I can only remember using it once, which
if I remember involved a long discussion with the haematologist. It may seem
like an expensive treatment but if you can improve prognosis by limiting the
extent of bleeding, decreasing hospital stay then it may be cost effective. Are
their any good RCT’s of its use?
Andy Webster
Registrar in Emergency Medicine
From:
Sent: 04 June 2005 02:54
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
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.
________________________________________________________________________Doctors.net.uk e-mail is protected from spam and viruses Doctors.net.uk - the network of 114,000 UK ________________________________________________________________________