# A 75-year-old client on chronic dabigatran 150 mg twice daily for atrial fibrillation arrives at the ED with severe gastrointestinal hemorrhage and hemodynamic instability. The provider orders the dabigatran-specific reversal agent. Which medication and administration plan does the nurse anticipate as the priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=374982&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PA ## Question A 75-year-old client on chronic dabigatran 150 mg twice daily for atrial fibrillation arrives at the ED with severe gastrointestinal hemorrhage and hemodynamic instability. The provider orders the dabigatran-specific reversal agent. Which medication and administration plan does the nurse anticipate as the priority? ## Option 1. Vitamin K 10 mg slow IV push, 4-factor prothrombin complex concentrate (4F-PCC) 50 units/kg IV over 15 minutes; administered through separate lines; flush with normal saline before and after; monitor for thrombosis and re-bleeding; resume oral anticoagulant once INR is less than 2.0 and hemodynamically stable. 2. Protamine sulfate 50 mg IV push over 10 minutes, and a single dose of platelets 1 unit; administer via separate IV line; flush with normal saline before and after; monitor for thrombosis and re-bleeding; resume heparin infusion no sooner than 4 hours after reversal once aPTT is less than 40 seconds and hemodynamically stable. 3. Andexanet alfa low-dose protocol (400 mg IV bolus at 30 mg/min, then 4 mg/min infusion for up to 120 minutes); flush IV line with normal saline before and after; monitor for thrombosis and re-bleeding; resume dabigatran no sooner than 6 hours after reversal once hemodynamically stable. 4. Idarucizumab (Praxbind) 5 g IV — administered as two consecutive 2.5 g IV infusions or boluses given within 15 minutes of each other; flush IV line with normal saline before and after; monitor for thrombosis and re-bleeding; resume dabigatran no sooner than 24 hours after reversal once hemodynamically stable. **✔ Correct answer** **Correct answer: 4** ## Explanation Idarucizumab — dabigatran-specific reversal Idarucizumab (Praxbind) is a humanized monoclonal antibody fragment with high affinity for dabigatran (binds ~350× stronger than dabigatran binds thrombin). It rapidly neutralizes the anticoagulant effect. Indications: • Life-threatening or uncontrolled bleeding in patients on dabigatran. • Emergency surgery or urgent procedures that cannot be delayed. Administration: • 5 g IV total: given as two 2.5 g doses (each in 50 mL vials) IV bolus or short infusion (~5–10 min) within 15 minutes of each other. • Flush the IV line with NS before and after each vial; do not mix with other medications. • Onset within minutes; effect typically lasts 24 hours. • Repeat 5 g dose may be given if dabigatran resurges or rebound bleeding occurs. • Monitor for thrombosis (because the underlying indication for dabigatran returns once the drug is neutralized). • Resume dabigatran no sooner than 24 hours after reversal — only when hemostasis is achieved and patient is hemodynamically stable; bridge with parenteral anticoagulant if needed. Other choices: • Vitamin K + PCC reverses warfarin, not dabigatran. • Protamine reverses heparin, not dabigatran. • Andexanet alfa reverses Xa inhibitors (apixaban / rivaroxaban / edoxaban), not the thrombin inhibitor dabigatran; repeat oral dabigatran in 6 hours during active bleed is wrong. ## In-depth explanation Clinical reasoning summary Idarucizumab — dabigatran-specific reversal Idarucizumab (Praxbind) is a humanized monoclonal antibody fragment with high affinity for dabigatran (binds ~350× stronger than dabigatran binds thrombin). It rapidly neutralizes the anticoagulant effect. Indications: • Life-threatening or uncontrolled bleeding in patients on dabigatran. • Emergency surgery or urgent procedures that cannot be delayed. Administration: • 5 g IV total: given as two 2.5 g doses (each in 50 mL vials) IV bolus or short infusion (~5–10 min) within 15 minutes of each other. • Flush the IV line with NS before and after each vial; do not mix with other medications. • Onset within minutes; effect typically lasts 24 hours. • Repeat 5 g dose may be given if dabigatran resurges or rebound bleeding occurs. • Monitor for thrombosis (because the underlying indication for dabigatran returns once the drug is neutralized). • Resume dabigatran no sooner than 24 hours after reversal — only when hemostasis is achieved and patient is hemodynamically stable; bridge with parenteral anticoagulant if needed. Other choices: • Vitamin K + PCC reverses warfarin, not dabigatran. • Protamine reverses heparin, not dabigatran. • Andexanet alfa reverses Xa inhibitors (apixaban / rivaroxaban / edoxaban), not the thrombin inhibitor dabigatran; repeat oral dabigatran in 6 hours during active bleed is wrong. ## Related questions - [A nurse is reviewing the morning lab results for an adult client receiving warfarin for at…](https://mymerci.kr/pages/nclex_q.php?qn_id=360515&lang=en) - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=en) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. 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