Reversal of antithrombotics in the critically ill: An international online survey

Purpose: Critically ill patients face an increased risk of both thrombotic and bleeding complications, necessitating careful administration of antithrombotic agents such as platelet aggregation inhibitors (PAI), anticoagulants and fibrinolytics for prophylactic and therapeutic purposes, but also posing challenges for reversal strategies. This survey aims to assess the current clinical practice of reversal of antithrombotics in the intensive care unit (ICU). Methods: An international online 79-item survey was performed among critical care physicians. The survey was disseminated via multiple intensive care societies. Reversal practices for PAI, vitamin K antagonists (VKA), heparins, factor Xa inhibitors, direct thrombin inhibitors (DTI) and fibrinolytics were surveyed. Results: From June 2023 to January 2024, 477 participants started the survey, with 208 completed surveys from 49 countries. The majority (79 %) of respondents practiced ICU medicine in Europe. Only 17 % of the included participants indicated the presence of an ICU-specific antithrombotic reversal protocol in their hospital. Of those, specific protocols were present for 92 % for reversal of VKA, 75 % for unfractioned heparin, 58 % for low-molecular-weight heparin, 53 % for factor Xa inhibitors, 50 % for PAI, 44 % for DTI and 31 % for fibrinolytics. There was heterogeneity in reported reversal practice for different antithrombotics in specific scenarios and between continents. However, dosing strategies of applicable reversal agents were similar. Conclusion: This survey shows variability in the reported clinical approaches to reverse antithrombotic agents in the ICU. The majority of hospitals included do not have a specific protocol for antithrombotic agents reversal emphasizing the need for ICU specific guidelines.