Neurocritical Care

, Volume 27, Issue 3, pp 334–340 | Cite as

Low-dose Prothrombin Complex Concentrate for Warfarin-Associated Intracranial Hemorrhage with INR Less Than 2.0

  • Wesley R. Zemrak
  • Kathryn E. Smith
  • Stephen S. Rolfe
  • Teresa May
  • Robert L. Trowbridge
  • Timothy L. Hayes
  • Gene A. Grindlinger
  • David B. Seder
Original Article
First Online:

Abstract

Background

Prothrombin complex concentrates (PCCs) have become the first-line therapy for warfarin reversal in the setting of central nervous system (CNS) hemorrhage. Randomized, controlled studies comparing agents for warfarin reversal excluded patients with international normalized ratio (INR) <2, yet INR values of 1.6–1.9 are also associated with poor outcomes.

Methods

We retrospectively reviewed our use of a low-dose (15 units/kg) strategy of 4-factor PCC (4F-PCC) on warfarin reversal (INR 1.6–1.9) in the setting of both traumatic and spontaneous intracranial bleeding.

Results

A total of 21/134 (15.7%) patients with either spontaneous or traumatic intracranial hemorrhage presented with an INR value of 1.6–1.9. Nine patients (43%) presented with traumatic bleeding and 12 (57%) with spontaneous bleeding. The median (IQR) presenting INR was 1.8 (1.7, 1.9) which decreased to 1.3 (1.2, 1.3) following the administration of low-dose 4F-PCC (median dose = 1062 units; 15.2 units/kg). A total of 19/20 (95%) patients achieved a goal INR value of ≤1.5 on the first check following dosing and 17/20 (85%) achieved an INR value ≤1.3. One patient did not have follow-up INR testing due to withdrawal of life support. No patient experienced hematoma expansion within 48 h of 4F-PCC, and there were no thromboembolic events within 72 h of administration.

Conclusions

The administration of low dose (15 units/kg) of 4F-PCC for urgent warfarin reversal in the setting of CNS hemorrhage was effective in correcting the INR in patients presenting with INR values of 1.6–1.9. Further assessment of low-dose PCC for urgent reversal of modest INR elevation is warranted.

Keywords

Warfarin Prothrombin complex concentrate Intracranial hemorrhage Reversal 
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Notes

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

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Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Wesley R. Zemrak
    • 1
  • Kathryn E. Smith
    • 1
  • Stephen S. Rolfe
    • 1
  • Teresa May
    • 2
  • Robert L. Trowbridge
    • 3
  • Timothy L. Hayes
    • 4
  • Gene A. Grindlinger
    • 5
  • David B. Seder
    • 2
  1. 1.Department of PharmacyMaine Medical CenterPortlandUSA
  2. 2.Division of Neurocritical CareMaine Medical CenterPortlandUSA
  3. 3.Department of MedicineMaine Medical CenterPortlandUSA
  4. 4.Department of PathologyMaine Medical CenterPortlandUSA
  5. 5.Division of Surgical Critical CareMaine Medical CenterPortlandUSA

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