Prothrombin Complex Concentrates for Bleeding in the Perioperative Setting

Three‐factor prothrombin complex concentrates for refractory bleeding after cardiovascular surgery within an algorithmic approach to haemostasis

“…In a study by Ranucci , fibrinogen levels of 300–350 mg/dl obviated the need for PCCs when bleeding was encountered after complex cardiovascular surgery. Although our institutional practice is not to overcorrect the fibrinogen levels owing to the large volume of multidonor‐pooled cryoprecipitate required, normalization of fibrinogen levels between 200 and 250 mg/dl prior to factor concentrate administration aims to increase fibrin cross‐linkage, optimize clot strength and facilitate the haemostatic effect of thrombin generation with lower doses of PCC or recombinant factor VIIa . This rationale is also consistent with observations on failed haemostasis after recombinant factor VIIa previously reported .…”

Use of prothrombin complex concentrate for management of coagulopathy after cardiac surgery: a propensity score matched comparison to plasma

“…7 In contrast, as PCCs do not contain the full, balanced complement of procoagulants and anticoagulants that are present in plasma, they may be less effective or carry a higher risk for thrombotic events and acute kidney injury (AKI) than plasma for management of coagulopathy. 10,11 Despite the potential advantages of PCCs over plasma, there are few direct comparisons between the two therapies for managing the coagulopathy of cardiac surgery. Nevertheless, at our institution, PCC is being increasingly used to supplement or supplant plasma in bleeding cardiac surgical patients, providing us with a cohort of patients who received PCC, plasma, or both during their surgery.…”

Perioperative management of the bleeding patient

“…ROTEMV C and TEGV C ) offers guided coagulopathy treatment that also includes antifibrinolytic agents, cryoprecipitate and factor concentrates. 5,56,57 In our transfusion algorithm for adult noncardiac surgery ( Figure 2), initial steps include utilization of laboratory data in parallel with packed RBCs. Discussion of specific components within this algorithm is described in separate sections in this review.…”

“…Prothrombin complex concentrates (PCCs) are purified coagulation factors that include procoagulant factors II, VII, IX and X and anticoagulant proteins C, S and Z in variable concentrations; minimal antithrombin and heparin are present in some preparations, as recently reviewed. 5 The use of PCCs for the emergent or urgent vitamin K antagonist anticoagulants reversal is extensively reported in guidelines. 105,119 Currently, there is extensive and increased use for off-label applications, include reversing direct oral anticoagulants (DOACs) such as apixiban, dabigatran, rivaroxaban, and edoxaban, and for treating refractory bleeding in surgical patients.…”

“…Management of perioperative bleeding consists of identifying patients at risk, understanding the impact of the operation on haemostasis, institution of allogeneic blood and factor concentrate based therapies, utilizing point-of-care laboratory testing, and understanding the limitations of monitoring techniques. 5 Clinically important bleeding can paradoxically evolve into pathologic thrombosis, with the transition of perioperative coagulopathy to hypercoagulability related to the acute phase response. This can be exacerbated by overzealous replacement of deficient procoagulant factors, inattention to deficient anticoagulant factors, and reluctance to initiate needed anticoagulant agents for venous thromboembolic prophylaxis after a recent bleed.…”