J. Butz1, Y. Shan1, R. Shadis1, T. Vu1, O. Kirton1 1Abington Hospital, Jefferson Health,Surgery,Abington, PA, USA
Introduction: The Neurocritical Care Society and Society of Critical Care medicine are recommending the Prothrombin Complex Concentrate (PCC) as the preferred method of reversal for patient with warfarin related intracranial hemorrhage (ICH). The recommendation is based on studies, in which trauma patients are excluded. In trauma patients, protocol-based fresh frozen plasma (FFP) reversal may not be inferior.
Methods: Our institution utilized a FFP reversal protocol for warfarin related traumatic ICH. The trauma registry (2010 – 2017) was surveyed for patients with ICH, who underwent warfarin reversal. Primary outcome was mortality. Secondary outcomes included ICH progression based on Stockholm score, neurological deterioration, need for surgical intervention, fluid overload, VTE complication, and re-admission. We compared the data to the previous published large population studies (n > 100) referenced in the Neurocritical Care Guideline.
Results: Total of 140 patients underwent FFP reversal protocol. Demographics were of the following: average age 80.8 ± 8.3 years, male 53.6%, female 46.4%, BMI 27.0 ± 6.0 kg/m2, fall 68%, Initial SBP 157 ± 32, Initial HR 80 ± 19, and Initial GCS of 13-15 96.4%. Average time to reversal (INR ≤ 1.5) was 6.1 ± 3.8 hours. Morality was 17.1%, ICH progression was 32.4%, and neurological deterioration was 18.6%. These were lower or comparable to previously published results after PCC reversal of 32-37% (1,2), 35.3% (3), and 20% (2) respectively. In these same studies, results from FFP reversal were 45.6-54%, 45.4%, and 11% respectively. Surgical intervention was done in 7.1% of patients. Fluid overload was 2.9%. VTE complication was 3.6%. Re-admission rate for ICH was 6.4%.
Conclusion: Studies on reversal of warfarin in hemorrhagic stroke patients may not be generalized to warfarin associated traumatic ICH patients. Dedicated studies on trauma patients are needed to evaluate the benefit of warfarin reversal with PCC.
1. Parry-Jones, AR. Napoli, MD. Goldstein, JN. et al. Reversal Strategies for Vitamin K Antagonists in Acute Intracerebral Hemorrhage. Annals of Neurology. 2015 78(1): 54-62
2. Majeed, A. Meijer, K. Larrazabal, R. et al. Mortality in Vitamin K antagonist-related intracerebral bleeding treated with plasma or 4-factor prothrombin complex concentrate. Thrombosis and Haemostasis. 2014; 111:233-239
3. Kuramatsu JB, Gerner ST, Schellinger PD, et al. Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage. JAMA 2015; 313:824–836.