gms | German Medical Science

Objective: With the increased use of oral anticoagulation with vitamin K antagonists, neurosurgeons encounter a growing number of emergency patients requiring rapid reversal of anticoagulant effects. Administration of prothrombin complex concentrates (PCC) is recommended for anticoagulation reversal in patients with potentially life-threatening hemorrhage. Point of care (POC) devices enable a rapid and valid assessment of hemostasis within one minute and therefore, their use has been associated with major advantages in the emergency treatment of respective patients. In this study we report our initial experiences with POC-guided titration of PCC in anticoagulated patients requiring emergency anticoagulation reversal.

Method: The POC coagulometer CoaguChek XS^® was used in 9 anticoagulated patients with a condition requiring urgent anticoagulation reversal (traumatic intracranial haemorrhage: n=2; subdural hematoma: n=4; subarachnoid haemorrhage: n=1; other: n=2). PCC dosage was calculated on body weight and laboratory findings according to manufacturer's instructions in order to reach INR levels of <1.4. Following administration of 50% of this calculated dosage (+ x I.U. as complete 500 I.U. vials were administered), POC assessment of INR was carried out. In cases of INR>1.4, further 500 I.U. were administered. Four patients underwent immediate surgical treatment (external ventricular drainage, burr-hole trepanation, laminectomy, abscess evacuation). A Bland-Altman-Plot analysis was carried out for comparison of POC results with those of central laboratory assessment.

Results: In 8 of 9 patients, 50%+x of the calculated dosage was sufficient to achieve an INR of <1.4. (INR before PCC: 3.14; INR after PCC: 1.21). One patient required further 500 I.U. in order to achieve INR levels of <1.4. The mean administered dosage of PCC was 1444 I.U. while mean manufacturer's instruction-based calculated dosage was 2452 I.U. The mean reduction of PCC through this approach was 39% (mean cost reduction of approximately 200 Euro per patient). POC INR values correlated well with INR assessment in the central laboratory with a mean INR deviation of 0.017 ± 0.05.

Conclusions: Our initial experiences demonstrate that POC-guided anticoagulation reversal in neurosurgical emergencies significantly reduces the dosage of PCC. Hereby the thromboembolic risk associated with PCC can be reduced in this patient population. Furthermore, the use is also associated with a considerable reduction of economic expenses.