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Condeni MS, Weant KA, Neyens RR, Eriksson EA, Miano TA. Safety and efficacy of fixed versus variable-dose prothrombin complex concentrate for emergent reversal of vitamin K antagonists: A systematic review and meta-analysis. Am J Emerg Med 2024; 77:91-105. [PMID: 38118388 DOI: 10.1016/j.ajem.2023.11.066] [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: 05/18/2023] [Revised: 11/02/2023] [Accepted: 11/29/2023] [Indexed: 12/22/2023] Open
Abstract
STUDY OBJECTIVE Four-factor prothrombin complex concentrate (4F-PCC) is standard of care for emergent vitamin K antagonist (VKA) reversal but optimal dosing is uncertain. This meta-analysis estimated the proportion of patients treated with fixed dose (FD) 4F-PCC who achieved adequate reversal and compared safety and efficacy of FD versus weight-based dose (WB) strategies. METHODS This review was conducted according to PRISMA guidelines. Medline and Scopus were searched and included studies evaluating FD regimens and comparing FD and WB for emergent VKA reversal. Data was pooled using random effects. Subgroup analyses examined heterogeneity. Risk of bias was assessed with Newcastle-Ottawa Scale and RoB2 score. RESULTS Twenty-three studies (n = 2055) were included with twelve (n = 1143) comparing FD versus WB. The proportion of patients achieving goal INR with FD varied depending on the INR target, being significantly higher for INR <2 (90.9%, 95% Confidence Interval (CI) 87.2, 94.06) compared to INR <1.6 (70.97%, 95%CI 65.33, 76.31). Compared to WB, FD was less likely to achieve a goal INR <1.6 (Risk Difference (RD) -13%, 95% CI -21, -4) but achieved similar reversal for a goal INR <2.0, (RD -1%, 95%CI -7, 4). There was no difference in hospital mortality (RD 4%, 95%CI -2, 9) or thrombosis (RD 0.0%, 95%CI -3, 3). CONCLUSION FD VKA reversal was associated with significantly lower attainment of goal INR compared to WB with lower INR targets. This did not translate to differences in hospital mortality, but these results should be interpreted cautiously in light of the observational nature of the included studies.
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Affiliation(s)
- Melanie Smith Condeni
- Medical University of South Carolina, MUSC Health, Department of Pharmacy, 150 Ashley Avenue, Charleston, SC 29425, United States of America.
| | - Kyle A Weant
- University of South Carolina, College of Pharmacy, Department of Clinical Pharmacy and Outcome Sciences, 715 Sumter St, Columbia, SC 29208, United States of America.
| | - Ron R Neyens
- Medical University of South Carolina, MUSC Health, Department of Pharmacy, 150 Ashley Avenue, Charleston, SC 29425, United States of America.
| | - Evert A Eriksson
- Medical University of South Carolina, MUSC Health, Department of Surgery, 96 Jonathan Lucas St #312, Charleston, SC 29425, United States of America.
| | - Todd A Miano
- Perelman School of Medicine at the University of Pennsylvania, Department of Biostatistics, Epidemiology, and Informatics, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States of America.
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Mekkawy KL, Chaudhry YP, Mawn JG, MacMahon A, Oni JK, Sterling RS, Sotsky RB, Khanuja HS. Determining a preoperative international normalised ratio threshold safe for hip fracture surgery. Hip Int 2023; 33:941-947. [PMID: 36650617 DOI: 10.1177/11207000221148096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION The purpose of this study was first, to assess the relationship between preoperative INR (international normalised ratio) and postoperative complication rates in patients with a hip fracture, and second, to establish a threshold for INR below which the risk of complications is comparable to those in patients with a normal INR. METHODS We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program and found 35,910 cases who had undergone surgery for a hip fracture between 2012 and 2018. Cases were stratified into 4 groups based on their preoperative INR levels: <1.4; ⩾1.4 and <1.6; ⩾1.6 and <1.8 and ⩾1.8. These cohorts were assessed for differences in preoperative factors, intraoperative factors, and postoperative course. Multivariate logistic regression was used to assess the risk of transfusion, 30-day mortality, cardiac complications, and wound complications adjusting for all preoperative and intraoperative factors. RESULTS Of the 35,910 cases, 33,484 (93.2%) had a preoperative INR < 1.4; 867 (2.4%) an INR ⩾1.4 and <1.6; 865 (2.4%) an INR ⩾ 1.6 and <1.8 and 692 (1.9%) an INR ⩾ 1.8. A preoperative INR ⩾ 1.8 was independently associated with an increased risk of bleeding requiring transfusion. A preoperative INR ⩾ 1.6 was associated with an increased risk of mortality. CONCLUSIONS We found that an INR of <1.6 is a safe value for patients who are to undergo surgery for a hip fracture. Below this value, patients avoid an increased risk of both transfusion and 30-day mortality seen with higher INR values. These findings may allow adjustment of preoperative protocols and improve the outcome of hip fracture surgery in this group of patients.
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Affiliation(s)
- Kevin L Mekkawy
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yash P Chaudhry
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - John G Mawn
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aoife MacMahon
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Julius K Oni
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert S Sterling
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rachel B Sotsky
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Harpal S Khanuja
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Cui Z, Liu C, Sun G, Huang L, Zhou W. A prognostic nomogram incorporating red cell distribution width for patients with intracerebral hemorrhage. Medicine (Baltimore) 2020; 99:e23557. [PMID: 33327308 PMCID: PMC7738053 DOI: 10.1097/md.0000000000023557] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is the second most common subtype of stroke with higher mortality and morbidity, and it lacks effective prognostic markers. The aim of this research is to construct newly valuable prognostic nomogram incorporating red blood cell distribution width (RDW) for ICH patients.We retrospectively analyzed 953 adult patients with ICH. The impacts of RDW on short-term mortality and functional prognosis were calculated using Akaike information criterion (AIC), Bayesian information criteria (BIC) and the area under the curve (AUC) respectively, which could be used to compare with Glasgow coma scale (GCS) and ICH score. The independent factors of prognosis were identified by univariate and multivariate logistic regression analysis. A nomogram based on RDW for nerve functional prognosis was further constructed and validated. Its clinical value was subsequently explored utilizing decision curve analysis.Cumulative clinical results were retrieved for 235 inpatients from Jan 2012 to June 2017. In 30-day mortality sets, GCS and ICH score had better prognostic performance than RDW (AUC: 0.929 and 0.917 vs 0.764; AIC: 124.101 and 134.188 vs 221.372; BIC: 131.021 and 141.107 vs 228.291). In 30-day functional prognosis sets, the consequences of evaluation systems were inconsistent. GCS was the best parameter for predicting outcome using AIC (262.350 vs 276.392 and 264.756) and BIC (269.269 vs 283.311 and 271.675). However, RDW was higher than GCS and ICH score considering AUC (0.784 vs 0.759 and 0.722). Age, GCS, RDW, platelet distribution width, and surgery were independent prognostic factors by multivariate logistic regression analysis, and those coefficients were used to formulate a nomogram. This nomogram can provide accurate prediction with the concordance index of 0.880 (95% CI, 0.837-0.922) higher than Harrell's concordance index of GCS system 0.759 (95% CI, 0.698-0.819) and RDW 0.784 (95% CI, 0.721-0.847). The calibration plots showed optimal consistency between bootstrap-predicted and the actual observed values of 30-day unfavorable prognosis. Decision curve analysis showed an increased net benefit for utilizing the nomogram.High RDW values are associated with an unfavorable outcome after ICH. The established nomogram incorporating RDW should be considered for a 30-day functional prognosis.
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Affiliation(s)
- Zhe Cui
- Division of Hematology and Transfusion Medicine, Department of Laboratory Medicine, Tianjin Baodi Hospital, Tianjin Baodi Affiliated Hospital of Tianjin Medical University, Baodi District, Tianjin
| | - Chengwang Liu
- Division of Hematology and Transfusion Medicine, Department of Laboratory Medicine, Tianjin Baodi Hospital, Tianjin Baodi Affiliated Hospital of Tianjin Medical University, Baodi District, Tianjin
| | - Guozhong Sun
- Division of Hematology and Transfusion Medicine, Department of Laboratory Medicine, Tianjin Baodi Hospital, Tianjin Baodi Affiliated Hospital of Tianjin Medical University, Baodi District, Tianjin
| | - Liping Huang
- Department of Oncology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province
| | - Weiwen Zhou
- Department of Emergency Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Yuexiu District, Guangzhou, China
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Correction of international normalised ratio in major bleeding related to vitamin K antagonists is associated with better survival: A UK study. Thromb Res 2020; 197:153-159. [PMID: 33220564 DOI: 10.1016/j.thromres.2020.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/04/2020] [Accepted: 11/06/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The association between international-normalised-ratio (INR) correction and mortality in patients with major bleeding on vitamin-K-antagonists (VKA) is important for evaluating the efficacy of reversal agents for oral anticoagulants. OBJECTIVES We evaluate if INR correction (defined as ≤1.3) following intervention in major bleeding on VKA is associated with better survival, and if there is a dose-response relationship between Vitamin K (VK) and INR correction. METHODS Data on patients' characteristics, haematological management and 30-day outcomes reported by 32 UK hospitals (October 2013-August 2016) were analysed. Associations between INR correction and: (a) 30-day mortality; (b) VK dose were estimated using multivariable logistic regression, using multiple imputation to handle missing INR values. RESULTS Of 1771 patients, 77%, 73% and 33% received prothrombin-complex-concentrate (PCC), VK (92% intravenous) and red cells and fresh frozen plasma transfusion respectively. Proportionally more intracranial haemorrhage (ICH) cases (87%) than non-ICH cases (69%) received PCC. VK administration did not vary by ICH group, with 10 mg (33%) and 5 mg (28%) doses being the most common. Higher doses of VK (10 mg) were more likely to correct INR than lower doses (5 mg). Post-intervention INR > 1.3 in treated patients was associated with 3.2 (95%CI: 2.1-4.9) times higher odds of death within 30 days, compared with INR ≤ 1.3, with no difference between ICH and non-ICH. CONCLUSIONS INR correction after intervention to manage major bleeding on VKA is associated with better survival. Higher VK doses (10 mg) improve INR correction more than lower doses (5 mg) in major bleeding, but further studies are warranted to compare the relative benefits/risks of 5 mg versus 10 mg doses.
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Imanaka S, Kuwabara T, Ikeda H, Miyake Y, Enomoto H, Sakamoto T, Yasuno N. Emergency intensive care unit pharmacist's intervention may reduce time to four-factor prothrombin complex concentrate administration: a retrospective study. J Pharm Health Care Sci 2020; 6:7. [PMID: 32266076 PMCID: PMC7118855 DOI: 10.1186/s40780-020-00161-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/03/2020] [Indexed: 11/24/2022] Open
Abstract
Background Four-factor prothrombin complex concentrate (4F-PCC) must be administered as soon as possible, and in our emergency intensive care unit (EICU), pharmacists are available on weekdays for consultation on expediting 4F-PCC administration. Although recent reports have described a reduction in time to 4F-PCC administration, few studies have addressed if this is because of EICU pharmacist’s intervention, and there are no such studies in Japan. Therefore, we aimed to examine whether EICU pharmacist’s intervention reduced time to 4F-PCC administration. Methods This single-center retrospective cohort study was conducted from December 2017 to May 2019. We enrolled patients who received 4F-PCC due to major bleeding or requirement of urgent surgical/invasive procedures (n = 10). Patients were divided into two groups, namely, the intervention group (n = 5), in which EICU pharmacists consulted on weekdays, and the nonintervention group (n = 5), in which an intervention was not possible because of the absence of the EICU pharmacist. Results The median time from patient presentation to the EICU to 4F-PCC administration (103 min vs. 111 min, p = 0.4) was similar between the two groups; however, the median time from 4F-PCC prescription ordering to administration was significantly shorter in the intervention group than in the nonintervention group (21 min vs. 60 min, p = 0.02). Conclusions EICU pharmacist’s intervention improves the process from 4F-PCC prescription to administration and can reduce time to 4F-PCC administration.
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Affiliation(s)
- Shoichi Imanaka
- 1Pharmaceutical Department, Teikyo University School of Medicine Hospital, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605 Japan
| | - Tatsuro Kuwabara
- 1Pharmaceutical Department, Teikyo University School of Medicine Hospital, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605 Japan
| | - Hiroto Ikeda
- 2Department of Emergency Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605 Japan
| | - Yasufumi Miyake
- 2Department of Emergency Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605 Japan
| | - Hiromi Enomoto
- 1Pharmaceutical Department, Teikyo University School of Medicine Hospital, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605 Japan
| | - Tetsuya Sakamoto
- 2Department of Emergency Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605 Japan
| | - Nobuhiro Yasuno
- 1Pharmaceutical Department, Teikyo University School of Medicine Hospital, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605 Japan.,3Laboratory of Hospital Pharmacy Sciences, Faculty of Pharma Science, Teikyo University, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605 Japan
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Rudasill SE, Liu J, Kamath AF. Revisiting the International Normalized Ratio Threshold for Bleeding Risk and Mortality in Primary Total Hip Arthroplasty: A National Surgical Quality Improvement Program Analysis of 17,567 Patients. J Bone Joint Surg Am 2020; 102:52-59. [PMID: 31609891 DOI: 10.2106/jbjs.19.00160] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Efforts to identify preoperative risk factors for primary total hip arthroplasty have amplified with its increasing incidence. The international normalized ratio (INR) is 1 measure that may influence postoperative outcomes. This study of a national database assessed whether there exists an association between preoperative INR and postoperative bleeding and mortality among patients who underwent primary total hip arthroplasty. METHODS We retrospectively analyzed 17,567 adult patients who underwent primary total hip arthroplasty in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) between 2005 and 2016. Patients were stratified by preoperative INR into 4 groups: INR <1.0, 1.0 to <1.25, 1.25 to <1.5, and ≥1.5. Bleeding necessitating transfusion was the primary outcome, and secondary outcomes included mortality, infection, and readmission. Multivariable logistic regressions controlled for baseline differences. RESULTS Among the patients who underwent total hip arthroplasty, 20.5% had INR <1.0, 73.6% had INR 1.0 to <1.25, 4.2% had INR 1.25 to <1.5, and 1.8% had INR ≥1.5. Mortality increased incrementally from 0.3% for INR <1.0 to 4.9% for INR ≥1.5 (p < 0.001), and bleeding risk increased from 13.2% for INR <1.0 to 29.3% for INR ≥1.5 (p < 0.001). After adjustment, bleeding risk was increased for INR 1.25 to <1.5 (odds ratio [OR], 1.55 [95% confidence interval (CI), 1.26 to 1.92]) and INR ≥1.5 (OR, 1.55 [95% CI, 1.15 to 2.08]) compared with INR <1.0. The only group associated with increased mortality was INR ≥1.5 (OR, 2.69 [95% CI, 1.07 to 6.76]). The length of stay significantly increased with increasing INR, from 3.6 to 6.3 days (p < 0.001). CONCLUSIONS This study found a significant, independent effect between increased preoperative INR and increased bleeding and mortality. Bleeding risk becomes evident at INR ≥1.25, and those patients with INR ≥1.5 are at significantly increased risk of mortality. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sarah E Rudasill
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Jiabin Liu
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Barton CA, Bierman J. Factor products. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Sezgin G, Georgiou A, Hardie RA, Li L, Pont LG, Badrick T, Franco GS, Westbrook JI, Rinehart N, McLeod A, Pearce C, Shearer M, Whyte R, Deveny E. Compliance with pathology testing guidelines in Australian general practice: protocol for a secondary analysis of electronic health record data. BMJ Open 2018; 8:e024223. [PMID: 30429148 PMCID: PMC6252775 DOI: 10.1136/bmjopen-2018-024223] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION In Australia, general practitioners usually are the first point of contact for patients with non-urgent medical conditions. Appropriate and efficient utilisation of pathology tests by general practitioners forms a key part of diagnosis and monitoring. However overutilisationand underutilisation of pathology tests have been reported across several tests and conditions, despite evidence-based guidelines outlining best practice in pathology testing. There are a limited number of studies evaluating the impact of these guidelines on pathology testing in general practice. The aim of our quantitative observational study is to define how pathology tests are used in general practice and investigate how test ordering practices align with evidence-based pathology guidelines. METHODS AND ANALYSIS Access to non-identifiable patient data will be obtained through electronic health records from general practices across three primary health networks in Victoria, Australia. Numbers and characteristics of patients, general practices, encounters, pathology tests and problems managed over time will be described. Overall rates of encounters and tests, alongside more detailed investigation between subcategories (encounter year, patient's age, gender, and location and general practice size), will also be undertaken. To evaluate how general practitioner test ordering coincides with evidence-based guidelines, five key candidate indicators will be investigated: full blood counts for patients on clozapine medication; international normalised ratio measurements for patients on warfarin medication; glycated haemoglobin testing for monitoring patients with diabetes; vitamin D testing; and thyroid function testing. ETHICS AND DISSEMINATION Ethics clearance to collect data from general practice facilities has been obtained by the data provider from the RACGP National Research and Evaluation Ethics Committee (NREEC 17-008). Approval for the research group to use these data has been obtained from Macquarie University (5201700872). This study is funded by the Australian Government Department of Health Quality Use of Pathology Program (Agreement ID: 4-2QFVW4M). Findings will be reported to the Department of Health and disseminated in peer-reviewed academic journals and presentations (national and international conferences, industry forums).
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Affiliation(s)
- Gorkem Sezgin
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Rae-Anne Hardie
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Ling Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Lisa G Pont
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Tony Badrick
- The Royal College of Pathologists of Australasia Quality Assurance Program, St Leonards, New South Wales, Australia
| | - Guilherme S Franco
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | | | - Adam McLeod
- Outcome Health, Burwood, Victoria, Australia
| | | | | | - Robin Whyte
- Eastern Melbourne Primary Health Network, Box Hill, Victoria, Australia
| | - Elizabeth Deveny
- South Eastern Melbourne Primary Health Network, Heatherton, Victoria, Australia
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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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Imberti D, Permunian ET, Croci E, Ageno W, Dentali F. Risk factors for suboptimal efficacy of 3-factor prothrombin complex concentrates in emergency VKA anticoagulation reversal. Thromb Haemost 2017; 112:621-3. [DOI: 10.1160/th13-10-0851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 04/23/2014] [Indexed: 11/05/2022]
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Langstraat E, Martinelli A, Spoelhof B, Shah S. Effect of pharmacy management on turnaround time of 4-factor prothrombin complex concentrate. Am J Health Syst Pharm 2017; 74:S61-S66. [DOI: 10.2146/ajhp160698] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
| | - Ashley Martinelli
- Department of Pharmacy, Univeristy of Maryland Medical Center, Baltimore, MD
| | | | - Shailly Shah
- Department of Pharmacy, Emory University Hospital Midtown, Atlanta, GA
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Jacobs A, Bassa F, Decloedt EH. A preliminary review of warfarin toxicity in a tertiary hospital in Cape Town, South Africa. Cardiovasc J Afr 2017; 28:346-349. [PMID: 28656193 PMCID: PMC5885058 DOI: 10.5830/cvja-2017-029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 05/16/2017] [Indexed: 11/06/2022] Open
Abstract
AIM Warfarin is a widely used anticoagulant for the prevention and treatment of thromboembolism. We conducted a retrospective review to determine the causes and management of warfarin toxicity of patients admitted to Tygerberg hospital between June 2014 and June 2015. RESULTS We identified and evaluated 126 patients who met the inclusion criteria. The cause of warfarin toxicity was identified and addressed in only 14.3% (18/126) of patients. Where the cause was identified, 56% (10/18) was due to dosing errors and 17% (3/18) drug-drug interaction (DDI). However, 77% (97/126) of patients were retrospectively identified as receiving concomitant medicines known to interact with warfarin at the time of admission. Twenty-eight percent (35/126) of patients presented with major bleeding, which included seven cases of intracranial haemorrhage. Patients were admitted for a median of eight days at an average treatment cost of R10 578. CONCLUSION We found that warfarin toxicity carries significant mortality and cost, but little attention is paid to the causes of toxicity.
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Affiliation(s)
- Annemarie Jacobs
- Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa.
| | - Fatima Bassa
- Division of Haematology, Department of Medicine, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
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Fischer R, Brettig S, Pearce A. Retrospective review of Prothrombinex use by SAAS MedSTAR. Emerg Med Australas 2016; 29:178-183. [PMID: 27875857 DOI: 10.1111/1742-6723.12710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/22/2016] [Accepted: 09/27/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aim of this study was to review and describe the use of Prothrombinex by a physician-led retrieval service based remote from a hospital blood bank. METHODS This is a retrospective observational study. Patients to whom Prothrombinex was administered by the retrieval team were identified from the retrieval service patient database. The paper case cards of the identified patients were then manually reviewed and the data matched to patients in the state-wide electronic laboratory record. RESULTS Between 1 January 2010 and 30 November 2013 38 cases were identified. For 28 the indication was warfarinisation associated with life-threatening bleeding (most commonly intracranial or gastrointestinal tract). In the remaining 10 cases, Prothrombinex was used to treat coagulopathy associated with liver disease or massive haemorrhage. The median time saved by the retrieval team administering PTX-VF, rather than waiting to the receiving centre, was 120 min (interquartile range: 85-195 min). The median dose of PTX-VF administered was 23.25 IU/kg (interquartile range: 20-33 IU/kg). Paired international normalised ratios (INRs) were available for 33 of the 38 patients. In the warfarin group, all patients had an improvement in their INR and 21 of 25 had correction of their INR. In the non-warfarin group, the effect on INR was more variable. CONCLUSION Prothrombinex is a clinically useful product that can be relatively easily stored and used by retrieval services, even if they are based in isolation from a hospital blood bank. More research is required to look at the utility of Prothrombinex for non-warfarin-related bleeding in the pre-hospital and retrieval environment.
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Affiliation(s)
- Roy Fischer
- MedSTAR Emergency Medical Retrieval, SA Ambulance Service (SAAS), Adelaide, South Australia, Australia
| | - Simon Brettig
- MedSTAR Emergency Medical Retrieval, SA Ambulance Service (SAAS), Adelaide, South Australia, Australia
| | - Andrew Pearce
- MedSTAR Emergency Medical Retrieval, SA Ambulance Service (SAAS), Adelaide, South Australia, Australia
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Becattini C, Franco L, Masotti L, Nitti C, Cattinelli S, Cappelli R, Manina G, Sbrojavacca R, Pomero F, Agnelli G. Clinical management and outcome of major bleeding in patients on treatment with vitamin K antagonists. Eur J Intern Med 2016; 33:47-54. [PMID: 27289494 DOI: 10.1016/j.ejim.2016.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 05/11/2016] [Accepted: 05/17/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND The optimal management of major bleeding associated with vitamin K antagonists remains unclear. OBJECTIVES The aim of the study was to assess the determinants of outcome of vitamin K antagonists-associated major bleeding and the outcome of bleeding in relation with the therapeutic management. METHODS Patients hospitalized for major bleeding while on vitamin K antagonists were included in a prospective, cohort study. Major bleeding was defined according to the criteria of the International Society of Thrombosis Haemostasis. The primary study outcome was death at 30days from major bleeding. RESULTS 544 patients were included in this study, of which 282 with intracranial hemorrhage. Prothrombin complex concentrates were used in 51% and in 23% of patients with intracranial hemorrhage or non-intracranial major bleeding, respectively (p<0.001); fresh frozen plasma was used in 7% and in 17% of patients with intracranial hemorrhage or non-intracranial major bleeding (p<0.001). Death at 30days occurred in 100 patients (18%), 72 patients with intracranial hemorrhage and 28 patients with non-intracranial major bleeding. Age over 85years, low Glasgow Coma Scale score and shock were independent predictors of death at 30days. Invasive procedures were associated with decreased risk of death. CONCLUSIONS Among the patients hospitalized for major bleeding while on vitamin K antagonists, the risk for death is substantial. The risk for death is associated with the clinical severity of major bleeding as assessed by the GCS score and by the presence of shock more than with the initial localization of major bleeding (ICH vs other sites).
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Affiliation(s)
- C Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Italy.
| | - L Franco
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Italy
| | - L Masotti
- Internal Medicine, Santa Maria Nuova Hospital, Firenze, Italy
| | - C Nitti
- Emergency Medicine, Ospedali Riuniti Umberto I - Lancisi - Salesi, Ancona, Italy
| | - S Cattinelli
- Emergency Medicine, Ospedale Cattinara, Trieste, Italy
| | - R Cappelli
- Internal Medicine, University of Siena, Italy
| | - G Manina
- Emergency Medicine, Policlinico Maggiore, Milano, Italy
| | - R Sbrojavacca
- Emergency Medicine, Santa Maria della Misericordia Hospital, Udine, Italy
| | - F Pomero
- Internal Medicine, Santa Croce Hospital, Cuneo, Italy
| | - G Agnelli
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Italy
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Stadler RR, Soyka MB. A prospective pilot study comparing nasal blood sampling and venipuncture for the assessment of hemoglobin levels and INR. Laryngoscope 2016; 127:577-581. [PMID: 27076256 DOI: 10.1002/lary.26002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 02/20/2016] [Accepted: 02/29/2016] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS This study is a pilot study evaluating the feasibility of sampling nose blood during an emergency using a commercially available rapid test device. It also compares the accuracy of rapid nasal blood test results to the results of standard laboratory methods using venous blood sampling. METHODS Nose blood was collected in patients suffering from active epistaxis. In an emergency setting, hemoglobin levels and the international normalized ratio (INR) were assessed using a rapid point-of-care test device. These results were compared to standard laboratory analyses from venous blood taken at the same time from the same patient. Twenty patients consented to and participated in these assessments. RESULTS Linear regression comparing venous and nasal samples revealed strong correlations between the two methods for both hemoglobin and INR measurement. A Bland-Altman analysis showed the mean difference to be 2.3 g/L when comparing hemoglobin measurements made using the rapid point-of-care device to hemoglobin measurements made using conventional lab assessment. The corresponding mean difference for INR measurements was 0.14. CONCLUSION The results of this pilot study support the use of point-of-care test devices using nasal blood sampling and provide preliminary data demonstrating that a rapid testing method can be reliable, practicable, and time-efficient. In our opinion, rapid hematologic screening for nasal and capillary blood should be available in emergency wards that treat epistaxis. LEVEL OF EVIDENCE 4. Laryngoscope, 127:577-581, 2017.
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Affiliation(s)
- Rafael R Stadler
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich USZ, University of Zurich UZH, Zurich, Switzerland
| | - Michael B Soyka
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich USZ, University of Zurich UZH, Zurich, Switzerland
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Monitoring of hematological and hemostatic parameters in neurocritical care patients. Neurocrit Care 2015; 21 Suppl 2:S168-76. [PMID: 25208669 DOI: 10.1007/s12028-014-0023-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Anemia and bleeding are paramount concerns in neurocritical care and often relate to the severity of intracranial hemorrhage. Anemia is generally associated with worse outcomes, and efforts to minimize anemia through reduced volume of blood sampled are encouraged. Point-of-care-testing reliably detects the use of non-steroidal anti-inflammatory drugs that may worsen bleeding and reduce platelet activity, particularly in patients with intracerebral hemorrhage. How best to monitor the effect of platelet transfusion or platelet-activating therapy is not well studied. For patients known to take novel oral anticoagulants, drug-specific coagulation tests before neurosurgical intervention are prudent.
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Voils SA, Holder MC, Premraj S, Catlin JR, Allen BR. Comparative effectiveness of 3- versus 4-factor prothrombin complex concentrate for emergent warfarin reversal. Thromb Res 2015; 136:595-8. [DOI: 10.1016/j.thromres.2015.07.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/01/2015] [Accepted: 07/23/2015] [Indexed: 10/23/2022]
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Bordeleau S, Poitras J, Marceau D, Breton C, Beaupré P, Archambault PM. Use of prothrombin complex concentrate in warfarin anticoagulation reversal in the emergency department: a quality improvement study of administration delays. BMC Health Serv Res 2015; 15:106. [PMID: 25880097 PMCID: PMC4365812 DOI: 10.1186/s12913-015-0775-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 03/02/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Quick reversal of warfarin anticoagulation is important in life threatening bleeding. The aim of this study is to improve the administration delay when using Prothrombin Complex Concentrate (PCC) for the emergent reversal of warfarin anticoagulation in the emergency department. METHODS An audit and feedback quality improvement project was conducted in three phases: a retrospective audit phase, an analysis and feedback phase and prospective evaluation phase. The charts of all eligible patients in a single Emergency Department (ED) in Québec, Canada, who received PCC since the introduction of this product in 2009 until October 31, 2011, were retrospectively audited. The administration delay of PCC was calculated from the time of prescription to the time of administration. With the data, we determined where improvements could be attained, and jointly with all stakeholders in the ED and the blood bank, we created an action plan to ensure the timely administration of PCC. The action plan was then implemented and a six-month prospective evaluation study was conducted to determine any improvement. RESULTS Seventy-seven charts were reviewed in the retrospective chart audit. The mean administration delay was 73.6 minutes (STD [34.1]) with a median of 70.0 minutes (25-75% IQR [45.0-95.0]). We found that this delay was principally due to the following barriers: communication problems between the ED and the blood bank as well as delivery inefficiencies. An action plan that involved a flowchart to remind all clinicians how to order PCC and a new delivery method from the blood bank to the ED were developed. During the 6 months following the implementation of our action plan, 39 patients received PCC and the mean administration time decreased to 33.2 minutes (STD [14.2])(p < .0001) with a median of 30.0 minutes (25-75% IQR [24.3-38.8]). CONCLUSION By implementing an action plan comprising of a flowchart and a new delivery process, this audit and feedback quality improvement project reduced the administration time of PCC by more than half. Future studies to measure the impact of a similar audit and feedback process involving an action plan in other centers should be conducted before this type of quality improvement process is implemented on wider scale.
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Affiliation(s)
- Simon Bordeleau
- Emergency Medicine Training Program, Département de médecine familiale et médecine d'urgence, Université Laval, Québec, QC, Canada.
| | - Julien Poitras
- Centre de santé et de services sociaux Alphonse-Desjardins (Centre hospitalier affilié universitaire de Lévis), Lévis, QC, Canada.
- Département de médecine familiale et médecine d'urgence, Université Laval, Québec, QC, Canada.
| | - Danièle Marceau
- Centre de santé et de services sociaux Alphonse-Desjardins (Centre hospitalier affilié universitaire de Lévis), Lévis, QC, Canada.
- Blood bank director, Quebec, Province of Quebec, Région 12, Canada.
| | - Carolle Breton
- Transfusion Safety Officer, Quebec, Province of Quebec, Région 12, Canada.
| | - Pierre Beaupré
- Centre de santé et de services sociaux Alphonse-Desjardins (Centre hospitalier affilié universitaire de Lévis), Lévis, QC, Canada.
- Département de médecine familiale et médecine d'urgence, Université Laval, Québec, QC, Canada.
| | - Patrick M Archambault
- Centre de santé et de services sociaux Alphonse-Desjardins (Centre hospitalier affilié universitaire de Lévis), Lévis, QC, Canada.
- Département de médecine familiale et médecine d'urgence, Université Laval, Québec, QC, Canada.
- Division de soins intensifs, Département d'anesthésiologie, Université Laval, Québec, QC, Canada.
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Menzin J, Sussman M, Nichols C, Friedman M, Zbrozek A. Use of blood products in patients with anticoagulant-related major bleeding: an analysis of inhospital outcomes. Am J Health Syst Pharm 2014; 71:1635-45. [PMID: 25225449 DOI: 10.2146/ajhp130729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The impact of correcting elevated International Normalized Ratio (INR) values on inhospital mortality in patients with warfarin-associated major bleeding is presented. METHODS Using patient information from the database of a large U.S. health system, a retrospective analysis was conducted to (1) evaluate inpatient practice patterns in correcting INR elevations among patients hospitalized with warfarin-related intracranial hemorrhage (ICH) or non-ICH bleeding and (2) test the hypothesis that achieving INR correction, defined as an INR of ≤1.5, at any point during the hospital stay is correlated with lower inhospital mortality. Cox proportional hazards models were constructed to assess predictors of inhospital death. RESULTS Among the 354 patients who met the study selection criteria, INR correction was achieved in 87.9% overall (92.5% and 85.5% of patients with ICH and non-ICH bleeds, respectively). Patients whose elevated INR values were corrected had significantly lower inhospital death rates than those with uncorrected elevations: 15.3% versus 55.6% (p = 0.010) among patients with ICH and 2.0% versus 11.8% (p = 0.017) among those with non-ICH bleeds. After adjusting for baseline demographics and comorbidities, the correlation between failure to correct INR elevations and increased mortality risk was significant only for patients with ICH (hazard ratio, 8.04; 95% confidence interval, 2.07-31.18; p = 0.003). CONCLUSION Results of this study indicated that correction of elevated INR values was associated with a lower likelihood of inhospital death among warfarin-treated patients hospitalized for ICH or non-ICH major bleeding.
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Affiliation(s)
- Joseph Menzin
- Joseph Menzin, Ph.D., is President; Matthew Sussman, M.A., is Associate Managing Director; Christine Nichols, M.A., is Research and Data Analyst II; and Mark Friedman, M.D., is Medical Director, Boston Health Economics, Waltham, MA. Arthur Zbrozek, Ph.D., is Senior Director, Global Health Economics, CSL Behring, King of Prussia, PA.
| | - Matthew Sussman
- Joseph Menzin, Ph.D., is President; Matthew Sussman, M.A., is Associate Managing Director; Christine Nichols, M.A., is Research and Data Analyst II; and Mark Friedman, M.D., is Medical Director, Boston Health Economics, Waltham, MA. Arthur Zbrozek, Ph.D., is Senior Director, Global Health Economics, CSL Behring, King of Prussia, PA
| | - Christine Nichols
- Joseph Menzin, Ph.D., is President; Matthew Sussman, M.A., is Associate Managing Director; Christine Nichols, M.A., is Research and Data Analyst II; and Mark Friedman, M.D., is Medical Director, Boston Health Economics, Waltham, MA. Arthur Zbrozek, Ph.D., is Senior Director, Global Health Economics, CSL Behring, King of Prussia, PA
| | - Mark Friedman
- Joseph Menzin, Ph.D., is President; Matthew Sussman, M.A., is Associate Managing Director; Christine Nichols, M.A., is Research and Data Analyst II; and Mark Friedman, M.D., is Medical Director, Boston Health Economics, Waltham, MA. Arthur Zbrozek, Ph.D., is Senior Director, Global Health Economics, CSL Behring, King of Prussia, PA
| | - Arthur Zbrozek
- Joseph Menzin, Ph.D., is President; Matthew Sussman, M.A., is Associate Managing Director; Christine Nichols, M.A., is Research and Data Analyst II; and Mark Friedman, M.D., is Medical Director, Boston Health Economics, Waltham, MA. Arthur Zbrozek, Ph.D., is Senior Director, Global Health Economics, CSL Behring, King of Prussia, PA
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L’administration de concentrés de complexes prothrombiniques et de vitamine K selon les recommandations françaises est associée à une réduction de la mortalité des patients victimes d’une hémorragie grave sous anti-vitamine K (Étude EPAHK). ANNALES FRANCAISES DE MEDECINE D URGENCE 2014. [DOI: 10.1007/s13341-014-0474-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tazarourte K, Riou B, Tremey B, Samama CM, Vicaut E, Vigué B. Guideline-concordant administration of prothrombin complex concentrate and vitamin K is associated with decreased mortality in patients with severe bleeding under vitamin K antagonist treatment (EPAHK study). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R81. [PMID: 24762166 PMCID: PMC4057200 DOI: 10.1186/cc13843] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 04/15/2014] [Indexed: 12/26/2022]
Abstract
Introduction In vitamin K antagonist (VKA)-treated patients with severe hemorrhage, guidelines recommend prompt VKA reversal with prothrombin complex concentrate (PCC) and vitamin K. The aim of this observational cohort study was to evaluate the impact of guideline concordant administration of PCC and vitamin K on seven-day mortality. Methods Data from consecutive patients treated with PCC were prospectively collected in 44 emergency departments. Type of hemorrhage, coagulation parameters, type of treatment and seven-day mortality mortality were recorded. Guideline-concordant administration of PCC and vitamin K (GC-PCC-K) were defined by at least 20 IU/kg factor IX equivalent PCC and at least 5 mg of vitamin K performed within a predefined time frame of eight hours after admission. Multivariate analysis was used to assess the effect of appropriate reversal on seven-day mortality in all patients and in those with intracranial hemorrhage (ICH). Results Data from 822 VKA-treated patients with severe hemorrhage were collected over 14 months. Bleeding was gastrointestinal (32%), intracranial (32%), muscular (13%), and “other” (23%). In the whole cohort, seven-day mortality was 13% and 33% in patients with ICH. GC-PCC-K was performed in 38% of all patients and 44% of ICH patients. Multivariate analysis showed a two-fold decrease in seven-day mortality in patients with GC-PCC-K (odds ratio (OR) = 2.15 (1.20 to 3.88); P = 0.011); this mortality reduction was also observed when only ICH was considered (OR = 3.23 (1.53 to 6.79); P = 0.002). Conclusions Guideline-concordant VKA reversal with PCC and vitamin K within eight hours after admission was associated with a significant decrease in seven-day mortality.
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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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Teo KC, Mahboobani NR, Lee R, Siu CW, Cheung RTF, Ho SL, Lau KK, Chan KH. Warfarin associated intracerebral hemorrhage in Hong Kong Chinese. Neurol Res 2013; 36:143-9. [DOI: 10.1179/1743132813y.0000000275] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Soyka MB, Holzmann D. Should we test the prothrombin time in anticoagulated epistaxis patients? ALLERGY & RHINOLOGY 2013; 4:e52-3. [PMID: 23772329 PMCID: PMC3679570 DOI: 10.2500/ar.2013.4.0049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Epistaxis is one of the most frequent emergencies in rhinology. Patients using anticoagulative medication are at increased risk for epistaxis. We evaluated the prothrombin time and the international normalized ratio (INR) in anticoagulated epistaxis patients. Patients suffering from epistaxis were prospectively included in a database and results from prothrombin testing were analyzed in the context of anticoagulation. One hundred sixteen of 591 epistaxis cases were identified to be on oral anticoagulation. The INR was found to be above therapeutic levels in 19 (16%) of these cases. We strongly recommend prothrombin time and INR testing in all epistaxis patients taking any sort of vitamin K antagonists.
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Affiliation(s)
- Michael B Soyka
- Department of Otorhinolaryngology Head and Neck Surgery University Hospital Zurich, Zurich, Switzerland
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Kerebel D, Joly LM, Honnart D, Schmidt J, Galanaud D, Negrier C, Kursten F, Coriat P. A French multicenter randomised trial comparing two dose-regimens of prothrombin complex concentrates in urgent anticoagulation reversal. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R4. [PMID: 23305460 PMCID: PMC4057510 DOI: 10.1186/cc11923] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 01/10/2013] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Prothrombin complex concentrates (PCC) are haemostatic blood preparations indicated for urgent anticoagulation reversal, though the optimal dose for effective reversal is still under debate. The latest generation of PCCs include four coagulation factors, the so-called 4-factor PCC. The aim of this study was to compare the efficacy and safety of two doses, 25 and 40 IU/kg, of 4-factor PCC in vitamin K antagonist (VKA) associated intracranial haemorrhage. METHODS We performed a phase III, prospective, randomised, open-label study including patients with objectively diagnosed VKA-associated intracranial haemorrhage between November 2008 and April 2011 in 22 centres in France. Patients were randomised to receive 25 or 40 IU/kg of 4-factor PCC. The primary endpoint was the international normalised ratio (INR) 10 minutes after the end of 4-factor PCC infusion. Secondary endpoints were changes in coagulation factors, global clinical outcomes and incidence of adverse events (AEs). RESULTS A total of 59 patients were randomised: 29 in the 25 IU/kg and 30 in the 40 IU/kg group. Baseline demographics and clinical characteristics were comparable between the groups. The mean INR was significantly reduced to 1.2 - and ≤1.5 in all patients of both groups - 10 minutes after 4-factor PCC infusion. The INR in the 40 IU/kg group was significantly lower than in the 25 IU/kg group 10 minutes (P = 0.001), 1 hour (P = 0.001) and 3 hours (P = 0.02) after infusion. The 40 IU/kg dose was also effective in replacing coagulation factors such as PT (P = 0.038), FII (P = 0.001), FX (P <0.001), protein C (P = 0.002) and protein S (0.043), 10 minutes after infusion. However, no differences were found in haematoma volume or global clinical outcomes between the groups. Incidence of death and thrombotic events was similar between the groups. CONCLUSIONS Rapid infusion of both doses of 4-factor PCC achieved an INR of 1.5 or less in all patients with a lower INR observed in the 40 IU/kg group. No safety concerns were raised by the 40 IU/kg dose. Further trials are needed to evaluate the impact of the high dose of 4-factor PCC on functional outcomes and mortality. TRIAL REGISTRATION Eudra CT number 2007-000602-73.
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Voils SA, Baird B. Systematic review: 3-factor versus 4-factor prothrombin complex concentrate for warfarin reversal: Does it matter? Thromb Res 2012; 130:833-40. [DOI: 10.1016/j.thromres.2012.10.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 09/28/2012] [Accepted: 10/01/2012] [Indexed: 10/27/2022]
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Real world usage of PCC to "rapidly" correct warfarin induced coagulopathy. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2012; 11:500-5. [PMID: 23114527 DOI: 10.2450/2012.0113-12] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 08/09/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND Life threatening bleeding and emergency procedures in patients on vitamin K antagonists are indications for urgent reversal with prothrombin complex concentrate and vitamin K. Rapid reversal in these situations is emphasized in the literature and guidelines, but only very limited information is available on its real life use, especially on the timing of treatment in relation to presentation. MATERIALS AND METHODS We retrospectively audited emergency warfarin reversal in 131 consecutive patients. We studied the indication, use of vitamin K, time between presentation and administration of vitamin K and PCC, effectiveness in INR reduction and clinical outcome. RESULTS The median PCC dose was 26.8 IU/kg. The median INR was reduced from 3.1 to 1.2. Vitamin K (5 mg) was given in 91.6% of evaluable patients. We found significant delays in administration of PCC and vitamin K. The median time between presentation and administration of vitamin K/PCC was 3.6 and 5.2 hours respectively. The times in intracranial haemorrhage were 2.7 and 3.0 hours and in emergency procedures 17.4 and 15.9 hours respectively. Mortality related to bleeding was 7.6% overall but in patients with intracranial haemorrhage 22.8%. The thrombotic rate within 7 days of reversal was 1.5%. DISCUSSION The local protocol for reversal with PCC and vitamin K was adhered to well but the delay in pre-procedural patients, suggests that intravenous vitamin K alone may be sufficient in many cases and PCC administration can be avoided by better planning. Intracranial haemorrhage in warfarinised patients carries a high mortality. Treatment delays should be avoided by making PCC stocks available within emergency departments, simple dosing structures independent of INR and administering PCC without waiting for INR and CT scan results in those with strong suspicion of intracranial haemorrhage and clear trauma. Future reports and studies should always include the time from presentation to PCC treatment.
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