Short Attention Span Summary
A patient on warfarin needs LP
Prothrombin complex concentrate (PCC) was effective at reducing the INR <1.5 in 89.2% of 37 patients in this retrospective review. Median time to LP was 135 minutes. There was one MI, “possibly” related to PCC administration. This hospital in Germany used 4-factor PCC.
PCC is an effective way to reverse warfarin for emergent LP.
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Ann Emerg Med. 2016 Sep;68(3):340-4. doi: 10.1016/j.annemergmed.2016.03.003. Epub 2016 Apr 14.
Treatment With Prothrombin Complex Concentrate to Enable Emergency Lumbar Puncture in Patients Receiving Vitamin K Antagonists.
Laible M1, Beynon C2, Sander P3, Purrucker J1, Müller OJ4, Möhlenbruch M5, Ringleb PA1, Rizos T6.
- 1Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.
- 2Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany.
- 3Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany; Department of Cerebrovascular diseases, Hetzelstift, Neustadt an der Weinstrasse, Germany.
- 4Department of Internal Medicine III, Heidelberg University Hospital, Heidelberg, Germany; German Center for Cardiovascular Research, partner site Heidelberg/Mannheim, Heidelberg, Germany.
- 5Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany.
- 6Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany. Electronic address: email@example.com.
Lumbar punctures are frequently necessary in neurologic emergencies, but effective oral anticoagulation with vitamin K antagonists represents a contraindication. We report the effectiveness of prothrombin complex concentrates to reverse vitamin K antagonist to enable emergency lumbar punctures, as well as evaluate lumbar puncture- and prothrombin complex concentrates-related complications.
Consecutive patients treated with prothrombin complex concentrates between December 2004 and June 2014 to enable emergency lumbar puncture were included. International normalized ratio (INR) before and after prothrombin complex concentrates treatment and the time between start of reversal treatment and lumbar puncture were recorded. A target INR of less than or equal to 1.5 was defined as effective prothrombin complex concentrates treatment. Bleeding events, thromboembolic events, and allergic reactions after prothrombin complex concentrates treatment were identified and classified as “related,” “probably,” “possibly,” “unlikely related,” or “not related” to the lumbar puncture and prothrombin complex concentrates infusion.
Thirty-seven patients were included (64.9% men; median age 76.0 years; interquartile range [IQR] 71.0 to 84.0 years). The intervention with prothrombin complex concentrates was effective in 33 of 37 patients (89.2%; 95% confidence interval [CI], 78.4% to 97.3%). The median INR was 2.2 (IQR 1.8 to 2.9; 95% CI, 1.9 to 2.5) before and 1.3 (IQR 1.2 to 1.4; 95% CI, 1.2 to 1.3) after prothrombin complex concentrates treatment. The median time between start of prothrombin complex concentrates treatment and lumbar puncture was 135 minutes (IQR 76 to 266 minutes; 95% CI, 84 to 198 minutes). One clinically irrelevant intracranial subdural hematoma “related” to the lumbar puncture developed. No allergic reaction was observed, but 2 of 37 patients (5.4%; 95% CI, 0% to 13.5%) experienced a thromboembolic event (1 ischemic stroke, classified “unlikely related,” and 1 myocardial infarction, “possibly related” to prothrombin complex concentrates treatment).
Reversing the effect of vitamin K antagonist with prothrombin complex concentrates to enable emergency lumbar puncture appears effective and safe, particularly in regard to bleeding events.
Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
PMID: 27085368 [PubMed – in process]
2 thoughts on “PCC reverses warfarin for LP”
The conclusion that PCC is "safe" seems a bit overstated here. This study enrolled 37 patients, of which one had a stroke multiple days later (agree that this is unlikely to be caused by the pcc) and one person who had an MI the same day as he received the PCC! While I agree that you cannot prove causation, this event seems to have been dismissed a little casually for my taste.
If this study can be replicated safely and successfully, I’ll be happy to start giving PCC for these patients, until then, however, I’ll pass.
I completely agree. It’s effective. But it’s a stretch to conclude it is safe yet.