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Smith EC, Chen JG, Bayya M. A Rare Case of Skin Necrosis Following Extravasation of Prothrombin Complex Concentrate (PCC) Infusion During Warfarin Reversal. Cureus 2023; 15:e37867. [PMID: 37214003 PMCID: PMC10199646 DOI: 10.7759/cureus.37867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 05/23/2023] Open
Abstract
Warfarin-induced skin necrosis is a well-documented complication that can occur following commencement of warfarin. However, skin necrosis following extravasation of prothrombin complex concentrate (PCC) infusion is a very rare adverse event that is not commonly documented. This case illustrates the possibility of developing skin necrosis following the administration of an anticoagulation reversal agent rather than from anticoagulation itself. We report a case of a 58-year-old male who developed skin necrosis at the site of PCC infusion in the right upper extremity (RUE) for warfarin reversal of an elevated international normalized ratio (INR). The skin necrosis progressed into a full thickness chemical burn. As a result, the patient underwent allograft followed by split thickness autograft and RECELL placement. This case presentation describes the first reported case of skin necrosis following extravasation of PCC infusion during warfarin reversal.
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Affiliation(s)
- Emma C Smith
- Internal Medicine, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
| | - Justin G Chen
- Internal Medicine, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
| | - Maha Bayya
- Internal Medicine, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
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Al-Obaidi A, Tuck N, Al-Hadeethi D, Mohammed A, Truong Q. Spontaneous, Loculated, and Massive Hemothorax: An Uncommon Complication of Warfarin Therapy. Cureus 2021; 13:e14923. [PMID: 34123622 PMCID: PMC8189267 DOI: 10.7759/cureus.14923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Warfarin, a commonly used oral anticoagulant, is associated with several adverse drug reactions, principally bleeding. Of all hemorrhagic complications from warfarin therapy, thoracic hemorrhage accounts for only 3% and is usually related to trauma. Cases of spontaneous hemothorax secondary to anticoagulation therapy are rarely reported in the literature.
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Affiliation(s)
- Ammar Al-Obaidi
- Internal Medicine, University of Kansas School of Medicine, Wichita, USA
| | - Nicholas Tuck
- Internal Medicine, University of Kansas School of Medicine, Wichita, USA
| | - Daly Al-Hadeethi
- Internal Medicine/Hospital Medicine, Wesley Medical Center, Wichita, USA
| | - Alaeldin Mohammed
- Internal Medicine, Robert J. Dole Veterans Affairs Medical Center, Wichita, USA
| | - Quoc Truong
- Cancer Center of Kansas, University of Kansas School of Medicine, Wichita, USA
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Endres K, St Bernard R, Chin-Yee I, Hsia C, Lazo-Langner A. Efficacy and safety of four-factor prothrombin complex concentrate fixed, weight-based dosing for reversal of warfarin anticoagulation. ACTA ACUST UNITED AC 2021; 25:489-493. [PMID: 33317427 DOI: 10.1080/16078454.2020.1855745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Four-factor prothrombin complex concentrate (4F-PCC) is widely used for urgent reversal of anticoagulation with warfarin, but the optimal 4F-PCC dosing approach is unknown. Herein, we sought to determine the efficacy of a novel fixed, weight-based dosing nomogram. METHODS We retrospectively studied consecutive adult patients receiving fixed, weight-based 4F-PCC dosing for warfarin reversal between 30 April 2009 and 31 December 2010. The primary outcome was reversal of warfarin anticoagulation, defined as INR ≤1.5 within 6 h. Secondary outcome was the occurrence of thromboembolic events. RESULTS A total of 227 patients (56% male), with a median age of 74 years and a median weight of 76kg were evaluated. The most common indications for 4F-PCC were active bleeding (37.4%: 12.7% intracranial, 12.3% gastrointestinal, 4.0% trauma, 8.4% other), reversal for a procedure (22.0%), reversal for surgery (29.5%) or other (11.1%). 66.1% of patients achieved an INR ≤1.5 within 6 h of 4F-PCC administration. 95.0% (57/60) of patients completed a planned procedure and 95.7% (67/70) of patients completed a planned surgery. The median baseline INR was 2.9 (1.5-10) and decreased significantly to a median of 1.3 (1.0-3.7) (p < .001) post-4F-PCC administration. There was no statistically significant difference in response to a fixed, weight-based dose of 4F-PCC based on pre-PCC INR, as long as the pre-treatment INR was ≤ 4.5. Although the majority of patients in our study (99%) received doses over 1000IU, rates of thrombosis were low (1.8%). CONCLUSION Fixed, weight-based dosing of 4F-PCC is effective for reversing warfarin anticoagulation in patients with a pre-dosing INR ≤ 4.5.
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Affiliation(s)
- Kaitlin Endres
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Rosanne St Bernard
- Division of Hematology, Department of Medicine, Western University, London, Canada
| | - Ian Chin-Yee
- Division of Hematology, Department of Medicine, Western University, London, Canada
| | - Cyrus Hsia
- Division of Hematology, Department of Medicine, Western University, London, Canada
| | - Alejandro Lazo-Langner
- Division of Hematology, Department of Medicine, Western University, London, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Canada
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Koyama H, Yagi K, Hara K, Matsubara S, Tao Y, Uno M. Combination Therapy Using Prothrombin Complex Concentrate and Vitamin K in Anticoagulated Patients with Traumatic Intracranial Hemorrhage Prevents Progressive Hemorrhagic Injury: A Historically Controlled Study. Neurol Med Chir (Tokyo) 2020; 61:47-54. [PMID: 33208582 PMCID: PMC7812312 DOI: 10.2176/nmc.oa.2020-0252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Warfarin remains crucially involved in the treatment of patients at thrombotic or thromboembolic risk. However, warfarin increases the mortality rate among patients with traumatic intracranial hemorrhage (TICH) through progressive hemorrhagic injury (PHI). Therefore, a rapid anticoagulation reversal could be required in patients with TICH to prevent PHI. Differences in the warfarin reversal effect between combination therapy of prothrombin complex concentrate (PCC) with vitamin K (VK) and VK monotherapy remain unclear. However, studies have reported that PCC has greater effectiveness and safety for warfarin reversal compared with fresh frozen plasma (FFP). This retrospective study aimed to evaluate the warfarin reversal effects of combination therapy of PCC with VK and VK monotherapy on TICH. We compared the clinical outcomes between the periods before and after the PCC introduction in our hospital. There were 13 and 7 patients who received VK monotherapy and PCC with VK, respectively. PHI predictors were evaluated using univariate regression analyses. Warfarin reversal using PCC had a significant negative association with PHI (odds ratio: 0.03, 95% confidence interval: 0.00-0.41, P = 0.004). None of the patients presented with thrombotic complications. Warfarin reversal through a combination of PCC with VK could be more effective for inhibiting post-trauma PHI compared with VK monotherapy. This could be attributed to a rapid and stable warfarin reversal. PCC should be administered to patients with TICH taking warfarin for PHI prevention.
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Affiliation(s)
- Hiroshi Koyama
- Department of Neurosurgery, Kawasaki Medical School.,Department of Neurosurgery, Tokushima University Hospital
| | - Kenji Yagi
- Department of Neurosurgery, Kawasaki Medical School
| | - Keijiro Hara
- Department of Neurosurgery, Kawasaki Medical School
| | | | | | - Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School
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Munshi LB, Thyagarajan B, Jacob A, Patel S, Liu SZ, Szallasi A. Reversal of warfarin-coagulopathy: How to improve plasma transfusion practice in a community hospital setting? Asian J Transfus Sci 2019; 13:100-104. [PMID: 31896915 PMCID: PMC6910035 DOI: 10.4103/ajts.ajts_110_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 04/20/2018] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Plasma is often given inappropriately to reverse warfarin-induced coagulopathy, wasting health-care resources and exposing the patients to transfusion-associated risks. AIMS The clinical practice at our institution was evaluated in order to reduce the number of unnecessary plasma transfusions. MATERIALS AND METHODS Retrospective audit of plasma transfusions was done (July 2014 to June 2015). DESIGN To improve the clinical practice, a two-prong strategy was implemented: (1) in-service was given to clinicians on the warfarin-reversal guidelines and (2) for a 30-day period, plasma orders were placed on the approval list of the Transfusion Medicine Service. RESULTS Of the 729 units of plasma, 189 (26% of total) were given for the reversal of warfarin-induced coagulopathy. The medical charts of these patients were reviewed: 46 units of plasma (~25%) were given inappropriately (e.g., patients with minimally elevated international normalized ratio, no evidence of bleeding, and no surgery within 24 h). To check the effectiveness of our intervention, two audits of plasma transfusions were done. During the first audit (January 1-February 29, 2016), 24 patients received plasma to reverse warfarin-coagulopathy. Medical chart review revealed that the vast majority of plasma orders (96.66%) followed the guidelines. A second audit was carried out a year later (January 1-March 31, 2017): during this 3-month period, 47 patients were transfused with plasma for warfarin reversal with a 94% adherence to the guidelines. CONCLUSION We conclude that plasma transfusion practices may be improved by a combination of education and active enforcement of warfarin reversal guidelines.
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Affiliation(s)
- Lubna Bashir Munshi
- Department of Medicine and Pathology, Monmouth Medical Center, Long Branch, NJ, USA
| | | | - Aasems Jacob
- Department of Medicine and Pathology, Monmouth Medical Center, Long Branch, NJ, USA
| | - Shil Patel
- Department of Medicine and Pathology, Monmouth Medical Center, Long Branch, NJ, USA
| | - Steve Zheng Liu
- Department of Medicine and Pathology, Monmouth Medical Center, Long Branch, NJ, USA
| | - Arpad Szallasi
- Department of Medicine and Pathology, Monmouth Medical Center, Long Branch, NJ, USA
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Holt T, Taylor S, Abraham P, Mcmillian W, Harris S, Curtis J, Elder T. Three- versus four-factor prothrombin complex concentrate for the reversal of warfarin-induced bleeding. Int J Crit Illn Inj Sci 2018; 8:36-40. [PMID: 29619338 PMCID: PMC5869798 DOI: 10.4103/ijciis.ijciis_40_17] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective: The objective of this study was to evaluate the effectiveness of 3-factor prothrombin complex concentrate (3F-PCC) compared to 4-factor PCC (4F-PCC) in warfarin-associated bleeding. Methods: This multicenter, retrospective, cohort study analyzed data from patients admitted between May 2011 and October 2014 who received PCC for warfarin-associated bleeding. The primary outcome was the rate of international normalized ratio (INR) normalization, defined as an INR ≤1.3, after administration of 3F-PCC compared to 4F-PCC. Other variables of interest included the incidence of additional reversal agents, new thromboembolic events, and mortality. Results: A total of 134 patients were included in the analysis. The average dose of PCC administered was 24.6 ± 9.3 units/kg versus 36.3 ± 12.8 units/kg in the 3F-PCC and 4F-PCC groups, respectively, P < 0.001. Baseline INR in the 3F-PCC and 4F-PCC groups was 3.61 ± 2.3 and 6.87 ± 2.3, respectively P < 0.001. 4F-PCC had a higher rate of INR normalization at first INR check post-PCC administration compared to 3F-PCC (84.2% vs. 51.9%, P = 0.0001). Thromboembolic events, intensive care unit and hospital length of stay, and mortality were similar among both groups. Conclusion: The use of 4F-PCC leads to a more significant reduction in INR compared to 3F-PCC though no difference in mortality or length of stay was observed. Thromboembolism rates were similar among both groups.
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Affiliation(s)
- Tara Holt
- Department of Pharmacy, IU Health Methodist Hospital, Indianapolis, IN, USA
| | - Scott Taylor
- Department of Pharmacy, Via Christi Hospitals, Wichita, KS, USA
| | - Prasad Abraham
- Department of Pharmacy, Grady Health System, Atlanta, GA, USA
| | - Wesley Mcmillian
- Department of Pharmacy, Fletcher Allen Health Care, Burlington, VT, USA
| | - Serena Harris
- Department of Pharmacy, Eskenazi Health, Indianapolis, IN, USA
| | - James Curtis
- Department of Pharmacy, Bronson Methodist Hospital, Kalamazoo, MI, USA
| | - Tai Elder
- Department of Pharmacy, Via Christi Hospitals, Wichita, KS, USA
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Jablow LM, Jones CW, Carroll GG, Wilsey SV, Haroz R. Limb-threatening Deep Venous Thrombosis Complicating Warfarin Reversal with Three-factor Prothrombin Complex Concentrate: A Case Report. J Emerg Med 2016; 50:28-31. [PMID: 26603365 DOI: 10.1016/j.jemermed.2015.02.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 01/30/2015] [Accepted: 02/17/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Three- and four-factor prothrombin complex concentrates (PCC) are gaining popularity for acute reversal of vitamin K antagonist-associated bleeding. Although acute thrombosis after PCC administration has been described, it seems to be rare. CASE REPORT An 83-year-old woman on warfarin for history of deep venous thrombosis (DVT) presented to the Emergency Department with life-threatening gastrointestinal bleeding, requiring urgent PCC administration. After stabilization, she subsequently developed a new limb-threatening upper-extremity DVT. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As PCC therapy gains popularity for reversal of anticoagulant-induced bleeding in urgent bleeding scenarios, the emergency physician must be aware of the complications of PCC administration, including new limb-threatening DVT.
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Jones CA, Ducis K, Petrozzino J, Clark E, Fung MK, Peters C, Sarkar IN, Krol E, Pochal B, Boutrus A, Weimersheimer P, Freeman K. Prevention of treatment-related fluid overload reduces estimated effective cost of prothrombin complex concentrate in patients requiring rapid vitamin K antagonist reversal. Expert Rev Pharmacoecon Outcomes Res 2015. [PMID: 26211539 DOI: 10.1586/14737167.2015.1071194] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Fresh frozen plasma (FFP) is a frequently used human blood product to reverse the effects of vitamin K antagonists. While FFP is relatively economical, its large fluid volume can lead to hospitalization complications, therefore increasing the overall cost of use. MATERIALS & METHODS A recently published article by Sarode et al., in Circulation, described the rate of volume overload associated with FFP use for reversal of vitamin K antagonists. This condition, described as transfusion-associated circulatory overload, has a defined rate of intensive care admission, which also has a well-reported average cost. The additional monetary value of intensive care unit admission and caring for fluid overload is then compared to the cost of another product, four-factor prothrombin complex concentrates, which does not, as per the Sarode paper, result in fluid overload. RESULTS The increased costs attributed to FFP-associated fluid overload for vitamin K antagonist reversal partly defrays the increased upfront cost of four-factor prothrombin complex concentrates. DISCUSSION FFP is commonly used to acutely reverse the effects of vitamin K antagonists. However, its use requires significant time for infusion, may lead to fluid overload, and is not fully effective in compete anticoagulation reversal. One alternative therapy for anticoagulant reversal is use of prothrombin complex concentrates, which are rapidly infused, are not associated with fluid overload, and are effective in complete reversal of coagulation measurements. This should be considered for patients with acute bleeding emergencies.
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Affiliation(s)
- Christopher A Jones
- a 1 Global Health Economics Unit of the Center for Clinical and Translational Science, University of Vermont, College of Medicine, Burlington, VT, USA.,b 2 Department of Surgery, University of Vermont College of Medicine, Burlington, VT, USA.,c 3 Center for Science and Society, Trinity College, University of Oxford, Oxford, UK.,d 4 European Centre for International Political Economy, Brussels, Belgium
| | - Katrina Ducis
- b 2 Department of Surgery, University of Vermont College of Medicine, Burlington, VT, USA
| | - Jeffrey Petrozzino
- a 1 Global Health Economics Unit of the Center for Clinical and Translational Science, University of Vermont, College of Medicine, Burlington, VT, USA.,e 5 Compara Biomedical, Orlando, FL, USA
| | - Eric Clark
- a 1 Global Health Economics Unit of the Center for Clinical and Translational Science, University of Vermont, College of Medicine, Burlington, VT, USA.,b 2 Department of Surgery, University of Vermont College of Medicine, Burlington, VT, USA
| | - Mark K Fung
- b 2 Department of Surgery, University of Vermont College of Medicine, Burlington, VT, USA
| | - Christian Peters
- h 8 CSL Behring, In.c, Marburg, Germany.,i 9 Therakos In.c, 10 N. High St, West Chester, PA 19380, USA
| | - Indra Neil Sarkar
- a 1 Global Health Economics Unit of the Center for Clinical and Translational Science, University of Vermont, College of Medicine, Burlington, VT, USA.,f 6 Biomedical Informatics Unit of the Center for Clinical and Translational Science, University of Vermont, College of Medicine, Burlington, VT, USA
| | - Emilia Krol
- b 2 Department of Surgery, University of Vermont College of Medicine, Burlington, VT, USA
| | - Brina Pochal
- a 1 Global Health Economics Unit of the Center for Clinical and Translational Science, University of Vermont, College of Medicine, Burlington, VT, USA
| | - Amanda Boutrus
- g 7 University of Vermont, College of Medicine, Burlington, VT, USA
| | - Peter Weimersheimer
- b 2 Department of Surgery, University of Vermont College of Medicine, Burlington, VT, USA
| | - Kalev Freeman
- b 2 Department of Surgery, University of Vermont College of Medicine, Burlington, VT, USA
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Mendelson D, Kates S, Pacos J, Clark N, Wu J. Proximal tibia and fibula fragility fracture complicated by anticoagulation and demand-mediated myocardial infarction. Geriatr Orthop Surg Rehabil 2011; 2:110-6. [PMID: 23569680 DOI: 10.1177/2151458511412167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We present for discussion a case of a right displaced proximal metaphyseal tibial fracture with intraarticular extension and a same-level proximal fibula fracture with severe degenerative arthritis in a medically complex 89 year old community dwelling woman with a history of paroxysmal atrial fibrillation, right lower extremity deep venous thrombosis 1 month prior to this admission on warfarin, obesity, peripheral vascular disease, and previous stroke. Her course is complicated by demand-mediated myocardial infarction. This case demonstrates that comanagement can lead to minimal delays and a satisfactory outcome in a complex, high-risk patient.
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Affiliation(s)
- Daniel Mendelson
- Department of Medicine, Highland Hospital; Division of Geriatrics, University of Rochester School of Medicine & Dentistry, Rochester, NY
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