The Prospective Use of Prothrombin Complex Concentrates in an Administrative Region of the Province of Quebec.

Introduction:

Prothrombin complex concentrates (PCCs) are used in the rapid reversal of warfarin and all other vitamin K deficiencies in patients with a major bleed or who require an urgent procedure. The Local Advisory Committee on Transfusion Medicine standardised a protocol for the use of PCCs, outlining the indications and contra-indications for their use.

Methods:

The charts of all patients having received PCCs between a two year period at the 4 hospital centers of region 12 were reviewed to evaluate the respect of guidelines, adherence to the protocol, and the clinical outcomes of patients.

Results:

From Nov. 2009 to Nov. 2011, 129 patients were treated with PCCs: 97 (75%) in the emergency department, 14 (11%) in the intensive care unit, 16 (12%) on medical or surgical floors, and 2 (1.5%) in the operating room. 116 prescriptions (90%) respected the guidelines; among the extra, 4 (3%) were for elective surgeries and 3 (2.3%) for an elevated INR without evidence of bleeding. One patient did not have an INR prior to administration, 10 (8%) did not have a repeat INR 30-minutes post-administration, and Vitamin K was omitted in 10 cases (8%). The prescription is based on weight: 120 (93%) received the correct dose, 3 (2.3%) received too high a dose, and 5 (3.8%) received too low a dose. The clinical outcome was favourable in 94 cases (73%), with rapid reversal of the INR and eventual discharge from hospital. 22 (17%) died during hospitalization and 10 (8%) were lost to follow-up due to transfer to a neurosurgical facility. The INR was less than 1.4 in 86% of cases 30-minutes post-administration. 6 (4.6%) thromboembolic complications occurred: two pulmonary embolisms, two deep vein thrombosis, one stroke, one disseminated intravascular coagulation. Five had resumed warfarin, but none had a therapeutic INR.

Conclusion:

Our review demonstrates that the majority of physicians correctly apply the recommended practice guidelines for the use of PCCs, that these are effective at rapidly reversing the INR, and are associated with favourable clinical outcomes in the majority of cases. However, thromboembolic events are frequent, emphasizing that anticoagulation therapy should be resumed quickly once clinically appropriate