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Question 2#

A patient presents with a subdural hematoma with midline shift and was noted to be on warfarin. The patient’s INR is 3.5, and he is scheduled for an emergent decompressive craniotomy.

Which of the following is the best treatment for his coagulopathy?

A. Fresh Frozen Plasma
B. Cryoprecipitate
C. Platelets
D. Prothrombin complex concentrate (PCC)

Correct Answer is D

Comment:

Correct Answer: D

PCC can normalize the INR in 30 minutes. Dosing of PCC is based on the patient’s INR and ranges between 25 to 50 units per kilogram. Additionally, PCC is advantageous in that its administration constitutes a much smaller volume load compared to FFP. PCC is the recommended reversal agent for warfarin-induced INR elevation in the setting of intracranial hemorrhage.

FFP can take much longer to correct an elevated INR, and some studies found a median time of 30 hours for normalization of INR in patients with intraparenchymal bleeds. Moreover, the required volume of FFP can cause pulmonary edema, transfusion-related acute lung injury, and transfusionassociated circulatory overload.

Indications for cryoprecipitate include: hypofibrinogenemia, tPA-related life-threatening bleeding, von Willebrand’s disease, uremic bleeding, massive transfusion, and hemophilia A. Platelets may be transfused if the patient is thrombocytopenic.

Reference:

1. Frontera JA, Lewin JJIII, Rabinstein AA, et al. Guideline for reversal of antithrombotics in intracranial hemorrhage: a statement for healthcare professionals from the Neurocritical Care Society and Society of Critical Care Medicine. Neurocrit Care. 2016;24(1):6-46.