The anticoagulated bleeder and the MTP

This is massive haemorrhage in an anticoagulated patient, and the anticoagulation reversal runs in parallel with the MTP from the first minute. The apixaban (a factor Xa inhibitor) is reversed with andexanet alfa if it is available, or with prothrombin complex concentrate (PCC) as the alternative, given early alongside the blood products. The MTP is activated immediately: blood products in a balanced 1-to-1-to-1 ratio, the tranexamic acid if the onset is within the window (the CRASH-2 evidence, though this is a non-traumatic bleed, the principle of early antifibrinolytic holds), the calcium monitoring and replacement, the warming, and the avoidance of crystalloid.^[1][2][3]

The coordination is critical. The team leader integrates the MTP delivery, the reversal, the source control (the urgent gastroscopy or the colonoscopy, the interventional radiology for the angioembolisation), and the ongoing assessment. The blood bank is briefed on the likely scale of the transfusion and the need for the O-negative emergency blood while the crossmatch is completed. The laboratory is drawn at each pack for the coagulation, the ionised calcium and the viscoelastic testing (ROTEM) if available, to guide the targeted product administration — the fibrinogen, the platelets and the factors. The patient is admitted to the intensive care or the high-dependity unit after the source control.^[1]

The specific challenge of the DOAC is that the standard coagulation tests (the INR, the APTT) do not reliably reflect the anticoagulant effect, so the reversal is given on the clinical grounds of the known DOAC and the active bleeding, rather than awaiting a confirmatory test. The andexanet alfa or the PCC is given promptly because the bleeding will not stop while the anticoagulant is active.^[1]