1206

Abstract

Case Reports: Dabigatran is an appealing therapeutic alternative to warfarin, however safety concerns exist since neither a rapid, point-of-care assay to quantify the degree of anticoagulation nor a reversal antidote currently exists. Case: An 84 year old male presented with a bifrontal headache, confusion, and gait instability, with a last known dose of dabigatran taken 18 hours prior to admission. A head CT revealed a 3 centimeter subacute on chronic subdural hematoma with uncal herniation. Baseline coagulation labs were prolonged: activated partial thromboplastin time (aPTT) 41 seconds and thrombin time (TT) > 50 seconds with normal fibrinogen and platelets. FEIBA (43 units/kg) was administered in an effort to reverse anticoagulation. Repeat coagulation parameters remained prolonged (aPTT 36.5 seconds and TT > 50 seconds), thus placement of a subdural drain was delayed and a second dose of FEIBA (50 units/kg) was administered. Following the second dose, coagulation assays continued to be prolonged. Thromboelastography (TEG®) was ordered to better assess clot dynamics. Kaolin activated TEG® parameters were normal: R-time 4 minutes, K-time 1.6 minutes, alpha angle 68.8 degrees, and MA 58.9 mm, despite a prolonged TT of 47.5 seconds. A subdural drain was safely inserted, with marked clinical improvement and return to baseline over the next 5 days. Conclusion: The therapeutic impact of FEIBA in this case is uncertain. Consistent with previous literature, it had minimal effect on standard coagulation assays. Exclusive reliance on TT, which was prolonged to greater than twice the upper bound of the normal range for 36 hours from the last dabigatran ingestion, may mislead clinicians and limit appropriate interventions. TEG® may be a valuable tool to investigate hemostasis in patients on dabigatran requiring emergent procedures.