Abstract
Introduction
Data regarding use of prothrombin complex concentrate (PCC) for international normalization ratio (INR) reversal in warfarin-associated intracranial hemorrhage (wICH) is variable with regards to dosages, adjunctive agents, and product choice. In 2012, we implemented a fixed, weight-based [30 IU/kg] dosing protocol of 3-factor PCC (3PCC) utilizing a rapid infusion rate and no requirement for fresh frozen plasma (FFP) following factor product administration. We aimed to evaluate the impact of this protocol on immediate and delayed INR reversal in patients admitted with wICH in the absence of FFP co-administration.
Methods
We conducted a retrospective review of patients receiving 3PCC following wICH between January 1, 2012 and December 10, 2013. The primary objective was to determine the percentage of patients achieving goal INR (≤1.4) following 3PCC administration. Patients were excluded if their bleed was not intracranial in origin, received a dose outside of the specified protocol, or were given FFP as an adjunctive agent.
Results
We included 35 patients with a mean presenting INR of 3.2 ± 1.3. Thirty patients (85.7 %) achieved goal INR (≤1.4) following one dose of 3PCC. The mean INR after infusion of 3PCC was 1.3 ± 0.2. The median duration between 3PCC infusion and subsequent INR was 48.0 min (30–70.1 min). Vitamin K was utilized in 33 (94.3 %) patients. No patient experienced a thromboembolic event within 7 days of 3PCC administration.
Conclusions
Fixed, weight-based dosing of 3PCC without adjunctive FFP resulted in high rates of complete INR reversal without significant adverse events.
Similar content being viewed by others
References
Holbrook A, Schulman S, Witt DM, et al. Evidence-based management of anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical practice guidelines. Chest. 2012;141:e152S–84S.
Anderson CS, Huang Y, Arima H, et al. Effects of early intensive blood pressure-lowering treatment on the growth of hematoma and perihematomal edema in acute intracerebral hemorrhage: the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT). Stroke. 2010;41:307–12.
European Stroke Initiative Writing C, Writing Committee for the EEC, Steiner T, et al. Recommendations for the management of intracranial haemorrhage—part I: spontaneous intracerebral haemorrhage. The European Stroke Initiative Writing Committee and the Writing Committee for the EUSI Executive Committee. Cerebrovasc Dis. 2006;22:294–316.
Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G. Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke. 1993;24:987–93.
Qureshi AI, Palesch YY. Antihypertensive treatment of acute cerebral hemorrhage (ATACH) II: design, methods, and rationale. Neurocrit Care. 2011;15:559–76.
Brouwers HB, Greenberg SM. Hematoma expansion following acute intracerebral hemorrhage. Cerebrovas Dis. 2013;35:195–201.
Aguilar MI, Hart RG, Kase CS, et al. Treatment of warfarin-associated intracerebral hemorrhage: literature review and expert opinion. Mayo Clin Proc. 2007;82:82–92.
Yasaka M, Sakata T, Minematsu K, Naritomi H. Correction of INR by prothrombin complex concentrate and vitamin K in patients with warfarin related hemorrhagic complication. Thromb Res. 2002;108:25–30.
Tran HA, Chunilal SD, Harper PL, et al. An update of consensus guidelines for warfarin reversal. Med J Aust. 2013;198:198–9.
Samama CM. Prothrombin complex concentrates: a brief review. Eur J Anaesthesiol. 2008;25:784–9.
Pandey S, Vyas GN. Adverse effects of plasma transfusion. Transfusion. 2012;52(Suppl 1):65S–79S.
Rincon F, Mayer SA. Clinical review: critical care management of spontaneous intracerebral hemorrhage. Crit Care. 2008;12:237.
Treggiari MM. Participants in the international multi-disciplinary consensus conference on the critical care management of subarachnoid H. Hemodynamic management of subarachnoid hemorrhage. Neurocrit care. 2011;15:329–35.
Keeling D, Baglin T, Tait C, et al. Guidelines on oral anticoagulation with warfarin—fourth edition. Br J Haematol. 2011;154:311–24.
Shinohara Y, Yanagihara T, Abe K, et al. III. Intracerebral hemorrhage. J Stroke Cerebrovasc Dis. 2011;20:74–99.
Tran H, Collecutt M, Whitehead S, Salem HH. Prothrombin complex concentrates used alone in urgent reversal of warfarin anticoagulation. Intern Med J. 2011;41:337–43.
Imberti D, Barillari G, Biasioli C, et al. Emergency reversal of anticoagulation with a three-factor prothrombin complex concentrate in patients with intracranial haemorrhage. Blood Transfus. 2011;9:148–55.
van Aart L, Eijkhout HW, Kamphuis JS, et al. Individualized dosing regimen for prothrombin complex concentrate more effective than standard treatment in the reversal of oral anticoagulant therapy: an open, prospective randomized controlled trial. Thromb Res. 2006;118:313–20.
Khorsand N, Veeger NJ, Muller M, et al. Fixed versus variable dose of prothrombin complex concentrate for counteracting vitamin K antagonist therapy. Transfus Med. 2011;21:116–23.
Holland L, Warkentin TE, Refaai M, Crowther MA, Johnston MA, Sarode R. Suboptimal effect of a three-factor prothrombin complex concentrate (Profilnine-SD) in correcting supratherapeutic international normalized ratio due to warfarin overdose. Transfusion. 2009;49:1171–7.
Switzer JA, Rocker J, Mohorn P, et al. Clinical experience with three-factor prothrombin complex concentrate to reverse warfarin anticoagulation in intracranial hemorrhage. Stroke. 2012;43:2500–2.
Cabral KP, Fraser GL, Duprey J, et al. Prothrombin complex concentrates to reverse warfarin-induced coagulopathy in patients with intracranial bleeding. Clin Neurol Neurosurg. 2013;115:770–4.
Chapman SA, Irwin ED, Beal AL, Kulinski NM, Hutson KE, Thorson MA. Prothrombin complex concentrate versus standard therapies for INR reversal in trauma patients receiving warfarin. Ann Pharmacother. 2011;45:869–75.
Chong CT, Lew TW, Kuperan P, Tan JJ, Tan HL, Kwek TK. Rapid reversal of coagulopathy in warfarin-related intracranial haemorrhages with prothrombin complex concentrates. Anaesth Intensiv Care. 2010;38:474–80.
Woo CH, Patel N, Conell C, et al. Rapid warfarin reversal in the setting of intracranial hemorrhage: a comparison of plasma, recombinant activated factor VII, and prothrombin complex concentrate. World Neurosurg. 2014;81:110–5.
Panduranga P, Al-Mukhaini M, Al-Muslahi M, Haque MA, Shehab A. Management dilemmas in patients with mechanical heart valves and warfarin-induced major bleeding. World J Cardiol. 2012;4:54–9.
Makris M, Van Veen JJ. Three or four factor prothrombin complex concentrate for emergency anticoagulation reversal? Blood Transfus. 2011;9:117–9.
Sarode R, Milling TJ Jr, Refaai MA, et al. Efficacy and safety of a 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study. Circulation. 2013;128:1234–43.
Conflict of interest
Kerry M. Mohrien, Andrew B. Boucher, Lucas Elijovich, and G. Morgan Jones have no conflicts of interest to disclose.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Mohrien, K.M., Morgan Jones, G., Boucher, A.B. et al. Evaluation of a Fixed, Weight-Based Dose of 3-Factor Prothrombin Complex Concentrate Without Adjunctive Plasma Following Warfarin-Associated Intracranial Hemorrhage. Neurocrit Care 21, 67–72 (2014). https://doi.org/10.1007/s12028-014-9984-9
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12028-014-9984-9