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El Rahal A, Beck J, Ahlborn P, Bernasconi C, Marbacher S, Wanderer S, Burkhardt JK, Daniel RT, Ferrari A, Hausmann O, Kamenova M, Kothbauer K, Lutz K, Mariani L, Alfieri A, Schöni D, Schucht P, Raabe A, Regli L, Kuhlen D, Seule M, Soleman J, Starnoni D, Zaldivar J, Zweifel C, Schaller K, Fung C. Incidence, therapy, and outcome in the management of chronic subdural hematoma in Switzerland: a population-based multicenter cohort study. Front Neurol 2023; 14:1206996. [PMID: 37780710 PMCID: PMC10540067 DOI: 10.3389/fneur.2023.1206996] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/19/2023] [Indexed: 10/03/2023] Open
Abstract
Background Chronic subdural hematoma (cSDH) is a disease affecting mainly elderly individuals. The reported incidence ranges from 2.0/100,000 to 58 per 100,000 person-years when only considering patients who are over 70 years old, with an overall incidence of 8.2-14.0 per 100,000 persons. Due to an estimated doubling of the population above 65 years old between 2000 and 2030, cSDH will become an even more significant concern. To gain an overview of cSDH hospital admission rates, treatment, and outcome, we performed this multicenter national cohort study of patients requiring surgical treatment of cSDH. Methods A multicenter cohort study included patients treated in 2013 in a Swiss center accredited for residency. Demographics, medical history, symptoms, and medication were recorded. Imaging at admission was evaluated, and therapy was divided into burr hole craniostomy (BHC), twist drill craniostomy (TDC), and craniotomy. Patients' outcomes were dichotomized into good (mRS, 0-3) and poor (mRS, 4-6) outcomes. A two-sided t-test for unpaired variables was performed, while a chi-square test was performed for categorical variables, and a p-value of <0.05 was considered to be statistically significant. Results A total of 663 patients were included. The median age was 76 years, and the overall incidence rate was 8.2/100,000. With age, the incidence rate increased to 64.2/100,000 in patients aged 80-89 years. The most prevalent symptoms were gait disturbance in 362 (58.6%) of patients, headache in 286 (46.4%), and focal neurological deficits in 252 (40.7%). CSDH distribution was unilateral in 478 (72.1%) patients, while 185 presented a bilateral hematoma with no difference in the outcome. BHC was the most performed procedure for 758 (97.3%) evacuations. CSDH recurrence was noted in 104 patients (20.1%). A good outcome was seen in almost 81% of patients. Factors associated with poor outcomes were age, GCS and mRS on admission, and the occurrence of multiple deficits present at the diagnosis of the cSDH. Conclusion As the first multicenter national cohort-based study analyzing the disease burden of cSDH, our study reveals that the hospital admission rate of cSDH was 8.2/100,000, while with age, it rose to 64.2/100,000. A good outcome was seen in 81% of patients, who maintained the same quality of life as before the surgery. However, the mortality rate was 4%.
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Affiliation(s)
- Amir El Rahal
- Department of Neurosurgery, University Hospital of Geneva, Faculty of Medicine, Geneva, Switzerland
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Peter Ahlborn
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Corrado Bernasconi
- Department of Neurosurgery, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Stefan Wanderer
- Department of Neurosurgery, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Roy Thomas Daniel
- Department of Neurosurgery, University Hospital Center of Lausanne, Lausanne, Switzerland
| | - Andrea Ferrari
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Oliver Hausmann
- Department of Neurosurgery, Hirslanden Klinik St. Anna, Luzern, Switzerland
| | - Maria Kamenova
- Department of Neurosurgery, University Hospital Basel, Faculty of Medicine, Basel, Switzerland
| | - Karl Kothbauer
- Department of Neurosurgery, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Katharina Lutz
- Department of Neurosurgery, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital Basel, Faculty of Medicine, Basel, Switzerland
| | - Alex Alfieri
- Department of Neurosurgery, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Daniel Schöni
- Department of Neurosurgery, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Philippe Schucht
- Department of Neurosurgery, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Dominique Kuhlen
- Department of Neurosurgery, Regional Hospital Lugano (EOC), Lugano, Switzerland
| | - Martin Seule
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital Basel, Faculty of Medicine, Basel, Switzerland
| | - Daniele Starnoni
- Department of Neurosurgery, University Hospital Center of Lausanne, Lausanne, Switzerland
| | - Julien Zaldivar
- Department of Neurosurgery, University Hospital Center of Lausanne, Lausanne, Switzerland
| | - Christian Zweifel
- Department of Neurosurgery, Cantonal Hospital Graubünden, Chur, Switzerland
| | - Karl Schaller
- Department of Neurosurgery, University Hospital of Geneva, Faculty of Medicine, Geneva, Switzerland
| | - Christian Fung
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
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Pon G, Pelsue B, Reddy ST, Parsha K, Zhang X, Gulbis B, Barreto A, Savitz SI, Escobar M, Allison TA. Hemostatic efficacy of four factor prothrombin complex concentrate in intracerebral hemorrhage patients receiving warfarin vs. factor Xa inhibitors. Thromb Res 2023; 229:46-52. [PMID: 37406569 DOI: 10.1016/j.thromres.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/04/2023] [Accepted: 06/20/2023] [Indexed: 07/07/2023]
Abstract
INTRODUCTION 4-F PCC is administered for reversal of factor Xa inhibitor-associated coagulopathy despite a lack of quality evidence demonstrating hemostatic efficacy. The aim of this study was to evaluate the hemostatic efficacy of 4-F PCC in intracerebral hemorrhage patients who received factor Xa inhibitors versus warfarin. MATERIALS AND METHODS This was a multi-center, retrospective, observational cohort study at a large healthcare system. Patients taking warfarin received 4-F PCC 25-50 units/kg based on the presenting INR, while patients taking a factor Xa inhibitor received 35 units/kg. The primary outcome was the percentage of patients with good or excellent hemostatic efficacy as assessed by modified Sarode scale, with neurologic outcomes assessed as a secondary endpoint. Patients were included in the primary outcome population if they had a repeat CT scan within 24 h. RESULTS One hundred fifty-seven patients were included in the primary outcome population; [warfarin (n = 76), factor Xa inhibitors (n = 81)]. Hemostatic efficacy was 83 % in the warfarin group versus 75 % in the factor Xa inhibitor group (p = 0.24). The hemostatic efficacy risk difference between the groups was 7.6 % (95 % CI 5.1 %, 20.2 %). Good neurologic outcome (mRS 0-2) at discharge was 17 % in warfarin patients versus 12 % in the factor Xa inhibitor patients (p = 0.40). CONCLUSIONS There was no significant difference in hemostatic efficacy or clinical outcomes between patients taking warfarin or a factor Xa inhibitor following reversal with 4-F PCC. This study provides further support that 4-F PCC can be used for the reversal of factor Xa inhibitor-associated coagulopathy.
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Affiliation(s)
- Gregory Pon
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, 6411 Fannin St, Houston, TX 77030, United States of America
| | - Brittany Pelsue
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, 6411 Fannin St, Houston, TX 77030, United States of America
| | - Sujan Teegala Reddy
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center of Houston, 6431 Fannin St, Houston, TX 77030, United States of America; Mercy Hospital, Fort Smith, AR 72913, United States of America
| | - Kaushik Parsha
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center of Houston, 6431 Fannin St, Houston, TX 77030, United States of America; Division of Neurology, Baptist Memorial Hospital, Memphis TN 38120, United States of America
| | - Xu Zhang
- Center for Clinical and Translational Sciences, McGovern Medical School at The University of Texas Health Science Center of Houston, 7000 Fannin St, Houston, TX 77030, United States of America; Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center of Houston, 6431 Fannin St, MSB 1.150, Houston, TX 77030, United States of America
| | - Brian Gulbis
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, 6411 Fannin St, Houston, TX 77030, United States of America
| | - Andrew Barreto
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center of Houston, 6431 Fannin St, Houston, TX 77030, United States of America
| | - Sean I Savitz
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center of Houston, 6431 Fannin St, Houston, TX 77030, United States of America
| | - Miguel Escobar
- Department of Hematology, McGovern Medical School at The University of Texas Health, Science Center of Houston, 6410 Fannin St, STE 830, Houston, TX 77030, United States of America
| | - Teresa A Allison
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, 6411 Fannin St, Houston, TX 77030, United States of America.
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Nontraumatic Neurosurgical Emergencies. Crit Care Nurs Q 2023; 46:2-16. [DOI: 10.1097/cnq.0000000000000434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Hayes K, Fernando MC, Jordan V. Prothrombin complex concentrate in cardiac surgery for the treatment of coagulopathic bleeding. Cochrane Database Syst Rev 2022; 11:CD013551. [PMID: 36408876 PMCID: PMC9677522 DOI: 10.1002/14651858.cd013551.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Coagulopathy following cardiac surgery is associated with considerable blood product transfusion and high morbidity and mortality. The treatment of coagulopathy following cardiac surgery is challenging, with the replacement of clotting factors being based on transfusion of fresh frozen plasma (FFP). Prothrombin complex concentrate (PCCs) is an alternative method to replace clotting factors and warrants evaluation. PCCs are also an alternative method to treat refractory ongoing bleeding post-cardiac surgery compared to recombinant factor VIIa (rFVIIa) and also warrants evaluation. OBJECTIVES: Assess the benefits and harms of PCCs in people undergoing cardiac surgery who have coagulopathic non-surgical bleeding. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase and Conference Proceedings Citation Index-Science (CPCI-S) on the Web of Science on 20 April 2021. We searched Clinicaltrials.gov (www. CLINICALTRIALS gov), and the World Health Organisation (WHO) International Clinical Trials Registry Platform (ICTRP; apps.who.int/trialsearch/), for ongoing or unpublished trials. We checked the reference lists for additional references. We did not limit the searches by language or publication status. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised trials (NRSs). DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: Eighteen studies were included (4993 participants). Two were RCTs (151 participants) and 16 were NRSs. Both RCTs had low risk of bias (RoB) in almost all domains. Of the 16 NRSs, 14 were retrospective cohort analyses with one prospective study and one case report. The nine studies used in quantitative analysis were judged to have critical RoB, three serious and three moderate. 1. PCC versus standard treatment Evidence from RCTs showed PCCs are likely to reduce the number of units transfused compared to standard care (MD -0.89, 95% CI -1.78 to 0.00; participants = 151; studies = 2; moderate-quality evidence). Evidence from NRSs agreed with this, showing that PCCs may reduce the mean number of units transfused compared to standard care but the evidence is uncertain (MD -1.87 units, 95% CI -2.53 to -1.20; participants = 551; studies = 2; very low-quality evidence). There was no evidence from RCTs showing a difference in the incidence of red blood cell (RBC) transfusion compared to standard care (OR 0.53, 95% CI 0.20 to 1.40; participants = 101; studies = 1; low-quality evidence). Evidence from NRSs disagreed with this, showing that PCCs may reduce the mean number of units transfused compared to standard care but the evidence is uncertain (OR 0.54, 95% CI 0.30 to 0.98; participants = 1046; studies = 4; low-quality evidence). There was no evidence from RCTs showing a difference in the number of thrombotic events with PCC compared to standard care (OR 0.68 95% CI 0.20 to 2.31; participants = 152; studies = 2; moderate-quality evidence). This is supported by NRSs, showing that PCCs may have no effect on the number of thrombotic events compared to standard care but the evidence is very uncertain (OR 1.32, 95% CI 0.87 to 1.99; participants = 1359; studies = 7; very low-quality evidence). There was no evidence from RCTs showing a difference in mortality with PCC compared to standard care (OR 0.53, 95% CI 0.12 to 2.35; participants = 149; studies = 2; moderate-quality evidence). This is supported by evidence from NRSs, showing that PCCs may have little to no effect on mortality compared to standard care but the evidence is very uncertain (OR 1.02, 95% CI 0.69 to 1.51; participants = 1334; studies = 6; very low-quality evidence). Evidence from RCTs indicated that there was little to no difference in postoperative bleeding (MD -107.05 mLs, 95% CI -278.92 to 64.83; participants = 151, studies = 2; low-quality evidence). PCCs may have little to no effect on intensive care length of stay (RCT evidence: MD -0.35 hours, 95% CI -19.26 to 18.57; participants = 151; studies = 2; moderate-quality evidence) (NRS evidence: MD -18.00, 95% CI -43.14 to 7.14; participants = 225; studies = 1; very low-quality evidence) or incidence of renal replacement therapy (RCT evidence: OR 0.72, 95% CI 0.14 to 3.59; participants = 50; studies = 1; low-quality evidence) (NRS evidence: OR 1.46, 95% CI 0.71 to 2.98; participants = 684; studies = 2; very low-quality evidence). No studies reported on additional adverse outcomes. 2. PCC versus rFVIIa For this comparison, all evidence was provided from NRSs. PCC likely results in a large reduction of RBCs transfused intra-operatively in comparison to rFVIIa (MD-4.98 units, 95% CI -6.37 to -3.59; participants = 256; studies = 2; moderate-quality evidence). PCC may have little to no effect on the incidence of RBC units transfused comparative to rFVIIa; evidence is very uncertain (OR 0.16, 95% CI 0.02 to 1.56; participants = 150; studies = 1; very low-quality evidence). PCC may have little to no effect on the number of thrombotic events comparative to rFVIIa; evidence is very uncertain (OR 0.51, 95% CI 0.23 to 1.16; participants = 407; studies = 4; very low-quality evidence). PCC may have little to no effect on the incidence of mortality (OR 1.07, 95% CI 0.38 to 3.03; participants = 278; studies = 3; very low-quality evidence) or intensive care length of stay comparative to rFVIIa (MD -40 hours, 95% CI -110.41 to 30.41; participants = 106; studies = 1; very low-quality evidence); evidence is very uncertain . PCC may reduce bleeding (MD -674.34 mLs, 95% CI -906.04 to -442.64; participants = 150; studies = 1; very low-quality evidence) and incidence of renal replacement therapy (OR 0.29, 95% CI 0.12 to 0.71; participants = 106; studies = 1; very low-quality evidence) comparative to rFVIIa; evidence is very uncertain. No studies reported on other adverse events. AUTHORS' CONCLUSIONS: PCCs could potentially be used as an alternative to standard therapy for coagulopathic bleeding post-cardiac surgery compared to FFP as shown by moderate-quality evidence and it may be an alternative to rFVIIa in refractory non-surgical bleeding but this is based on moderate to very low quality of evidence.
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Affiliation(s)
- Katia Hayes
- Department of Cardiothoracic and ORL Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - Malindra C Fernando
- Department of Cardiothoracic and ORL Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - Vanessa Jordan
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Evans CR, Cuker A, Crowther M, Pishko AM. Prophylactic fresh frozen plasma versus prothrombin complex concentrate for preprocedural management of the coagulopathy of liver disease: A systematic review. Res Pract Thromb Haemost 2022; 6:e12724. [PMID: 36204546 PMCID: PMC9124952 DOI: 10.1002/rth2.12724] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 03/19/2022] [Accepted: 04/04/2022] [Indexed: 11/23/2022] Open
Abstract
Background The optimal prophylactic preprocedural management of patients with coagulopathy due to liver disease is not known. Objectives Our objective was to compare the efficacy and safety of fresh frozen plasma (FFP) with prothrombin complex concentrate (PCC) in the preprocedural management of patients with coagulopathy of liver disease. Methods We conducted a systematic review to examine published evidence regarding treatment with FFP or PCC in adults with coagulopathy of liver disease undergoing an invasive procedure. Direct comparisons and single-arm studies were eligible. Efficacy outcomes included major bleeding, mortality, and correction of prothrombin time (PT) and/or international normalized ratio (INR). Safety outcomes included thrombosis and transfusion-related complications. Results A total of 95 articles were identified for full-text review. Nine studies were eligible and included in the review. No randomized trials comparing FFP versus PCC were identified. Only two studies directly compared FFP versus PCC. In these studies, PCC appeared to result in higher rates of correction of PT/INR, but bleeding outcomes were not different. In the single-arm studies, bleeding events appeared low overall. Volume overload was the most common recorded adverse event in patients receiving FFP. Thromboembolic events occurred rarely, but exclusively in the PCC group. Due to heterogeneity in study definitions and bias, meta-analysis was not possible. Our study found no evidence to favor a specific product over another. Conclusions Insufficient data exist on the effects of FFP versus PCC administration before invasive procedures in patients with coagulopathy of liver disease to make conclusions with respect to relative efficacy or safety.
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Affiliation(s)
- Christina R. Evans
- Department of MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Adam Cuker
- Department of MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Pathology and Laboratory MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Mark Crowther
- Department of MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Allyson M. Pishko
- Department of MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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Abstract
Hemorrhagic stroke comprises about 20% of all strokes, with intracerebral hemorrhage (ICH) being the most common type. Frequency of ICH is increased where hypertension is untreated. ICH in particularly has a disproportionately high risk of early mortality and long-term disability. Until recently, there has been a paucity of randomized controlled trials (RCTs) to provide evidence for the efficacy of various commonly considered interventions in ICH, including acute blood pressure management, coagulopathy reversal, and surgical hematoma evacuation. Evidence-based guidelines do exist for ICH and these form the basis for a framework of care. Current approaches emphasize control of extremely high blood pressure in the acute phase, rapid reversal of vitamin K antagonists, and surgical evacuation of cerebellar hemorrhage. Lingering questions, many of which are the topic of ongoing clinical research, include optimizing individual blood pressure targets, reversal strategies for newer anticoagulant medications, and the role of minimally invasive surgery. Risk stratification models exist, which derive from findings on clinical exam and neuroimaging, but care should be taken to avoid a self-fulfilling prophecy of poor outcome from limiting treatment due to a presumed poor prognosis. Cerebral venous thrombosis is an additional subtype of hemorrhagic stroke that has a unique set of causes, natural history, and treatment and is discussed as well.
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Affiliation(s)
- Arturo Montaño
- Departments of Neurology and Neurosurgery, University of Colorado, Aurora, CO, United States
| | - Daniel F Hanley
- Departments of Neurology and Neurosurgery, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - J Claude Hemphill
- Departments of Neurology and Neurosurgery, University of California San Francisco, San Francisco, CA, United States.
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Faulkner H, Chakankar S, Mammi M, Lo JYT, Doucette J, Al-Otaibi N, Abboud J, Le A, Mekary RA, Bunevicius A. Safety and efficacy of prothrombin complex concentrate (PCC) for anticoagulation reversal in patients undergoing urgent neurosurgical procedures: a systematic review and metaanalysis. Neurosurg Rev 2020; 44:1921-1931. [PMID: 33009989 DOI: 10.1007/s10143-020-01406-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/28/2020] [Accepted: 09/28/2020] [Indexed: 12/31/2022]
Abstract
Anticoagulant therapy poses a significant risk for patients undergoing emergency neurosurgery procedures, necessitating reversal with prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP). Data on PCC efficacy lack consistency in this setting. This systematic review and metaanalysis aimed to evaluate efficacy and safety of PCC for anticoagulation reversal in the context of urgent neurosurgery. Articles from PubMed, Embase, and Cochrane databases were screened according to the PRISMA checklist. Adult patients receiving anticoagulation reversal with PCC for emergency neurosurgical procedures were included. When available, patients who received FFP were included as a comparison group. Pooled estimates of observational studies were calculated for efficacy and safety outcomes via random-effects modeling. Initial search returned 4505 articles, of which 15 studies met the inclusion criteria. Anticoagulants used included warfarin (83%), rivaroxaban (6.8%), phenprocoumon (6.1%), apixaban (2.2%), and dabigatran (1.5%). The mean International Normalized Ratio (INR) prePCC administration ranged from 2.3 to 11.7, while postPCC administration from 1.1 to 1.4. All-cause mortality at 30 days was 27% (95%CI 21, 34%; I2 = 44.6%; p-heterogeneity = 0.03) and incidence of thromboembolic events was 6.00% among patients treated with PCC (95%CI 4.00, 10.0%; I2 = 0%; p-heterogeneity = 0.83). Results comparing PCC and FFP demonstrated no statistically significant differences in INR reversal, mortality, or incidence of thromboembolic events. This metaanalysis demonstrated adequate safety and efficacy for PCC in the reversal of anticoagulation for urgent neurosurgical procedures. There was no significant difference between PCC and FFP, though further trials would be useful in demonstrating the safety and efficacy of PCC in this setting.
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Affiliation(s)
| | | | - Marco Mammi
- Neurosurgery Unit, Department of Neurosciences, University of Turin, via Cherasco 15, 10126, Turin, Italy
| | - Jack Yu Tung Lo
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Department of Neurosurgery, National Neuroscience Institute, 11 Jln Tan Tock Seng, Singapore, 308433, Singapore
| | - Joanne Doucette
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA
| | - Nawaf Al-Otaibi
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA
| | - Judi Abboud
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA
| | - Andrew Le
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA
| | - Rania A Mekary
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA. .,Neurosurgery Unit, Department of Neurosciences, University of Turin, via Cherasco 15, 10126, Turin, Italy.
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Abstract
OBJECTIVES Despite the availability of FDA-labeled anticoagulant reversal agents, there is considerable variability in clinical practice as to the regimen and agent used for reversal. The objective of this study was to characterize the current practices of pharmacists surrounding the reversal of anticoagulant-associated life-threatening hemorrhage. Methods: A cross-sectional analysis of critical care and emergency medicine pharmacists. Current practice was compared for the type of hospital, country region, and type of ordering physician. In addition, pharmacists were asked to rank their involvement with activities involved with the reversal of anticoagulants. Respondents ranked their involvement with these activities as either never involved, rarely involved, occasionally involved, frequently involved, or always involved. Results:281 respondents were included. The majority used 4-factor PCC for warfarin reversal (92.9%) and factor Xa inhibitor reversal (79.7%). However, only 58.7% used the labeled dose of 4-PCC for warfarin reversal. Of the 30.6% that utilized a fixed-dose regimen, the most common regimen was 1500 units once. A higher proportion of respondents practicing in a teaching hospital reported that they used activated prothrombin complex concentrates for reversal of factor Xa inhibitor (22 [12.2%] vs. 5 [5%]; p < 0.05) or coagulation factor Xa (recombinant)-inactivated-zhzo (31 [17.2%] vs. 5 [5%]; p < 0.05). In addition, the majority of respondents utilized idarucizumab for dabigatran reversal. The only involvement activity in which <50% of respondents said they were frequently involved or always involved was 'administration of reversal agent.' Conclusions: There is considerable variability in which agents were utilized for anticoagulant-associated bleeding reversal.
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Affiliation(s)
- A Shaun Rowe
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center , Knoxville, TN, USA
| | - Scott Dietrich
- Department of Pharmacy, University of Colorado Health, North Region , Colorado Springs, CO, USA
| | - Leslie A Hamilton
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center , Knoxville, TN, USA
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Hayes K, Fernando MC, Young L, Jordan V. Prothrombin complex concentrate in cardiac surgery for the treatment of non-surgical bleeding. Hippokratia 2020. [DOI: 10.1002/14651858.cd013551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Katia Hayes
- Auckland City Hospital; Department of Cardiothoracic and ORL Anaesthesia; Auckland New Zealand
| | - Malindra C Fernando
- Auckland District Health Board; Department of Cardiothoracic and ORL Anaesthesia; Auckland New Zealand
| | - Laura Young
- Auckland District Health Board; Cancer and Blood Services; 2 Park Road Grafton Auckland New Zealand 1023
| | - Vanessa Jordan
- University of Auckland; Department of Obstetrics and Gynaecology; Private Bag 92019 Auckland New Zealand 1003
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Agarwal P, Abdullah KG, Ramayya AG, Nayak NR, Lucas TH. A Retrospective Propensity Score-Matched Early Thromboembolic Event Analysis of Prothrombin Complex Concentrate vs Fresh Frozen Plasma for Warfarin Reversal Prior to Emergency Neurosurgical Procedures. Neurosurgery 2019; 82:877-886. [PMID: 29106685 DOI: 10.1093/neuros/nyx327] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 05/16/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Reversal of therapeutic anticoagulation prior to emergency neurosurgical procedures is required in the setting of intracranial hemorrhage. Multifactor prothrombin complex concentrate (PCC) promises rapid efficacy but may increase the probability of thrombotic complications compared to fresh frozen plasma (FFP). OBJECTIVE To compare the rate of thrombotic complications in patients treated with PCC or FFP to reverse therapeutic anticoagulation prior to emergency neurosurgical procedures in the setting of intracranial hemorrhage at a level I trauma center. METHODS Sixty-three consecutive patients on warfarin therapy presenting with intracranial hemorrhage who received anticoagulation reversal prior to emergency neurosurgical procedures were retrospectively identified between 2007 and 2016. They were divided into 2 cohorts based on reversal agent, either PCC (n = 28) or FFP (n = 35). The thrombotic complications rates within 72 h of reversal were compared using the χ2 test. A multivariate propensity score matching analysis was used to limit the threat to interval validity from selection bias arising from differences in demographics, laboratory values, history, and clinical status. RESULTS Thrombotic complications were uncommon in this neurosurgical population, occurring in 1.59% (1/63) of treated patients. There was no significant difference in the thrombotic complication rate between groups, 3.57% (1/28; PCC group) vs 0% (0/35; FFP group). Propensity score matching analysis validated this finding after controlling for any selection bias. CONCLUSION In this limited sample, thrombotic complication rates were similar between use of PCC and FFP for anticoagulation reversal in the management of intracranial hemorrhage prior to emergency neurosurgical procedures.
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Affiliation(s)
- Prateek Agarwal
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kalil G Abdullah
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashwin G Ramayya
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nikhil R Nayak
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Timothy H Lucas
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Hill R, Han TS, Lubomirova I, Math N, Bentley P, Sharma P. Prothrombin Complex Concentrates are Superior to Fresh Frozen Plasma for Emergency Reversal of Vitamin K Antagonists: A Meta-Analysis in 2606 Subjects. Drugs 2019; 79:1557-1565. [DOI: 10.1007/s40265-019-01179-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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12
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Ostermann H, von Heymann C. Prothrombin complex concentrate for vitamin K antagonist reversal in acute bleeding settings: efficacy and safety. Expert Rev Hematol 2019; 12:525-540. [PMID: 31159607 DOI: 10.1080/17474086.2019.1624520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Introduction: Current guidelines recommend the administration of prothrombin complex concentrate in combination with vitamin K for normalization of coagulation in patients presenting with vitamin K antagonist-associated major bleeding, but until recently no adequately powered comparative trials had been conducted to support these recommendations. In this article, the authors review the evidence from studies assessing prothrombin complex concentrate treatment in these patients. Areas covered: A PubMed search (spanning January 1900 to September 2018) was conducted using the following search terms: prothrombin complex concentrate* AND (warfarin or (vitamin K antagonist*)), and papers relevant to major hemorrhagic events were identified; results from studies that used a randomized controlled trial (RCT) or a prospective design are presented here. Overall, the identified studies support the current guideline recommendations and indicate that prothrombin complex concentrates have at least similar safety profiles to other treatment options, such as fresh frozen plasma and recombinant activated factor VII. Expert opinion: It is hoped that the results from studies discussed here will inform future guideline updates; however, local clinical practice may also occasionally act as a barrier to adoption of guideline recommendations. There is an urgent need for further RCTs/prospective trials directly comparing PCC and plasma administration in acute bleeding settings.
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Affiliation(s)
- Helmut Ostermann
- a Department of Hematology/Oncology , Ludwig-Maximilians-Universität München , Munich , Germany
| | - Christian von Heymann
- b Department of Anesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy , Vivantes Klinikum im Friedrichshain , Berlin , Germany
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13
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Pan R, Cheng J, Lai K, Huang Q, Wu H, Tang Y. Efficacy and safety of prothrombin complex concentrate for vitamin K antagonist-associated intracranial hemorrhage: a systematic review and meta-analysis. Neurol Sci 2019; 40:813-827. [DOI: 10.1007/s10072-019-3726-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 01/14/2019] [Indexed: 12/20/2022]
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14
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Paulo D, Semonche A, Choudhry O, Al-Mufti F, Prestigiacomo CJ, Roychowdhury S, Nanda A, Gupta G. History of Hemostasis in Neurosurgery. World Neurosurg 2018; 124:S1878-8750(18)32837-7. [PMID: 30579020 DOI: 10.1016/j.wneu.2018.12.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 12/01/2018] [Accepted: 12/03/2018] [Indexed: 11/17/2022]
Abstract
Control of bleeding in the confined area of the skull is imperative for successful neurosurgery and the prevention of devastating complications such as postoperative hemorrhage. This paper reviews the historical evolution of methods to achieve successful hemostasis in neurosurgery from the early1800s to today. The major categories of hemostatic agents (mechanical, chemical and thermal) are delineated and discussed in chronological order. The significance of this article is in its detailed history of the kinds of hemostatic methods that have evolved with our accumulating medical and surgical knowledge, which may inform future innovations and improvements.
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Affiliation(s)
- Danika Paulo
- Rutgers Robert Wood Johnson Medical School, Department of Neurosurgery, Clinical Academic Building Suite 2100, 125 Paterson St, New Brunswick, NJ 08901, United States
| | - Alexa Semonche
- Rutgers Robert Wood Johnson Medical School, Department of Neurosurgery, Clinical Academic Building Suite 2100, 125 Paterson St, New Brunswick, NJ 08901, United States
| | - Osamah Choudhry
- New York University, Department of Neurological Surgery, 550 1st Avenue, Skirball, Suite 8R, New York, NY 10016, United States
| | - Fawaz Al-Mufti
- University Hospital, Department of Neurology, 90 Bergen Street, Suite 5200, Newark, NJ 07101, United States
| | - Charles J Prestigiacomo
- Rutgers New Jersey Medical School, Department of Neurosurgery, Doctor's Office Center 90 Bergen Street, Newark, NJ 07101, United States
| | - Sudipta Roychowdhury
- Robert Wood Johnson University Hospital, Department of Radiology, Medical Education Building Suite #04, 1 Robert Wood Johnson Pl, New Brunswick, NJ 08901, United States
| | - Anil Nanda
- Robert Wood Johnson Medical School, Department of Neurosurgery, Clinical Academic Building Suite 2100, 125 Paterson St, New Brunswick, NJ 08901, United States
| | - Gaurav Gupta
- Robert Wood Johnson Medical School, Department of Neurosurgery, Clinical Academic Building Suite 2100, 125 Paterson St, New Brunswick, NJ 08901, United States.
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Abstract
Intraoperative bleeding can be minimized with optimal preoperative preparation but cannot be completely prevented. There are circumstances when patients need emergent operative intervention, and thorough hemostatic evaluation and preparation is not possible. In this review, the authors summarize the recommendations for rapid reversal of vitamin K antagonists and direct oral anticoagulants before procedures. The authors review the potential causes for intraoperative bleeding and the methods for rapid and accurate diagnosis. The authors summarize the current evidence for treatment options, including transfusion of platelets and coagulation factors and the use of topical agents, antidotes to direct-acting anticoagulants, antifibrinolytics, and desmopressin.
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Affiliation(s)
- Michal Bar-Natan
- Division of Hematology and Oncology, Department of Internal Medicine, Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, 240 East 38th Street, 19th Floor, New York, NY 10016, USA
| | - Kenneth B Hymes
- Division of Hematology and Oncology, Department of Internal Medicine, Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, 240 East 38th Street, 19th Floor, New York, NY 10016, USA.
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16
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Di Fusco SA, Lucà F, Benvenuto M, Iorio A, Fiscella D, D'Ascenzo F, Madeo A, Colivicchi F, Di Lenarda A, Gulizia MM. Major bleeding with old and novel oral anticoagulants: How to manage it. Focus on reversal agents. Int J Cardiol 2018; 268:75-79. [DOI: 10.1016/j.ijcard.2018.05.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/19/2018] [Accepted: 05/18/2018] [Indexed: 12/13/2022]
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17
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Intraoperative Blood and Coagulation Factor Replacement During Neurosurgery. Neurosurg Clin N Am 2018; 29:547-555. [DOI: 10.1016/j.nec.2018.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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18
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Akhter M, Morotti A, Cohen AS, Chang Y, Ayres AM, Schwab K, Viswanathan A, Gurol ME, Anderson CD, Greenberg SM, Rosand J, Goldstein JN. Timing of INR reversal using fresh-frozen plasma in warfarin-associated intracerebral hemorrhage. Intern Emerg Med 2018; 13:557-565. [PMID: 28573379 DOI: 10.1007/s11739-017-1680-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 05/18/2017] [Indexed: 10/19/2022]
Abstract
Rapid reversal of coagulopathy is recommended in warfarin-associated intracerebral hemorrhage (WAICH). However, rapid correction of the INR has not yet been proven to improve clinical outcomes, and the rate of correction with fresh-frozen plasma (FFP) can be variable. We sought to determine whether faster INR reversal with FFP is associated with decreased hematoma expansion and improved outcome. We performed a retrospective analysis of a prospectively collected cohort of consecutive patients with WAICH presenting to an urban tertiary care hospital from 2000 to 2013. Patients with baseline INR > 1.4 treated with FFP and vitamin K were included. The primary outcomes are occurrence of hematoma expansion, discharge modified Rankin Scale (mRS), and 30-day mortality. The association between timing of INR reversal, ICH expansion, and outcome was investigated with logistic regression analysis. 120 subjects met inclusion criteria (mean age 76.9, 57.5% males). Median presenting INR was 2.8 (IQR 2.3-3.4). Hematoma expansion is not associated with slower INR reversal [median time to INR reversal 9 (IQR 5-14) h vs. 10 (IQR 7-16) h, p = 0.61]. Patients with ultimately poor outcome received more rapid INR reversal than those with favorable outcome [9 (IQR 6-14) h vs. 12 (8-19) h, p = 0.064). We find no evidence of an association between faster INR reversal and either reduced hematoma expansion or better outcome.
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Affiliation(s)
- Murtaza Akhter
- Department of Emergency Medicine, University of Arizona College of Medicine-Phoenix and Maricopa Integrated Health System, Phoenix, AZ, USA.
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Andrea Morotti
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Abigail Sara Cohen
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yuchiao Chang
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alison M Ayres
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kristin Schwab
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anand Viswanathan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mahmut Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Steven Mark Greenberg
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan Rosand
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua Norkin Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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19
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Streiff M. Prothrombin complex concentrates for reversal of vitamin K antagonists: Assessing the risks. Thromb Haemost 2017; 106:389-90. [DOI: 10.1160/th11-08-0521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 08/01/2011] [Indexed: 11/05/2022]
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20
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Chai-Adisaksopha C, Hillis C, Siegal DM, Movilla R, Heddle N, Crowther M, Iorio A. Prothrombin complex concentrates versus fresh frozen plasma for warfarin reversal A systematic review and meta-analysis. Thromb Haemost 2017; 116:879-890. [DOI: 10.1160/th16-04-0266] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 06/22/2016] [Indexed: 01/02/2023]
Abstract
SummaryUrgent reversal of warfarin is required for patients who experience major bleeding or require urgent surgery. Treatment options include the combination of vitamin K and coagulation factor replacement with either prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP). However, the optimal reversal strategy is unclear based on clinically relevant outcomes. We searched in MEDLINE, EMBASE and Cochrane library to December 2015. Thirteen studies (5 randomised studies and 8 observational studies) were included. PCC use was associated with a significant reduction in all-cause mortality compared to FFP (OR= 0.56, 95 % CI; 0.37–0.84, p=0.006). A higher proportion of patients receiving PCC achieved haemostasis compared to those receiving FFP, but this was not statistically significant (OR 2.00, 95 % CI; 0.85–4.68). PCC use was more likely to achieve normalisation of international normalised ratio (INR) (OR 10.80, 95 % CI; 6.12–19.07) and resulted in a shorter time to INR correction (mean difference –6.50 hours, 95 %CI; –9.75 to –3.24). Red blood cell transfusion was not statistically different between the two groups (OR 0.88, 95 % CI: 0.53–1.43). Patients receiving PCC had a lower risk of post-transfusion volume overload compared to FFP (OR 0.27, 95 % CI; 0.13–0.58). There was no statistically significant difference in the risk of thromboembolism following administration of PCC or FFP (OR 0.91, 95 % CI; 0.44–1.89). In conclusion, as compared to FFP, the use of PCC for warfarin reversal was associated with a significant reduction in all-cause mortality, more rapid INR reduction, and less volume overload without an increased risk of thromboembolic events.Supplementary Material to this article is available online at www.thrombosis-online.com.
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21
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Chow JH, Lee K, Abuelkasem E, Udekwu OR, Tanaka KA. Coagulation Management During Liver Transplantation: Use of Fibrinogen Concentrate, Recombinant Activated Factor VII, Prothrombin Complex Concentrate, and Antifibrinolytics. Semin Cardiothorac Vasc Anesth 2017; 22:164-173. [DOI: 10.1177/1089253217739689] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Coagulation management, and transfusion practice in liver transplantation (LT) have been evolving in the recent years due to better understanding of coagulation abnormalities in end-stage liver disease, and clinical management of LT patients. Avoidance of allogeneic blood components is feasible in some patients, but multi-modal coagulation therapies may be necessary in others who develop complex coagulopathy due to hemorrhage, hemodilution, hypothermia, and acid-base disturbances. Transfusions of plasma and cryoprecipitate remain to be the mainstay therapy for procoagulant factor replacement during LT. Clinical efficacy and safety of these products are limited by logistic issues (eg, thawing), and mostly noninfectious complications. Considering potential alternatives to conventional transfusion is thus important to improve hemostatic resuscitation in complex LT cases. The present review is mainly focused on procoagulant properties of plasma and platelet transfusion, and currently available plasma-derived and recombinant factor concentrates, and antifibrinolytic agents in LT patients. The role of viscoelastic coagulation tests to guide specific component therapies will be also discussed.
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Affiliation(s)
| | - Khang Lee
- University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Obi R. Udekwu
- University of Maryland School of Medicine, Baltimore, MD, USA
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22
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Abstract
Patients with cSDH presenting with new or worsening neurological deficits, especially if they are debilitating and adversely affecting quality of life require urgent medical and surgical attention. Neurological and neurosurgical critical care team need to stabilize the patient by reversing any underlying coagulopathy states in order to prevent further hematoma expansion.In the event of brain herniation and presumed ICP elevation and CPP compromise, step-wise ICP management should be instituted promptly.Seizure prophylaxis treatment is reasonable. Timing of surgical evacuation is not always easy to determine but the presence of significant neurological deficits with impending herniation require immediate surgical Intervention. Consideration of the clot density along with patient's current neurological status would determine the timing and type of surgical interventions. Postoperative critical care management is not trivial. In addition to detecting any changes in neurological conditions, timely initiation (typically within the first 48 hours if clinical and radiographic conditions are stable with no co-existing coagulopathy) of venous thromboembolism prophylaxis is essential. Resuming antiplatelets and anticoagulants are warranted for those with clear indications including atrial fibrillation, atrial thrombus, known deep vein thrombosis, mechanical heart valves and other preexisting hypercoagulable conditions, but it is generally advised to hold antiplatelets and anticoagulants for about 10-14 post injury and/or surgical intervention.
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Affiliation(s)
- Jeremy T Ragland
- Departments of Neurosurgery and Neurology, Division of Neurocritical Care McGovern Medical School, 6431 Fannin Street, Medical School Building 7.152, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Kiwon Lee
- Departments of Neurosurgery and Neurology, Division of Neurocritical Care McGovern Medical School, 6431 Fannin Street, Medical School Building 7.152, University of Texas Health Science Center at Houston, Houston, TX 77030, USA.
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23
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Alaraj A, Esfahani DR, Hussein AE, Darie I, Amin-Hanjani S, Slavin KV, Du X, Charbel FT. Neurosurgical Emergency Transfers: An Analysis of Deterioration and Mortality. Neurosurgery 2017; 81:240-250. [DOI: 10.1093/neuros/nyx012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 01/13/2017] [Indexed: 11/13/2022] Open
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Burk DR, Smith JL, Wild JR. Prothrombin Complex Concentrates: An Alternative to Fresh Frozen Plasma. Orthopedics 2017; 40:e367-e369. [PMID: 27942737 DOI: 10.3928/01477447-20161202-02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 10/31/2016] [Indexed: 02/03/2023]
Abstract
Insufficiency fractures are a common cause of morbidity among geriatric patients worldwide. Improved outcomes are known to result from decreased delay to definitive operative fixation and mobilization. Use of warfarin is an important potential cause of delay. The ideal mode of warfarin reversal is currently unknown. Prothrombin complex concentrates (PCCs) offer rapid correction with small infusion volume, both of which are important for elderly patients with multiple comorbidities. The authors present 2 cases of insufficiency fractures occurring in geriatric patients receiving warfarin therapy reversed with a 3-factor PCC. Both patients were independent, community ambulators without significant functional disability and returned to their prior level of functioning. There were no significant bleeding or venous thromboembolic complications. To the authors' knowledge, no previous reports have described the use of PCC in geriatric patients with fractures. Nonetheless, its potential is well documented in emergency and trauma surgery literature. The use of PCC could potentially allow surgeons and hospitals to avoid complications related to immobility and the associated costs of treatment, extended hospital stay, and readmission. The authors' limited experience suggests 3-factor PCC preparations may provide adequate correction to allow expeditious surgical treatment. [Orthopedics. 2017; 40(2):e367-e369.].
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Abstract
Intracerebral hemorrhage (ICH) is a potentially devastating neurologic injury representing 10-15% of stroke cases in the USA each year. Numerous risk factors, including age, hypertension, male gender, coagulopathy, genetic susceptibility, and ethnic descent, have been identified. Timely identification, workup, and management of this condition remain a challenge for clinicians as numerous factors can present obstacles to achieving good functional outcomes. Several large clinical trials have been conducted over the prior decade regarding medical and surgical interventions. However, no specific treatment has shown a major impact on clinical outcome. Current management guidelines do exist based on medical evidence and consensus and these provide a framework for care. While management of hypertension and coagulopathy are generally considered basic tenets of ICH management, a variety of measures for surgical hematoma evacuation, intracranial pressure control, and intraventricular hemorrhage can be further pursued in the emergent setting for selected patients. The complexity of management in parenchymal cerebral hemorrhage remains challenging and offers many areas for further investigation. A systematic approach to the background, pathology, and early management of spontaneous parenchymal hemorrhage is provided.
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26
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Chang Y, Kim YJ, Song TJ. Management of Oral Anti-Thrombotic Agents Associated Intracerebral Hemorrhage. JOURNAL OF NEUROCRITICAL CARE 2016. [DOI: 10.18700/jnc.160082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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27
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Evaluation of Warfarin Reversal with 4-Factor Prothrombin Complex Concentrate Compared to 3-Factor Prothrombin Complex Concentrate at a Tertiary Academic Medical Center. J Emerg Med 2016; 50:7-13. [PMID: 26433428 DOI: 10.1016/j.jemermed.2015.07.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 07/12/2015] [Accepted: 07/25/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND The U.S. Food and Drug Administration recently approved a four-factor prothrombin complex concentrate (4-PCC) for warfarin reversal. The literature supporting its use over three-factor prothrombin complex concentrate (3-PCC) is limited. OBJECTIVE Our objective was to retrospectively compare the efficacy of 3-PCC to 4-PCC in reversing warfarin in patients who were actively bleeding. METHODS We conducted a single-center, retrospective cohort analysis of adult patients who received 3-PCC or 4-PCC for international normalized ratio (INR) reversal. Our study excluded patients not actively bleeding and not on warfarin. The main outcome was the percentage of patients who achieved warfarin reversal defined as INR ≤ 1.3 at first INR check post factor administration. We recorded baseline data including PCC dose, location of bleed, pre- and posttreatment INR, and time to INR reversal. RESULTS We included a total of 53 patients. Intracranial hemorrhage was the most common site of bleeding (26 [74.3%] in 3-PCC vs. 12 [66.7%] in 4-PCC). The mean dose of 3-PCC was 25.5 units/kg, compared to 27.9 units/kg of 4-PCC. The mean baseline INR was 2.3 in the 3-PCC group and 3 in the 4-PCC group (p = 0.03), and the first posttreatment INRs were 1.4 and 1.2, respectively (p < 0.01). Warfarin reversal was achieved in 15 (42.9%) patients who received 3-PCC and 15 (83.3%) patients who received 4-PCC (p < 0.01). Faster time to INR reversal was noted in the 4-PCC group vs. the 3-PCC group (3.7 vs. 5 h, p = 0.48). CONCLUSION A higher percentage of patients achieved warfarin reversal with 4-PCC compared to 3-PCC treatment. A prospective randomized control trial is necessary to confirm our results.
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Dudaryk R, Sheffy N, Hess JR. Changing Paradigms in Hemostatic Resuscitation: Timing, Extent, Economic Impact, and the Role of Factor Concentrates. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0143-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Vaglio S, Prisco D, Biancofiore G, Rafanelli D, Antonioli P, Lisanti M, Andreani L, Basso L, Velati C, Grazzini G, Liumbruno GM. Recommendations for the implementation of a Patient Blood Management programme. Application to elective major orthopaedic surgery in adults. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 14:23-65. [PMID: 26710356 PMCID: PMC4731340 DOI: 10.2450/2015.0172-15] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Stefania Vaglio
- Italian National Blood Centre, National Institute of Health, Rome, Italy
- Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gianni Biancofiore
- Liver Transplant Anaesthesia and Critical Care, University Hospital Pisana, Pisa, Italy
| | - Daniela Rafanelli
- Immunohaematology and Transfusion Unit, Pistoia 3 Local Health Authority, Pistoia, Italy
| | - Paola Antonioli
- Department of Infection Prevention Control and Risk Management, Ferrara University Hospital, Ferrara, Italy
| | - Michele Lisanti
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Lorenzo Andreani
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Leonardo Basso
- Orthopaedics and Trauma Ward, Cottolengo Hospital, Turin, Italy
| | - Claudio Velati
- Transfusion Medicine and Immunohaematology Department of Bologna Metropolitan Area, Bologna, Italy, on behalf of Italian Society of Transfusion Medicine and Immunohaematology (SIMTI); Italian Society of Italian Society of Orthopaedics and Traumatology (SIOT); Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Therapy (S.I.A.A.R.T.I.); Italian Society for the Study of Haemostasis and Thrombosis (SISET), and the National Association of Hospital Medical Directors (ANMDO) working group
| | - Giuliano Grazzini
- Italian National Blood Centre, National Institute of Health, Rome, Italy
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Khorsand N, Majeed A, Sarode R, Beyer-Westendorf J, Schulman S, Meijer K. Assessment of effectiveness of major bleeding management: proposed definitions for effective hemostasis: communication from the SSC of the ISTH. J Thromb Haemost 2016; 14:211-4. [PMID: 26391431 DOI: 10.1111/jth.13148] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 09/04/2015] [Indexed: 12/27/2022]
Affiliation(s)
- N Khorsand
- Department of Hematology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Central Hospital Pharmacy, the Hague, the Netherlands
| | - A Majeed
- Coagulation Unit, Hematology Center, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - R Sarode
- Division of Transfusion Medicine and Hemostasis, Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - J Beyer-Westendorf
- Thrombosis Research Unit, Center of Vascular Diseases, Dresden University Hospital 'Carl Gustav Carus', Dresden, Germany
| | - S Schulman
- Coagulation Unit, Hematology Center, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - K Meijer
- Department of Hematology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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O'Donnell JM, Nácul FE. Blood Products. SURGICAL INTENSIVE CARE MEDICINE 2016. [PMCID: PMC7123257 DOI: 10.1007/978-3-319-19668-8_35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Perioperative hemorrhage, anemia, thrombocytopenia, and coagulopathy are common in the surgical intensive care unit. As a result, blood product transfusion occurs frequently. While red blood cell, plasma, and platelet transfusions have a lifesaving role in the resuscitation of patients with trauma and hemorrhagic shock, their application in other settings is under scrutiny. Current data would suggest a conservative approach be taken, thus avoiding unnecessary transfusion and associated potential adverse events. New and developmental products such as prothrombin complex concentrates offer appealing alternatives to traditional transfusion practice—potentially with fewer risks—however, further investigation into their safety and efficacy is required before practice change can take place.
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Affiliation(s)
- John M. O'Donnell
- Department of Surgical Critical Care; Lahey Hospital and Medical Center, Division of Surgery, Burlington, Massachusetts USA
| | - Flávio E. Nácul
- Surgical Critical Care Medicine, Pr�-Card�o Hospital, Critical Care Medicine, University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro Brazil
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Prothrombin Complex Concentrate for Intracerebral Hemorrhage Secondary to Vitamin K Deficiency Bleeding in a 6-Week-Old Child. J Pediatr 2015; 167:1443-4. [PMID: 26454577 DOI: 10.1016/j.jpeds.2015.09.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 08/05/2015] [Accepted: 09/09/2015] [Indexed: 11/24/2022]
Abstract
Four-factor prothrombin complex concentrate is approved for use of life-threatening bleeding secondary to vitamin K antagonism in adults. We describe the use of four-factor prothrombin complex concentrate for hemostasis in a 6-week-old child with life-threatening vitamin K dependent-bleeding who never received vitamin K prophylaxis at birth.
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Ekezue BF, Sridhar G, Ovanesov MV, Forshee RA, Izurieta HS, Selvam N, Parunov LA, Jain N, Mintz PD, Epstein JS, Anderson SA, Menis MD. Clotting factor product administration and same-day occurrence of thrombotic events, as recorded in a large healthcare database during 2008-2013. J Thromb Haemost 2015; 13:2168-79. [PMID: 26414338 DOI: 10.1111/jth.13155] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 09/12/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Thrombotic events (TEs) are serious adverse events that can occur following administration of clotting factors (CFs). OBJECTIVES To evaluate occurrence of same-day TEs for different CF products and potential risk factors. METHODS A retrospective cohort study of individuals exposed to CF products during 2008-2013 was conducted using a large commercial insurance database. CF products were identified by procedure codes, and TEs were ascertained via diagnosis codes. Crude same-day TE rates (per 1000 persons exposed) were estimated overall and by congenital factor deficiency (CFD) status, CF products, age and gender. Multivariable logistic regression analyses were used to control for confounding. Laboratory analysis was used to compare the procoagulant activities of FIX products. RESULTS Of 3801 individuals exposed to CFs, 117 (30.8 per 1000) had same-day TEs recorded. The crude same-day TE rate was higher for CF users without CFD, 70.2 (102 of 1452), as compared with those with CFD, 6.4 (15 of 2349) (RR, 11.0; 95% CI, 6.4-18.9). For individuals without CFD, a significantly increased same-day TE risk was identified for factor IX complex (OR, 6.92; 95% CI, 3.11-15.40), factor VIIa (OR, 9.42; 95% CI, 4.99-17.78) and other products when compared with fibrin sealant. An increased risk of a TE was found with older age (≥ 45 years), history of TEs and underlying health conditions. The laboratory identified elevated procoagulant activity in Profilnine(®) and Benefix(®) . CONCLUSIONS The study shows an increased same-day TE risk for CF users without CFD and suggests substantial off-label CF use. The study findings also show elevated same-day TE rates for different CF products and suggest the importance of product properties and patient factors.
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Affiliation(s)
| | - G Sridhar
- HealthCore Inc, Silver Spring, MD, USA
| | - M V Ovanesov
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - R A Forshee
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - H S Izurieta
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - N Selvam
- HealthCore Inc, Silver Spring, MD, USA
| | - L A Parunov
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - N Jain
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - P D Mintz
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - J S Epstein
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - S A Anderson
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - M D Menis
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
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Sridharan M, Wysokinski WE, Pruthi R, Oyen L, Freeman WD, Rabinstein AA, McBane RD. Periprocedural warfarin reversal with prothrombin complex concentrate. Thromb Res 2015; 139:160-5. [PMID: 26657301 DOI: 10.1016/j.thromres.2015.11.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 11/13/2015] [Accepted: 11/15/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Approximately 10% of chronically anticoagulated patients require an invasive procedure annually. One in 10 procedures is emergent and requires prompt anticoagulation reversal. The study objective is to determine the safety and efficacy of a 3 factor prothrombin complex concentrate (PCC) for periprocedural anticoagulation reversal. MATERIALS AND METHODS Consecutive patients receiving 3 factor PCC for warfarin reversal for either urgent/emergent invasive procedures or major bleeding were analyzed. Primary endpoints included percent achieving INR <1.5, peri-operative major hemorrhage, thromboembolism and death during the 40day post-infusion period. RESULTS Between January 1, 2010-December 31, 2012, 52 patients were treated with PCC for pre-procedural warfarin reversal and 113 patients for major bleeding. Within the peri-procedure group, there were 24 intra-abdominal surgeries, 12 percutaneous interventions, 6 cardiothoracic surgeries, 5 orthopedic and 3 endoscopic procedures. INR values <1.5 were achieved in 51% at 2.5h post-infusion. Major bleeding (13%), thromboembolism (13%) and mortality rates (15%) were high. Within the major bleeding group, PCC therapy reversed INR values (<1.5) in 75% of patients within 4h. For this group, thromboembolism (21%) and mortality rates (16%) were likewise high. Post-PCC anticoagulation, reinitiated in 37%, had no impact on bleeding or thrombotic complications. Mortality rates were threefold higher for those patients not restarting warfarin therapy. CONCLUSIONS Although PCC therapy promptly and effectively reverses INR values for patients requiring urgent/emergent invasive procedure both thromboembolic and fatal complications are soberingly high and call for judicious use of these agents in these high risk populations.
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Affiliation(s)
- Meera Sridharan
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Waldemar E Wysokinski
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States; Division of Hematology Research, Mayo Clinic, Rochester, MN, United States
| | - Rajiv Pruthi
- Division of Hematology Research, Mayo Clinic, Rochester, MN, United States
| | - Lance Oyen
- Pharmacy Services, Mayo Clinic, Rochester, MN, United States
| | | | | | - Robert D McBane
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States; Division of Hematology Research, Mayo Clinic, Rochester, MN, United States.
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Limb-threatening Deep Venous Thrombosis Complicating Warfarin Reversal with Three-factor Prothrombin Complex Concentrate: A Case Report. J Emerg Med 2015; 50:28-31. [PMID: 26603365 DOI: 10.1016/j.jemermed.2015.02.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 01/30/2015] [Accepted: 02/17/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Three- and four-factor prothrombin complex concentrates (PCC) are gaining popularity for acute reversal of vitamin K antagonist-associated bleeding. Although acute thrombosis after PCC administration has been described, it seems to be rare. CASE REPORT An 83-year-old woman on warfarin for history of deep venous thrombosis (DVT) presented to the Emergency Department with life-threatening gastrointestinal bleeding, requiring urgent PCC administration. After stabilization, she subsequently developed a new limb-threatening upper-extremity DVT. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As PCC therapy gains popularity for reversal of anticoagulant-induced bleeding in urgent bleeding scenarios, the emergency physician must be aware of the complications of PCC administration, including new limb-threatening DVT.
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Johansen M, Wikkelsø A, Lunde J, Wetterslev J, Afshari A. Prothrombin complex concentrate for reversal of vitamin K antagonist treatment in bleeding and non-bleeding patients. Cochrane Database Syst Rev 2015; 2015:CD010555. [PMID: 26151108 PMCID: PMC6516823 DOI: 10.1002/14651858.cd010555.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Treatment with vitamin K antagonists is associated with increased morbidity and mortality. Reversal therapy with prothrombin complex concentrate (PCC) is used increasingly and is recommended in the treatment of patients with bleeding complications undertaking surgical interventions, as well as patients at high risk of bleeding. Evidence is lacking regarding indication, dosing, efficacy and safety. OBJECTIVES We assessed the benefits and harms of PCC compared with fresh frozen plasma in the acute medical and surgical setting involving vitamin K antagonist-treated bleeding and non-bleeding patients. We investigated various outcomes and predefined subgroups and performed sensitivity analysis. We examined risks of bias and applied trial sequential analyses (TSA) to examine the level of evidence, and we prepared a 'Risk of bias' table to test the quality of the evidence. SEARCH METHODS We searched the following databases from inception to 1 May 2013: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (Ovid SP); EMBASE (Ovid SP); International Web of Science; Latin American and Caribbean Health Sciences Literature (LILACS) (via BIREME); the Chinese Biomedical Literature Database; advanced Google and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We applied a systematic and sensitive search strategy to identify relevant randomized clinical trials and imposed no language or date restrictions. We adapted our MEDLINE search strategy for searches in all other databases. We reran the search in October 2014 and found one potential new study of interest. We added this study to a list of 'Studies awaiting classification', and we will incorporate this study into the formal review findings at the time of the review update. SELECTION CRITERIA We included randomized controlled trials (RCTs), irrespective of publication status, date of publication, blinding status, outcomes published or language. We contacted investigators and study authors to request relevant data. DATA COLLECTION AND ANALYSIS Three review authors independently abstracted data and resolved disagreements by discussion. Our primary outcome measures were 'overall mortality longest follow-up' and 'overall 28-day mortality'. We performed subgroup analyses to assess the effects of PCC in adults in terms of various clinical and physiological outcomes. We presented pooled estimates of the effects of interventions on dichotomous outcomes as risk ratios (RRs), and on continuous outcomes as mean differences (MDs), with 95% confidence intervals (CIs). We assessed risk of bias by assessing trial methodological components and risk of random error through TSA. MAIN RESULTS We included four RCTs with a total of 453 participants and determined that none of these trials had overall low risk of bias. We found six ongoing trials from which we were unable to retrieve further data. Three trials provided data on mortality. Meta-analysis showed no statistical effect on overall mortality (RR 0.93, 95% CI 0.37 to 2.33; very low quality of evidence). We were unable to associate use of PCC with the number of complications probably related to the intervention (RR 0.92, 95% CI 0.78 to 1.09; very low quality of evidence). Lack of transfusion data and apparent differences in study design prevented review authors from finding a beneficial effect of PCC in reducing the volume of fresh frozen plasma (FFP) transfused to reverse the effect of vitamin K antagonist treatment. The number of new occurrences of transfusion of red blood cells (RBCs) did not seem to be associated with the use of PCC (RR 1.08, 95% CI 0.82 to 1.43; very low quality of evidence). Still, the included studies demonstrate the possibility of equally reversing vitamin K-induced coagulopathy using PCC without the need for transfusion of FFP. No effect on other predefined outcomes was observed. AUTHORS' CONCLUSIONS In the four included RCTs, use of prothrombin complex concentrate does not appear to reduce mortality or transfusion requirements but demonstrates the possibility of reversing vitamin K-induced coagulopathy without the need for transfusion of fresh frozen plasma. All included trials have high risk of bias and are underpowered to detect mortality, benefit or harm. Clinical and statistical heterogeneity is high, and definitions of clinically important outcomes such as adverse events are highly dissimilar between trials. Only weak observational evidence currently supports the use of PCC in vitamin K antagonist-treated bleeding and non-bleeding patients, and the current systematic review of RCTs does not support the routine use of PCC over FFP. Additional high-quality research is urgently needed.
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Affiliation(s)
- Mathias Johansen
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre ‐ Anaesthesia and Surgical Clinic Department 4013CopenhagenDenmark
| | - Anne Wikkelsø
- Hvidovre Hospital, University of CopenhagenDepartment of Anaesthesiology and Intensive Care MedicineKettegård Alle 30,HvidovreDenmark2650
| | - Jens Lunde
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre ‐ Anaesthesia and Surgical Clinic Department 4013CopenhagenDenmark
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Arash Afshari
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre ‐ Anaesthesia and Surgical Clinic Department 4013CopenhagenDenmark
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Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald RL, Mitchell PH, Scott PA, Selim MH, Woo D. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46:2032-60. [PMID: 26022637 DOI: 10.1161/str.0000000000000069] [Citation(s) in RCA: 2007] [Impact Index Per Article: 223.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage. METHODS A formal literature search of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and Stroke Council Leadership Committee. RESULTS Evidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated. CONCLUSIONS Intracerebral hemorrhage remains a serious condition for which early aggressive care is warranted. These guidelines provide a framework for goal-directed treatment of the patient with intracerebral hemorrhage.
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Münzberg M, Mutschler M, Paffrath T, Trentzsch H, Wafaisade A, Walcher F, Raum M, Flohé S, Wölfl C. Level of Evidence Analysis for the Latest German National Guideline on Treatment of Patients with Severe and Multiple Injuries and ATLS. World J Surg 2015; 39:2061-7. [DOI: 10.1007/s00268-015-3063-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Zeller MP, Al-Habsi KS, Golder M, Walsh GM, Sheffield WP. Plasma and Plasma Protein Product Transfusion: A Canadian Blood Services Centre for Innovation Symposium. Transfus Med Rev 2015; 29:181-94. [PMID: 25862281 DOI: 10.1016/j.tmrv.2015.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Revised: 03/12/2015] [Accepted: 03/13/2015] [Indexed: 12/27/2022]
Abstract
Plasma obtained via whole blood donation processing or via apheresis technology can either be transfused directly to patients or pooled and fractionated into plasma protein products that are concentrates of 1 or more purified plasma protein. The evidence base supporting clinical efficacy in most of the indications for which plasma is transfused is weak, whereas high-quality evidence supports the efficacy of plasma protein products in at least some of the clinical settings in which they are used. Transfusable plasma utilization remains composed in part of applications that fall outside of clinical practice guidelines. Plasma contains all of the soluble coagulation factors and is frequently transfused in efforts to restore or reinforce patient hemostasis. The biochemical complexities of coagulation have in recent years been rationalized in newer cell-based models that supplement the cascade hypothesis. Efforts to normalize widely used clinical hemostasis screening test values by plasma transfusion are thought to be misplaced, but superior rapid tests have been slow to emerge. The advent of non-vitamin K-dependent oral anticoagulants has brought new challenges to clinical laboratories in plasma testing and to clinicians needing to reverse non-vitamin K-dependent oral anticoagulants urgently. Current plasma-related controversies include prophylactic plasma transfusion before invasive procedures, plasma vs prothrombin complex concentrates for urgent warfarin reversal, and the utility of increased ratios of plasma to red blood cell units transfused in massive transfusion protocols. The first recombinant plasma protein products to reach the clinic were recombinant hemophilia treatment products, and these donor-free equivalents to factors VIII and IX are now being supplemented with novel products whose circulatory half-lives have been increased by chemical modification or genetic fusion. Achieving optimal plasma utilization is an ongoing challenge in the interconnected worlds of transfusable plasma, plasma protein products, and recombinant and engineered replacements.
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Affiliation(s)
- Michelle P Zeller
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - Khalid S Al-Habsi
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - Mia Golder
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada
| | - Geraldine M Walsh
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada
| | - William P Sheffield
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada.
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Siegal DM, Savage WJ. Plasma versus prothrombin complex concentrate for warfarin-associated major bleeding: a systematic review. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:448-453. [PMID: 26637757 DOI: 10.1182/asheducation-2015.1.448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Deborah M Siegal
- McMaster University and St. Joseph's Healthcare, Hamilton, ON; and Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - William J Savage
- McMaster University and St. Joseph's Healthcare, Hamilton, ON; and Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Khorsand N, Kooistra HA, van Hest RM, Veeger NJ, Meijer K. A systematic review of prothrombin complex concentrate dosing strategies to reverse vitamin K antagonist therapy. Thromb Res 2015; 135:9-19. [DOI: 10.1016/j.thromres.2014.11.019] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 11/12/2014] [Accepted: 11/16/2014] [Indexed: 11/16/2022]
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Kinard TN, Sarode R. Four factor prothrombin complex concentrate (human): review of the pharmacology and clinical application for vitamin K antagonist reversal. Expert Rev Cardiovasc Ther 2014; 12:417-27. [PMID: 24650310 DOI: 10.1586/14779072.2014.896195] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Vitamin K antagonists (VKAs) have been used for decades for the treatment and prophylaxis of thromboembolic events. Due to their wide range of therapeutic indications, they are the most prescribed oral anticoagulant worldwide. However, they are associated with bleeding complications due to their narrow therapeutic range, variability in individual dose responses and laboratory monitoring, and overdoses. Despite off-label use of 3-factor prothrombin complex concentrates and recombinant activated factor VII, until recently, vitamin K and plasma were the only recommended therapeutic options for reversing VKAs in the USA. In 2013, a 4-factor prothrombin complex concentrate (4F-PCC) was approved in the USA for VKA reversal in patients with bleeding or requiring emergency surgery and invasive procedure. Recent randomized controlled clinical trials have shown that 4F-PCC (Kcentra™) is non-inferior for hemostatic efficacy and superior for international normalized ratio correction as compared to plasma and has a similar safety profile.
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Affiliation(s)
- Theresa N Kinard
- Department of Pathology, Division of Transfusion Medicine and Hemostasis, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
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Matsushima K, Benjamin E, Demetriades D. Prothrombin complex concentrate in trauma patients. Am J Surg 2014; 209:413-7. [PMID: 25457236 DOI: 10.1016/j.amjsurg.2014.08.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 07/30/2014] [Accepted: 08/04/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite recent advances, trauma care providers nowadays face a number of coagulopathic patients. Coagulopathy in trauma patients can be secondary to the traumatic insult or therapeutic effect of the anticoagulants including the Vitamin K antagonist. The efficacy of a concentrated product of Vitamin K-dependent coagulation factors, prothrombin complex concentrate (PCC), to reverse coagulopathy has been tested mainly in nontrauma setting. DATA SOURCES Currently available literature on the use of PCC was identified by searches of electronic database. The indications (trauma vs nontrauma) and types of the PCC products (3 vs 4 factors) were also reviewed in each article. CONCLUSIONS There are small studies that show promising results regarding PCC use to reverse the Vitamin K antagonist-related coagulopathy in trauma patients. It remains unanswered whether PCC can be effective as an adjunct in patients who require massive transfusion.
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Affiliation(s)
- Kazuhide Matsushima
- Division of Acute Care Surgery, University of Southern California, 1200 North State Street, Inpatient Tower (C), Room C5L100, Los Angeles, CA 90033, USA.
| | - Elizabeth Benjamin
- Division of Acute Care Surgery, University of Southern California, 1200 North State Street, Inpatient Tower (C), Room C5L100, Los Angeles, CA 90033, USA
| | - Demetrios Demetriades
- Division of Acute Care Surgery, University of Southern California, 1200 North State Street, Inpatient Tower (C), Room C5L100, Los Angeles, CA 90033, USA
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Pluym M, Howell G. Management of hemorrhage with the target-specific oral anticoagulants. Hosp Pract (1995) 2014; 42:75-83. [PMID: 25255409 DOI: 10.3810/hp.2014.08.1120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The target-specific oral anticoagulants have recently been introduced as alternatives to warfarin for both prophylactic and therapeutic indications. Although their efficacy and side-effect profiles have been favorable, there is significant concern about management of hemorrhage with these agents as there is no direct reversal agent available. It is important for clinicians to be aware of these agents and the issues that surround them. Most of the management of hemorrhage is based on expert opinion and case reviews. Given the potentially catastrophic consequences of acute hemorrhage while patients are on anticoagulation, specific treatments are needed. Some methods that have been described include activated charcoal, hemodialysis, prohemostatic agents, and transfusions. Target-specific therapies have been shown to be effective in early studies in animal models; however, the effects in humans are still under investigation. More investigation is needed on the management of bleeding complications from target-specific oral anticoagulants.
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Affiliation(s)
- Mark Pluym
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO.
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Tilton R, Michalets EL, Delk B, Sutherland SE, Ramming SA. Outcomes Associated With Prothrombin Complex Concentrate for International Normalized Ratio Reversal in Patients on Oral Anticoagulants With Acute Bleeding. Ann Pharmacother 2014; 48:1106-1119. [PMID: 24899340 DOI: 10.1177/1060028014537897] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Management of bleeding in patients on oral anticoagulants (OACs) is crucial in optimizing outcomes. No large studies examine 3-factor prothrombin complex concentrate (PCC) for OAC reversal. OBJECTIVE To assess outcomes after administration of 3-factor PCC for reversal of international normalized ratio (INR). METHOD We conducted an institutional review board-approved retrospective cohort study in all patients admitted to our level II trauma center over a 5-year period from 2007 to 2012 who received PCC for INR reversal and bleeding management. The primary outcome was assessment of efficacy as measured by achievement of INR < 1.5. Secondary objectives were to evaluate: factors associated with achievement of target INR, cessation of bleeding, mortality, outcome differences with or without fresh frozen plasma (FFP) or protocol utilization, safety, and cost. RESULT A total of 403 patients were evaluated. Target INR was achieved in 88.8% of patients and was influenced by baseline INR. Associated factors were younger age (P = 0.02), utilization of the institution's protocol (P < 0.01), and concomitant administration of vitamin K (P < 0.01). Concomitant FFP did not affect achievement. Bleeding cessation occurred in 333 (82.6%) patients, and 68 (16.9%) patients died. Patients who achieved target INR were more likely to have bleeding cessation (P < 0.01). The odds of survival for those who reached target INR was 3.8 times greater (P < 0.01). The incidence of thromboembolism was 3.7%. CONCLUSION Three-factor PCC administration with IV vitamin K was effective for INR reversal and bleeding cessation and should continue to be a mainstay of therapy pending head-to-head outcome and cost comparisons with 4-factor products.
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Affiliation(s)
- Ryan Tilton
- Mission Health System Department of Pharmacy, Asheville, NC, USA
| | - Elizabeth Landrum Michalets
- Mission Health System Department of Pharmacy, Asheville, NC, USA University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Bethany Delk
- University of Virginia Health System Department of Pharmacy, Charlottesville, VA, USA
| | | | - Scott A Ramming
- Mission Health System and Carolina Mountain Emergency Medicine, Asheville, NC, USA
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Reversal of Coagulopathy Using Prothrombin Complex Concentrates is Associated with Improved Outcome Compared to Fresh Frozen Plasma in Warfarin-Associated Intracranial Hemorrhage. Neurocrit Care 2014; 21:397-406. [DOI: 10.1007/s12028-014-9972-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Aufhebung einer therapeutischen Antikoagulation im Notfall. Notf Rett Med 2014. [DOI: 10.1007/s10049-013-1830-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Shander A, Michelson EA, Sarani B, Flaherty ML, Shulman IA. Use of plasma in the management of central nervous system bleeding: evidence-based consensus recommendations. Adv Ther 2014; 31:66-90. [PMID: 24338742 DOI: 10.1007/s12325-013-0083-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Central nervous system (CNS) hemorrhage is a potentially life-threatening condition, especially in patients with acquired coagulopathy. In this setting, treatment of CNS bleeding includes hemostatic therapy to replenish coagulation factors. There is currently a debate over the hemostatic efficacy of plasma in many clinical settings, alongside increasing concern about transfusion-associated adverse events. Despite these concerns, plasma is widely used. Moreover, plasma transfusion practice is variable and there is currently no uniform approach to treatment of traumatic, surgical or spontaneous CNS hemorrhage. This study addresses the need for guidance on the indications and potential risks of plasma transfusion in these settings. An Expert Consensus Panel was convened to develop recommendations guiding the use of plasma to treat bleeding and/or coagulopathy associated with CNS hemorrhage. The panel did not advise on the best treatment available but rather proposed recommendations to be used in the formulation of local procedures to support emergency physicians in their decision-making process. METHODS Evidence was systematically gathered from the literature and rated using methods established by the Scottish Intercollegiate Guidelines Network. The evidence was used to develop graded consensus recommendations, which are presented along with the evidence-based rationale for each in this report. RESULTS Sixty-five articles were identified covering both vitamin K antagonist-anticoagulation reversal and treatment of bleeding/coagulopathy in non-anticoagulated patients. Recommendations were then developed in four clinical scenarios within each area, and agreed on unanimously by all members of the panel. CONCLUSION The Panel considered plasma to be reasonable therapy for CNS hemorrhage requiring urgent correction of coagulopathy, although physicians should be prepared for potential cardiopulmonary complications, and evidence suggests that alternative therapies have superior risk-benefit profiles. Plasma could not be recommended in the absence of hemorrhage or coagulopathy. Consideration of the absolute risks and benefits of plasma therapy before transfusion is imperative.
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Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology and Critical Care Medicine, Englewood Hospital and Medical Center, Englewood, NJ, USA
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Hanger HC, Geddes JAA, Wilkinson TJ, Lee M, Baker AE. Warfarin-related intracerebral haemorrhage: better outcomes when reversal includes prothrombin complex concentrates. Intern Med J 2013; 43:308-16. [PMID: 23176226 DOI: 10.1111/imj.12034] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 11/19/2012] [Indexed: 01/15/2023]
Abstract
BACKGROUND Warfarin-related intracerebral haemorrhage (WRICH) has high mortality. Haematoma expansion is prolonged in WRICH and independently predicts worse outcomes. Guidelines recommend prompt reversal of the warfarin coagulopathy, but evidence of benefit is lacking. AIMS To determine whether the introduction of a WRICH reversal protocol (late 2008), which includes prothrombin complex concentrates (PCC), improves outcomes METHODS All patients presenting with WRICH between January 2004 and July 2010 were included. Retrospective case note and radiology review was performed, collecting data on intracerebral haemorrhage (ICH) severity, degree and timeliness of reversal, and patient outcomes. Cox's proportional hazards analysis was used to compare outcomes associated with and without PCC after controlling for ICH severity. RESULTS Eighty-eight patients were included (27 treated palliatively). Mean international normalised ratio was 2.9. Vitamin K, PCC and fresh frozen plasma were given alone or in combination to 68, 23 and 44 patients, and mean time from computed tomography scanning to administration was 2.2, 3.3 and 3.1 h respectively. Four patients received PCC pre-protocol (none before 2007), two during development and seventeen patients post-protocol. Those who received PCC had improved survival (P < 0.001). After controlling for ICH score, hazard ratio for death was 0.27 (P < 0.01) for use of PCC. Survival tended to be greater with earlier administration of PCC (P = 0.053). Despite improved survival, discharge domicile and function were not significantly worse. CONCLUSIONS PCC reversal was associated with improved survival without worsened disability. Delays in administration may have reduced the potential benefits.
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Affiliation(s)
- H C Hanger
- Older Persons Health Specialist Service, Canterbury District Health Board, Christchurch, New Zealand.
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Dickneite G, Hoffman M. Reversing the new oral anticoagulants with prothrombin complex concentrates (PCCs): what is the evidence? Thromb Haemost 2013; 111:189-98. [PMID: 24136202 DOI: 10.1160/th13-05-0431] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 09/19/2013] [Indexed: 11/05/2022]
Abstract
Newer oral anticoagulants offer several advantages over traditional agents (e.g. warfarin), but they are still associated with a bleeding risk and currently there is no validated reversal treatment for them. While there is little support for the use of fresh frozen plasma, and limited data available on the effects of activated recombinant factor VII, preclinical data suggest that prothrombin complex concentrates (PCCs) may have potential in this setting. PCCs are currently used to successfully reverse warfarin-induced anticoagulation; however, clinical evidence for their use with new oral anticoagulants is lacking, with most of the available data coming from preclinical animal studies. Furthermore, there appears to be variation in the ability of different PCCs to reverse the coagulopathy induced by the new anticoagulants, and a lack of correlation between the reversal of laboratory test results and the reversal of anticoagulant-induced bleeding. Although there have been encouraging results, care must be taken in generalising findings from animal models and nonbleeding human subjects to the situation in bleeding patients. Ultimately, more evidence supporting anticoagulation reversal for new anticoagulants is needed, particularly regarding the treatment of bleeding in human patients in a clinical setting. According to the current evidence, use of PCCs may be considered a reasonable approach in dire clinical situations; however, a consensus has not yet been reached regarding PCC use or dosing, due to lack of clinical data.
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Affiliation(s)
- Gerhard Dickneite
- Prof. Dr. Gerhard Dickneite, Preclinical R&D, CSL Behring, PO Box 1230, 35002 Marburg, Germany, Tel.: +49 6421 39 2306, Fax: +49 6421 39 4663, E-mail:
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