Prothrombin complex concentrate in cardiac surgery for the treatment of coagulopathic bleeding

Hayes, Katia; Fernando, Malindra C; Jordan, Vanessa

doi:10.1002/14651858.cd013551.pub2

Cited by 7 publications

(10 citation statements)

References 90 publications

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“…PRBC 24 h post-4F-PCC, which was significantly lower than the FFP group, which received average of 3.2 units (P ¼ 0.05). At 7 days post-4F-PCC, blood product use including a combination of PRBC, FFP, and platelets was also significantly lower with a median (IQR) of 7 (5)(6)(7)(8)(9)(10)(11) units in the PCC group compared with 13 (8-19) units in the FFP group (P < 0.001). A meta-analysis assessing 4F-PCC compared with standard of care (FFP) also concluded that 4F-PCC reduced the amount of PRBC transfusions postoperatively with 3.4 units in the FFP group and 2.1 units in the 4F-PCC group [odds ratio (OR) 1.3, confidence interval (CI) 0.8-1.9; P < 0.0001] [4].…”

Section: Discussionmentioning

confidence: 97%

Utilization and safety of off-label prothrombin complex concentrate (four-factor prothrombin complex concentrate) in a surgical population

Sandquist,

Kaucher,

Newell

et al. 2024

Blood Coagulation &Amp; Fibrinolysis

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The aim of this study is to evaluate and describe the utilization and safety of 4F-PCC in a nonanticoagulated, surgical patient population at an academic, tertiary care center. This retrospective, single-center chart review evaluated nonanticoagulated adult patients at least 18 years of age who had at least one dose of 4F-PCC administered between 1 January 2017 and 30 September 2022 for a surgical or peri-procedural indication. Hemostatic efficacy following 4F-PCC administration was the primary outcome, assessed by subsequent blood product administration and hemoglobin and hematocrit reduction. Secondary outcomes included an assessment of thrombotic events within 30 days post-4F-PCC administration, in-hospital mortality, and the length of hospital stay. A total of 71 patients met the inclusion criteria, with 61 patients receiving 4F-PCC for cardiac surgery and 10 patients for other intraoperative or peri-procedural indications. The mean total 4F-PCC dose was 25.0 U/kg. For the primary outcome of hemostatic efficacy, 81% of patients had excellent hemostasis; however, blood product administration was reported in 95.8% of patients post-4F-PCC. Thromboembolic events occurred in 10 (14.1%) patients and 21.1% of patients expired prior to discharge in the total cohort. Off-label 4F-PCC use in nonanticoagulated patients is reported despite a lack of robust guidance for use. Following 4F-PCC administration, hemostatic efficacy based on hemoglobin and hematocrit changes was observed; however, blood product use was frequent, and 4F-PCC administration was not without risks, including thromboembolic complications such deep vein thrombosis (DVT), pulmonary embolism, and stroke. Further studies are needed to validate the off-label administration of 4F-PCC in nonanticoagulated patients.

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Section: Discussionmentioning

confidence: 97%

Utilization and safety of off-label prothrombin complex concentrate (four-factor prothrombin complex concentrate) in a surgical population

Sandquist,

Kaucher,

Newell

et al. 2024

Blood Coagulation &Amp; Fibrinolysis

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“…While it is essential to consider that bleeding in cardiac surgery is multifactorial, the incidence of rebound heparinization tends to be low. 18,19 Bleeding after cardiac surgery poses a significant challenge to cardiac surgeons, anesthesiologists as well as [18][19][20][21][22] The incidence of blood transfusion in cardiac surgery can range from 20% to 40%. Blood transfusion is associated with potential hazards and increased morbidity and mortality as well.…”

Section: Discussionmentioning

confidence: 99%

“…To reduce bleeding after CPB, many interventions are used including acute normovolemic hemodilution (ANH), heparin neutralizing agent (protamine), antifibrinolytics, recombinant clotting factors (e.g., prothrombin complex concentrate, fibrinogen concentrate, activated Factor VII, etc), and minimally invasive surgical techniques. However, these interventions are expensive and sometimes associated with increased morbidity and mortality 18–22 . The incidence of blood transfusion in cardiac surgery can range from 20% to 40%.…”

Section: Discussionmentioning

confidence: 99%

Protamine dosing and its impact in cardiac surgery transfusion practice—A retrospective bi‐institutional analysis

Mondal,

Abuelkasem,

Vesselinov

et al. 2024

Transfusion

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BackgroundBleeding after cardiac surgery is common and continues to require 10–20% of the national blood supply. Transfusion of allogeneic blood is associated with increased morbidity and mortality. Excessive protamine in the absence of circulating heparin after weaning off CPB can cause anticoagulation and precipitate bleeding. Hence, adequate dose calculation of protamine is crucial yet under evaluated.Study DesignRetrospective cohort study.MethodsWe conducted a retrospective bi‐institutional analysis of cardiac surgical patients who underwent cardiopulmonary bypass (CPB)‐assisted cardiac surgery to assess the impact of protamine dosing in transfusion practice. Total 762 patients were identified from two institutions using electronic medical records and the Society of Thoracic Surgery (STS) database who underwent cardiac surgery using CPB. Patients were similar in demographics and other baseline characteristics. We divided patients into two groups based on mg of protamine administered to neutralize each 100 U of unfractionated heparin (UFH)—low‐ratio group (Protamine: UFH ≤ 0.8) and high‐ratio group (Protamine: UFH > 0.8).ResultsWe observed a higher rate of blood transfusion required in high‐ratio group (ratio >0.8) compared with low‐ratio group (ratio ≤0.8) (p < .001). The increased requirement was consistently demonstrated for intraoperative transfusions of red blood cells, plasma, platelets, and cryoprecipitate.ConclusionHigh protamine to heparin ratio may cause increased bleeding and transfusion in cardiac surgical patients. Protamine to heparin ratio of 0.8 or lower is sufficient to neutralize circulating heparin after weaning off cardiopulmonary bypass.

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Section: Clinical Practicementioning

confidence: 99%

“…51 Prothrombin concentrate (PCC) is an Food and Drug Administration approved treatment for the urgent reversal of acquired coagulation factor deficiency due to vitamin K antagonists, but preliminary work has also studied PCC as a possible alternative treatment for postcardiac surgery coagulopathy. 52 Smith and colleagues hypothesized that PCC administration in cardiac surgery would reduce transfusion requirements and bleeding without increasing the risk of thrombosis. To test this hypothesis, they performed a prospective randomized clinical trial in patients undergoing complex cardiac surgery, defined as multiple cardiac procedures, repeat sternotomy, and aortic replacement surgery.…”

Section: Prothrombin Complex Concentrate Vs Plasma For Post-cardiopul...mentioning

confidence: 99%

Year in Review 2022: Noteworthy Literature in Cardiac Anesthesiology

Christensen

Morabito

Kowalsky

et al. 2023

Semin Cardiothorac Vasc Anesth

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Last year researchers made substantial progress in work relevant to the practice of cardiac anesthesiology. We reviewed 389 articles published in 2022 focused on topics related to clinical practice to identify 16 that will impact the current and future practice of cardiac anesthesiology. We identified 4 broad themes including risk prediction, postoperative outcomes, clinical practice, and technological advances. These articles are representative of the best work in our field in 2022.

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Prothrombin complex concentrate in cardiac surgery for the treatment of coagulopathic bleeding

Cited by 7 publications

References 90 publications

Utilization and safety of off-label prothrombin complex concentrate (four-factor prothrombin complex concentrate) in a surgical population

Utilization and safety of off-label prothrombin complex concentrate (four-factor prothrombin complex concentrate) in a surgical population

Protamine dosing and its impact in cardiac surgery transfusion practice—A retrospective bi‐institutional analysis

Year in Review 2022: Noteworthy Literature in Cardiac Anesthesiology

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