Rapid Reversal of Warfarin-Associated Hemorrhage in the Emergency Department by Prothrombin Complex Concentrates

Frumkin, Kenneth

doi:10.1016/j.annemergmed.2013.05.026

Cited by 17 publications

(10 citation statements)

References 159 publications

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“…Therefore, prevention of volume overload is necessary not only from a physiologic standpoint, but also from a health economics standpoint. One alternative to FFP for reversal of warfarin anticoagulation is prothrombin complex concentrate (PCC), which provides more rapid correction with a much lower volume . PCC is often deferred because of concerns about increased cost as compared with FFP .…”

Section: Discussionmentioning

confidence: 99%

Dose‐associated pulmonary complication rates after fresh frozen plasma administration for warfarin reversal

Marshall

Levine

Howell

et al. 2016

Journal of Thrombosis and Haemostasis

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AM, Nahed BV, Goldstein JN. Dose-associated pulmonary complication rates after fresh frozen plasma administration for warfarin reversal. J Thromb Haemost 2016; 14: 324-30. EssentialsFresh frozen plasma (FFP) may be associated with a dose-based risk of pulmonary complications. Patients received FFP for warfarin reversal at a large academic hospital over a 3-year period. Almost 20% developed pulmonary complications, and the risk was highest after > 3 units of FFP. The risk of pulmonary complications remained significant in multivariable analysis.Summary. Background: Fresh frozen plasma (FFP) is often administered to reverse warfarin anticoagulation. Administration has been associated with pulmonary complications, but it is unclear whether this risk is doserelated. Aims: We sought to characterize the incidence and dose relationship of pulmonary complications, including transfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury (TRALI), after FFP administration for warfarin reversal. Methods: We performed a structured retrospective review of patients who received FFP for warfarin reversal in the emergency department (ED) of an academic tertiary-care hospital over a 3-year period. Logistic regression was used to explore the relationship between FFP dose and risk of pulmonary events. Results: Two hundred and fiftyone patients met the inclusion criteria. Overall, 49 patients (20%) developed pulmonary complications, including 30 (12%) with TACO, two (1%) with TRALI, and 17 (7%) with pulmonary edema not meeting the criteria for TACO. Pulmonary complications were significantly more frequent in those who received > 3 units of FFP (34.0% versus 15.6%, 95% confidence interval for risk difference 7.9%-8.9%). After stratification by subtype of complication, only the risk of TACO was statistically significant (28.3% versus 7.6%, 95% confidence interval for risk difference 8.2%-16.6%). In multivariable analysis controlling for age, sex, initial systolic blood pressure, and intravenous fluids given in the ED, > 3 units of FFP remained a significant risk factor for pulmonary complications (odds ratio 2.49, 95% confidence interval 1.21-5.13). Conclusions: Almost 20% of patients who received FFP for warfarin reversal developed pulmonary complications, primarily TACO, and this risk increased with > 3 units of FFP. Clinicians should be aware of and prepared to manage these complications.

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Section: Discussionmentioning

confidence: 99%

Dose‐associated pulmonary complication rates after fresh frozen plasma administration for warfarin reversal

Marshall

Levine

Howell

et al. 2016

Journal of Thrombosis and Haemostasis

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“…Currently, there is little published evidence to support the use of PCC in the management of trauma‐related massive bleeding or iatrogenic injury . Our study showed that use of PCC for such an indication yielded a satisfactory level of efficacy in clinical practice.…”

Section: Discussionmentioning

confidence: 58%

Use and effectiveness of prothrombin complex concentrate in an emergency department: a review of 15 cases

Suzuki

Iwashita

Enokiya

et al. 2015

Acute Medicine & Surgery

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Aim: Hemostatic management of patients on oral anticoagulant therapy with critical bleeding continues to be a major challenge. The present study aimed to validate the efficacy, safety, and optimal dosage of prothrombin complex concentrate for rapidly normalizing elevated international normalized ratio (INR) values and achieving control of hemorrhage at an emergency department in Japan. Methods:We retrospectively collected data from all patients who were treated with PCC at our emergency department between January 2013 and September 2014. We used a commercially available prothrombin complex concentrate.Results: Fifteen patients (male / female, 7/8; average, 71.4 years) received prothrombin complex concentrate (14 for bleeding, including trauma-related bleeding, and one for invasive intervention) without complications. All but one patient received warfarin and the INR value declined in all patients with 500 IU (average, 8.98 IU/kg) prothrombin complex concentrate (average INR value before and after treatment: 2.20 versus 1.26). Although two patients died because of multiple organ failure, a relatively satisfactory hemostatic response was obtained in at least 11/15 patients. However, patients with a baseline INR value above 2.5 never achieved an optimal response (INR value < 1.35). Conclusion:A single dose of 500 IU prothrombin complex concentrate is insufficient for normalization of INR value, especially in patients with prolonged INR values. Administration strategies for trauma, the ideal dose (e.g., higher than 500 IU/patient), target optimal INR values, as well as the confirmation of safety should be addressed in the future. Further clinical trials are warranted to confirm this preliminary report.

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“…The multifactors in PCC have a theoretical advantage in the reversal of TIC, over what rFVIIa provides, as it more completely repletes the clotting proteins. It should also be noted that there is variability in the contents of PCC under different brands, and that some of the formulations of PCC are only three factors, with no Factor VII, making them less preferred for reversal of TIC [11].…”

Section: Prothrombin Complex Concentrate (Pcc)mentioning

confidence: 99%

Trauma Induced Coagulopathy: Prevention and Intervention

DeMuro¹,

Hanna²

2014

J Blood Disord Transfus

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Rapid Reversal of Warfarin-Associated Hemorrhage in the Emergency Department by Prothrombin Complex Concentrates

Cited by 17 publications

References 159 publications

Dose‐associated pulmonary complication rates after fresh frozen plasma administration for warfarin reversal

Dose‐associated pulmonary complication rates after fresh frozen plasma administration for warfarin reversal

Use and effectiveness of prothrombin complex concentrate in an emergency department: a review of 15 cases

Trauma Induced Coagulopathy: Prevention and Intervention

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