is…
    • < 5 Decrease or skip a dose OR If INR is minimal OR associated with a causative factor, no dosage adjustment may be needed
    • ≥ 5 but < 9 Omit 1 – 2 doses OR If high bleeding risk: Omit 1 dose  + Vitamin K 1 – 2.5 mg
      • Consider risk of thrombosis
    • ≥ 9 Hold Warfarin Therapy + Vitamin K  2.5 – 5 mg
      • Consider risk of thrombosis

Recommend repeat INR within 12-24 hours

Approved by PN&T Committee October 2009
Information obtained from the 8th edition of ACCP Guidelines on Antithrombotic and Thrombolytic Therapy.  Ansell J, Hirsh J, Hylek E, et al.  Pharmacology and management of the vitamin K antagonists. Chest 2008;133:160S-198S.
Updated 5/24/16