On Wed, 8 Jun 2005 22:06:42 +0100, McCormick Simon Dr, Consultant, A&E
<[log in to unmask]> wrote:

>We had a similar, but different case, with a ruptured AAA who was on
warfarin.  He was to be transferred down the road for surgery but
critically the receiving unit WERE prepared to take him together with the
advice to fill him with BERIPLEX prior to surgery.  This was the quickest
way to ensure he got his treatment (surgery) and they were in agreement.
Only used BERIPLEX once before, in a SAH on warfarin.  Had to get the
haematologist to agree to it because of the expense but ultimately its the
drug of choice for rapid reversal.  Not difficult to give as I remember
but it was a few years ago.
>
>Simon
>-----Original Message-----
>From: Ray [mailto:[log in to unmask]]
>Sent: 08 June 2005 18:10
>To: [log in to unmask]
>Subject: Re: Subdural in the head injury patient on warfarin
>
>
>Well the neurosurgical centre stands it's ground despite Medical
Directors getting involved.
>
>I'd be interested in the policy of other neurosurgical centres?
>
>But my original question was...."Does anyone have experience of using
Prothrombin complex?"
>
>Thanks
>
>Ray
>----- Original Message -----
>From: Black,  <mailto:[log in to unmask]> John
>To: [log in to unmask]
>Sent: Wednesday, June 08, 2005 1:14 PM
>Subject: Re: Subdural in the head injury patient on warfarin
>
>Ray - I would be very surprised that this position highlighted below is
justifiable on clinical grounds, let alone on medico legally.
>
>To delay transfer until clotting has been normalised, and demonstrated to
be such - will needlessly delay to time critical (surgical) intervention
and therefore potentially outcome. Neurosurgical Units, after all, have
access to the same resources to correct clotting abnormalities as the ED.
>
>John Black
>
>-----Original Message-----
>From: Accident and Emergency Academic List [mailto:ACAD-AE-
[log in to unmask]] On Behalf Of Ray
>Sent: 03 June 2005 19:54
>To: [log in to unmask]
>Subject: Subdural in the head injury patient on warfarin
>
>I think this has been a thread before. The scenario is a recurring theme
for me and perhaps for you. We have over 2,000 patients on Warfarin in our
Trust.
>
>Our local neurosurgical centre won't accept the patient until the INR is
normal..... and the whole process of getting fresh frozen plasma into the
patient (often 8 units / 2 litres) and a repeat INR does slow down
the "patient journey".
>
>Does anyone have experience of using Prothrombin complex? I include a cut
and paste from "Up to Date" below
>
>Ray McGlone
>
>Lancaster A&E
>
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>
>Prothrombin-complex concentrates - Prothrombin-complex concentrates
(PCC), which consist of the vitamin K-dependent coagulation factors (ie,
factors II, VII, IX, and X), normalize the INR more rapidly than infusion
of FFP or vitamin K alone [9,20-22] and are easily administered.
Thrombotic events have complicated infusion of PCC, but this risk is
difficult to quantify due to varying preparations, doses, and differing
patient populations in available reports [21,23,24].
>Use of PCC alone may result in a secondary rise in the INR as the
coagulation factors are metabolized if vitamin K is not also given at the
time of presentation [9]. (See "Heparin prophylaxis" below and see "Plasma
derivatives and recombinant DNA-produced coagulation factors", section on
Prothrombin complex concentrates).
>The cost for a course of treatment with PCC in a patient with ICH and an
INR of 3.0 is estimated to be $1000 to $2000.
>There are limited data on the efficacy of PCC in patients with warfarin-
associated ICH. Successful treatment of nine such patients using
relatively low doses of PCC has been reported [9]. Patients were given 500
or 1000 IU depending upon prolongation of the INR to <4.5 or >4.5,
respectively, with additional administration of 500 IU based upon a repeat
INR obtained after the initial infusion. The INR was corrected within 10
minutes of completion of the infusion at a median dosage of 12.5 IU/kg.
Hematoma enlargement occurred in only two of the nine patients; there were
no thromboembolic episodes in this group, which included four patients
with prosthetic heart valves.
>In this and two other series of patients treated with PCC, there was only
one of 10 patients who suffered subsequent ICH enlargement when the INR
was corrected to normal [9,11,35]. Worsening occurred 12 to 72 hours later
in association with incomplete correction of the INR in four patients with
an incompletely corrected INR (eg, INRs of 1.5, 1.9, 2.7, and 3.2),
combined with the use of heparin in three. Based upon this anecdotal
evidence, it seems prudent to monitor the patient carefully in order to
keep the INR in the normal range (ie, INR <1.2) for the initial 72 hours
after ICH.
>Available data suggest that the use of PCC in warfarin-associated ICH is
relatively safe (show table 2). However, in one study, large ischemic
strokes occurred on days two, four, and five in 3 of 7 patients treated
with PCC (including two of seven with prosthetic heart valves) despite
concomitant treatment with low-dose heparin that did not prolong the
activated partial thromboplastin time [35]. The dosages and content of the
PCC preparation were not reported.
>

The haematlogists here will recommend Beriplex in preference to FFP for
correction of INR in the emergency setting. I've used it a few times with
the only problem being my anxiety that we might spill it!