Bleeding in Cardiac Surgery: FFP or PCC?

[jope]

Hi all,

Was reviewing some literature for control of coagulopathy in cardiac surgery. I was wondering if you or your centers routinely use PCC now instead of FFP. If so, what doses do you normally use? We don't have ROTEM or TEG here but our department is considering moving to PCCs as first line now.

Here is a recent review:

Prothrombin complex concentrates in cardiac surgery: where... : Current Opinion in Anesthesiology

These findings have led to off-label uses of prothrombin complex concentrates (PCCs) in cardiac surgery. The purpose of this review is to compare and contrast the use of FFP and PCC, review the components, limitations and risks of different types of PCCs, and discuss the latest evidence for the...

journals.lww.com

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[vector2]

We only use PCCs here firstline in the setting of a pt with significant uni or biventricular dysfunction/volume overload where we have a very high pretest probability that 1000-1200+cc of FFP is going to be poorly tolerated. For instance, last time I used it without ffp first was for a pt s/p MVR/CABG who was ESRD with pre-op moderate RV dysfunction and pulm HTN

 

[OTCAwesome]

After FFP/cryo/plt fail to correct whatever coagulopathy, our guys like us to give the concentrated factor 7.

 

[Iso4ane]

KCentra (the PCC I have experience comes in boxes of 500U and 1000U). 500U is worth about 500mLs (or 2 standard) of FFP. In adults I like to give 1000Us, which is a less than the recommend 15U/kg of KCentra (in most of my patient population.

 

[JiPo]

If the plan is to give more than 2 ffp, we usually just go straight to kcentra 1000u, especially in the setting of struggling ventricles.

 

[PpfSuxTube]

Cant remember the last time i gave ffp until last night when i needed the volume after our bentall, ascending, cabrol 4.5 hour pump run was a bit dry with inr 1.9 and aptt not correcting with protamine. It worked well...

But other than that, we almost never give ffp anymore. Any big cases get 4gms riastap, 1500 octaplex almost empirically. Then we do plateletworks and coag panel to decide on giving the platelets and where were at...

After probably a round or 2 of that 'protocol' we give f7a and pray. We had teg but license expired. Honestly i prefer this approach and seems to work very well.

 

[vector2]

But other than that, we almost never give ffp anymore. Any big cases get 4gms riastap, 1500 octaplex almost empirically. Then we do plateletworks and coag panel to decide on giving the platelets and where were at...

Holy smokes. I guess if you're calling it octaplex you're not in the US, but here, giving those two empirically would cost $10,000 right off the bat. A bag of FFP is $200-300.

 

[bocciball]

In a very busy private practice with >1700 pump cases per year and STS III rating in almost all categories. Significant amount of re operations, circulatory arrest, Bentall's, homografts. We typically administer a round of traditional product, desmopressin, and follow TEG. If volume overload becomes an issue or RV failure is evident, then we switch over to KCentra. We use a flat dose of 1500 units which is in the moderate range. To my knowledge we have not any thrombotic complications. Previously, before I arrived at the institution they were using Novoseven, and there were some operative complications related to thromboses.

 

[PpfSuxTube]

Ffp is ki

Holy smokes. I guess if you're calling it octaplex you're not in the US, but here, giving those two empirically would cost $10,000 right off the bat. A bag of FFP is $200-300.

octaplex is about 600$ last i checked. More expensive than ffp but not 20x more.

Riastap is expensive but we had research a while back that it was cost neutral when compared to other strategies that weren't as useful and invariably ended up in more blood transfusions and hence evened the price diff

 

[vector2]

Ffp is ki

octaplex is about 600$ last i checked. More expensive than ffp but not 20x more.

Riastap is expensive but we had research a while back that it was cost neutral when compared to other strategies that weren't as useful and invariably ended up in more blood transfusions and hence evened the price diff

I think most pricing for kcentra is closer to 2 bucks per unit nowadays, but for an average dose that's still like 3 grand.

 

[T-burglar]

What is your impression of the effectiveness of the PCCs ?

We generally give blood products but if I’m being honest, to my eyes hemostasis seems very random . some patients bleed a lot after coming off pump, some don’t and in most cases it seems like the hemostatic system behaves randomly regardless of our interventions. . Many times I’ve achieved what should be an adequate blood composition of plasma proteins, fibrinogen, platelets and reversed any hemostatic poisons - and the patient still bleeds. Other times we rewarm a patient from deep hypothermia and they really don’t bleed much.

Honestly I’m becoming a bit of a nihilist when it comes to hemostasis , outside of antidotes for specific drugs.

 

[lunaire]

No good quality evidence in the cardiac realm on PCC > FFP. There are some in neuro on faster normalization of coagulopathy with PCC.

General practice, in my experience, is to use PCC when you're concerned about volume overload. That is generally not a problem for a bleeding heart patient. The volume in FFP is generally a good thing. We're also an albumin heavy program, limited use of crystalloid bolus (I know, no real evidence for this either), so we don't generally have issue with fluid overload, if the patient is actually bleeding.

 

[dchz]

WTF? Unless it's a circ arrest case, tell them to stop blaming coagulopathy for the surgical bleeding.... then make fun of them for a long pump run.

 

[psychbender]

Many times I’ve achieved what should be an adequate blood composition of plasma proteins, fibrinogen, platelets and reversed any hemostatic poisons - and the patient still bleeds.

Sounds like an acute prolene deficiency, to me.