Traumatic Intracranial Hemorrhage in Patients on Warfarin.
Prothrombin complex concentrates (PCC) vs Fresh frozen plasma (FFP)
- PCC normalizes the INR much more rapidly than FFP (0.5 hr vs 6-12 hours from initiation of administration)
- Rapid normalization/and protocol driven care which expediates administration of either FFP or PCC has demonstrated a reduction in the expansion of traumatic intracranial hemorrhage
- ... however, this has never been demonstrated to improve mortality or neurologic outcomes.
- Similarly rapid INR correction can lead to faster neurosurgical intervention... although no proven improvement in outcomes
- FFP is associated with considerable risk of fluid overload (TACO- 1:68-1:1500 units transfused) in a volume dependent manner and is more likely in patients with chronic kidney disease and congestive heart failure (precisely the patients who frequently are on warfarin). FFP is also associated with rarer complications such as viral transmission and anaphylaxis.
- PCC does not have any of the complications associated with FFP, although it is believed to have an increased risk of thromboembolic events with incidence of ~1.8% based of retrospective studies primarily.
(note the below are COSTS which are usually multiple times less than CHARGES to patients)
- PCC is considerably more expensive than FFP.
- FFP is estimated to cost ~$1 mL. With average patient requiring 4 units of FFP that equals approximately $1000 in COSTS.
- PCC is $1.27 per UNIT. Dosing costs typically range from 2500-5000 units, which corresponds to costs of $3157 and $6350 respectively. CHARGES to patients are typically ~3x this amount.
Bottom Line: If cost were no issue then PCC would be the treatment of choice for probably all patients. Data appears to trend towards improved outcomes with more rapid reversal, which of course is a logical conclusion in a bleeding anticoagulated patient. Cost, however, is a consideration and at this time patient selection is key. For the younger, healthy patient with intracranial hemorrhage with high propensity for expansion (ex. subdural hematoma, epidural hematoma, intraparenchymal hemorrhage) reach for PCC without second thought. Patients with high risk of fluid overload are also a key population to consider PCC as treatment of choice.