Department of Pharmacy, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA.
Division of Neurocritical Care, Maine Medical Center, Portland, ME, USA.
Neurocrit Care. 2017 Dec;27(3):334-340. doi: 10.1007/s12028-017-0422-7.
Prothrombin complex concentrates (PCCs) have become the first-line therapy for warfarin reversal in the setting of central nervous system (CNS) hemorrhage. Randomized, controlled studies comparing agents for warfarin reversal excluded patients with international normalized ratio (INR) <2, yet INR values of 1.6-1.9 are also associated with poor outcomes.
We retrospectively reviewed our use of a low-dose (15 units/kg) strategy of 4-factor PCC (4F-PCC) on warfarin reversal (INR 1.6-1.9) in the setting of both traumatic and spontaneous intracranial bleeding.
A total of 21/134 (15.7%) patients with either spontaneous or traumatic intracranial hemorrhage presented with an INR value of 1.6-1.9. Nine patients (43%) presented with traumatic bleeding and 12 (57%) with spontaneous bleeding. The median (IQR) presenting INR was 1.8 (1.7, 1.9) which decreased to 1.3 (1.2, 1.3) following the administration of low-dose 4F-PCC (median dose = 1062 units; 15.2 units/kg). A total of 19/20 (95%) patients achieved a goal INR value of ≤1.5 on the first check following dosing and 17/20 (85%) achieved an INR value ≤1.3. One patient did not have follow-up INR testing due to withdrawal of life support. No patient experienced hematoma expansion within 48 h of 4F-PCC, and there were no thromboembolic events within 72 h of administration.
The administration of low dose (15 units/kg) of 4F-PCC for urgent warfarin reversal in the setting of CNS hemorrhage was effective in correcting the INR in patients presenting with INR values of 1.6-1.9. Further assessment of low-dose PCC for urgent reversal of modest INR elevation is warranted.
在中枢神经系统（CNS）出血的情况下，凝血酶原复合物浓缩物（PCC）已成为华法林逆转的一线治疗方法。比较华法林逆转药物的随机对照研究排除了 INR<2 的患者，然而 INR 值为 1.6-1.9 也与不良结局相关。
我们回顾性地回顾了我们在创伤性和自发性颅内出血的情况下使用低剂量（15 单位/公斤）4 因子 PCC（4F-PCC）策略对 INR 为 1.6-1.9 的华法林逆转的使用情况。
共有 21/134（15.7%）自发性或创伤性颅内出血患者的 INR 值为 1.6-1.9。9 例（43%）患者为创伤性出血，12 例（57%）为自发性出血。INR 的中位数（IQR）为 1.8（1.7，1.9），使用低剂量 4F-PCC 后降至 1.3（1.2，1.3）（中位数剂量=1062 单位；15.2 单位/公斤）。20 例患者中有 19 例（95%）在给药后第一次检查时达到 INR 值≤1.5，17 例（85%）达到 INR 值≤1.3。1 例患者因停止生命支持而未进行后续 INR 检测。在使用 4F-PCC 后 48 小时内，没有患者发生血肿扩大，在给药后 72 小时内没有发生血栓栓塞事件。
在 CNS 出血的情况下，为紧急华法林逆转而给予低剂量（15 单位/公斤）的 4F-PCC 可有效纠正 INR 值为 1.6-1.9 的患者的 INR。需要进一步评估低剂量 PCC 对中度 INR 升高的紧急逆转作用。
