FFP vs (iv Vit K+prothombin complex concentrate)

[DrMetal]

was doing a Mksap question, where an elderly patient comes into the ER with a SDH and mass effect, very symptomatic, Afib+coumadin with an INR=12. Which of the following is the most appropriate treatment?

my answer was FFP (and ~79% percent agreed).

But the correct answer was iv Vit K+prothombin complex concentrate.

Really? Isn't this a dire situation that requires immediate correction, wouldn't FFP provide that? (I understand that patient would likely need long term Vit K, you could start it at the same as the FFP). How many ER physicians know how to find 'prothombin complex concentrate'? Everybody's got FFP on standby, no?

---

Members don't see this ad.

 

[jdh71]

Prothrombin concentrate works better and faster with much less volume. BOOM! Reverses the anticoagilation. An INR of *12* would take 10-15 bags of FFP. That's a lot of fluid that isn't necessary. And yes the concentrates are readily commercially available. Every hospital has them.

 

[da8s0859q]

Prothrombin concentrate works better and faster with much less volume. BOOM! Reverses the anticoagilation. An INR of *12* would take 10-15 bags of FFP. That's a lot of fluid that isn't necessary. And yes the concentrates are readily commercially available. Every hospital has them.

This right here.

OP: When Bebulin (three-factor PCC) and Kcentra (four-factor) first came out, there was a lot of "hmm...", at least in my neck of the woods -- but in an elderly person with afib and lord knows what other medical history, with an INR of 12 and a head bleed, I'd give them PCC too. It's quickly become preferred in many, if not all, situations.

There have been studies done between PCC and FFP which admittedly aren't the most robust in terms of complications and/or use, but the bottom line is pretty sensible: you're giving concentrated clotting factors for a very specific reason in a minimum of volume and time.

Costs a ****load more, but better that than trying to give the FFP equivalent in this case.

 

[CopaceticOne]

How many ER physicians know how to find 'prothombin complex concentrate'?

Um, they put in the order for Kcentra.

But in all seriousness, the key points of the question are the INR of 12 + SDH w/ mass effect = serious bleeding!
FFP won't drop the INR sufficiently or fast enough.

 

[Raryn]

was doing a Mksap question, where an elderly patient comes into the ER with a SDH and mass effect, very symptomatic, Afib+coumadin with an INR=12. Which of the following is the most appropriate treatment?

my answer was FFP (and ~79% percent agreed).

But the correct answer was iv Vit K+prothombin complex concentrate.

Really? Isn't this a dire situation that requires immediate correction, wouldn't FFP provide that? (I understand that patient would likely need long term Vit K, you could start it at the same as the FFP). How many ER physicians know how to find 'prothombin complex concentrate'? Everybody's got FFP on standby, no?

4 factor PCC is a product explicitly made to counteract coumadin. It contains II, VII, IX, and X. It's your most direct and rapid reversal of the drug.

Many people don't know about it because it's relatively new, but that doesn't mean it's wrong.

 

[DrMetal]

Got it, thanks all. I have to abandon my old fashion FFP ways!


Sent from my iPhone using SDN mobile

 

[deleted547339]

Yea. This is something that I think EM was a little ahead of the curve on. When I was an intern we just had it come on formulary. With life threatening ICH of GI bleed, I gave it a few times only for the neurosurgeon or intensivist to tell me I'm crazy. Now I have to tell the neurosurgeon that the patient doesn't need PCC for an INR of 1.3 with an unchanged head CT and normal TEG.

 

[deleted820760]

Yes, like others said. If you want reference, per 2012 chest guidelines:

9.3. For patients with VKA-associated major bleeding, we suggest rapid reversal of anticoagulation with four-factor PCC rather than with plasma (Grade 2C).

We suggest the additional use of vitamin K 5 to 10 mg administered by slow IV injection rather than reversal with coagulation factors alone (Grade 2C)

FFP has the disadvantage of potential allergic reaction or transmission of infection, preparation time, and higher volume. PCC and recombinant factor VIIa are more rapidly concentrated with less infection transmission risk but have not been compared with FFP in adequately powered RCTs.

Several studies have compared products in addition to vitamin K, three of which reported rates of intracranial hemorrhage. A small case series of 17 patients compared the use of FFP and three-factor PCC; all patients received vitamin K.195 The mean INR decreased from 2.83 to 1.22 within 4.8 h in patients receiving PCC vs from 2.97 to 1.74 within 7.3 h for those receiving FFP (P < .001). The reaction level grade, used to assess symptoms and signs of intracerebral hemorrhage, suggested less progression in those receiving PCC (0.2 vs 1.9 grades on a scale of 1-8) (P < .05). Another small before-after study of 12 patients reported that the six patients receiving three-factor PCC compared with six age- and sex-matched historical controls given FFP had a mean INR correction time of 41 min for PCC vs 115 min for FFP.196

Finally, a small RCT compared factor IX complex concentrate (four-factor PCC) plus FFP vs FFP alone in 13 patients (five in factor IX concentrate and eight in FFP).197Factor IX concentrate plus FFP corrected the INR more quickly than FFP alone (2.95 vs 8.9 h, P < .01). In addition, five of eight patients in the FFP-alone group experienced significant fluid overload complications, despite monitoring of central venous pressure and the use of furosemide, compared with no reported complications in the combination group.