Bleeding Risks and Reversal Agents

Anticoagulant reversal is a matching problem under pressure. First decide whether the bleeding is major enough to justify reversal, identify the drug and timing of the last dose, and support perfusion while the team controls the source. Major bleeding includes bleeding in a critical site, hemodynamic instability with a MAP below 65 mmHg or SBP below 90 mmHg, a hemoglobin decrease of at least 2 g/dL, or transfusion of at least 2 units of packed RBCs. Emergency surgery or an urgent procedure that cannot be delayed is another indication for reversal. The anticoagulant determines the reversal strategy: idarucizumab targets dabigatran, andexanet alfa targets apixaban or rivaroxaban, and 4-factor PCC may be used when a specific antidote is unavailable. Reversal reduces anticoagulant activity but does not eliminate thrombotic risk. Record the anticoagulant, dose, last administration, renal and hepatic context, bleeding site, vital signs, and serial laboratory results so the response can be matched to the drug and reassessed.