Heme/Onc

80 yo lady presents with a hematoma after a fall

Mary Guan on Jan 22, 2019 - University of Michigan

CTA chest/abdomen/pelvis obtained upon arrival to University of Michigan ED demonstrated a large hematoma in the right pectoral region extending into the right inferior breast, right axilla and right lateral chest wall.  Anticoagulation was held as a result. Plastic surgery saw the patient and performed a bedside Incision and Drainage. There was expression of roughly 450-500 cc of clotted blood. The post-pectoral space was not explored. Anticoagulation continued to be held, and the patient returned to the OR the next day for definitive incision and drainage of right breast subglandular and subpectoral hematoma. Oozing was seen over pectoralis muscles, but no definitive bleeding source was identified.  Blood loss during the procedure was 30 cc of new blood loss and approximately 1.5L of old blood. Two flat JP drains were placed, one in the subglandular and 1 in the subcutaneous tissue.

Besides Vitamin K, what can be used for warfarin-associated bleeding?

Select all that apply
Expand all answers
FFP
May be given if no PCC is available.


Platelet transfusion
Yes, in the setting of thrombocytopenia.


RBC transfusion
Yes, if high amount of blood loss and/or low HGB.


Tranexamic acid
Yes. How does tranexamic acid work?


DDAVP
Yes. How does tranexamic acid work?


Factor VII concentrate
Although reports of Factor VII concentrate have been used to stop bleeding, it is not recommended.


4 factor Prothrombin complex concentrate
Yes, more effective than FFP and PCC


3 factor Prothrombin complex concentrate
May not be as effective as 4 factor PCC: https://www.ncbi.nlm.nih.gov/pubmed/28763307


Protamine sulfate
This is used for heparin overdose


FFP is frozen within a specific time period after collection both from a human donor, while PCC is pooled, virus-inactivated human plasma products. What advantages does PCC have over FFP?

Select all that apply
Expand all answers
FFP needs a couple hours to defrost
Yes


PCC has more rapid INR reduction.
Yes


PCC is associated with lower risk of TRALI (transfusion-related acute lung injury) and volume overload adverse events
Yes, more volumes of FFP are required for warfarin reversal (initial dose 15 to 30 mL/kg).


There is an increased risk of thromboembolic events with FFP
No, this is not the case


Anaphylaxis is more likely with FFP
Yes disease transmission, anaphylactoid reactions, alloimmunization, excessive intravascular volume, transfusion-related acute lung injury, and increased risk of infections are all associated with FFP.


PCC raises HGB and HCT more than FFP.
No, this does not occur in studies.


(Bonus) What factor does 4 factor PCC contain that exists in very low levels in 3 factor PCC?

Expand all answers
2
7
9
10

  1. Barton CA, Hom M, Johnson NB, Case J, Ran R, Schreiber M (2018). Protocolized warfarin reversal with 4-factor prothrombin complex concentrate versus 3-factor prothrombin complex concentrate with recombinant factor VIIa. American Journal of Surgery, 215(5):775.
  2. DeAngelo J, Jarrell D, Cosgrove R, Camamo J, Edwards C, Patanwala AE (2018). Comparison of 3-Factor Versus 4-Factor Prothrombin Complex Concentrate With Regard to Warfarin Reversal, Blood Product Use, and Costs. American Journal of Therapeutics, 25(3):e326-e332.

CTA chest/abdomen/pelvis obtained upon arrival to University of Michigan ED demonstrated a large hematoma in the right pectoral region extending into the right inferior breast, right axilla and right lateral chest wall.  Anticoagulation was held as a result. Plastic surgery saw the patient and performed a bedside Incision and Drainage. There was expression of roughly 450-500 cc of clotted blood. The post-pectoral space was not explored. Anticoagulation continued to be held, and the patient returned to the OR the next day for definitive incision and drainage of right breast subglandular and subpectoral hematoma. Oozing was seen over pectoralis muscles, but no definitive bleeding source was identified.  Blood loss during the procedure was 30 cc of new blood loss and approximately 1.5L of old blood. Two flat JP drains were placed, one in the subglandular and 1 in the subcutaneous tissue.

Besides Vitamin K, what can be used for warfarin-associated bleeding?

Select all that apply
Expand all answers
FFP
May be given if no PCC is available.


Platelet transfusion
Yes, in the setting of thrombocytopenia.


RBC transfusion
Yes, if high amount of blood loss and/or low HGB.


Tranexamic acid
Yes. How does tranexamic acid work?


DDAVP
Yes. How does tranexamic acid work?


Factor VII concentrate
Although reports of Factor VII concentrate have been used to stop bleeding, it is not recommended.


4 factor Prothrombin complex concentrate
Yes, more effective than FFP and PCC


3 factor Prothrombin complex concentrate
May not be as effective as 4 factor PCC: https://www.ncbi.nlm.nih.gov/pubmed/28763307


Protamine sulfate
This is used for heparin overdose


FFP is frozen within a specific time period after collection both from a human donor, while PCC is pooled, virus-inactivated human plasma products. What advantages does PCC have over FFP?

Select all that apply
Expand all answers
FFP needs a couple hours to defrost
Yes


PCC has more rapid INR reduction.
Yes


PCC is associated with lower risk of TRALI (transfusion-related acute lung injury) and volume overload adverse events
Yes, more volumes of FFP are required for warfarin reversal (initial dose 15 to 30 mL/kg).


There is an increased risk of thromboembolic events with FFP
No, this is not the case


Anaphylaxis is more likely with FFP
Yes disease transmission, anaphylactoid reactions, alloimmunization, excessive intravascular volume, transfusion-related acute lung injury, and increased risk of infections are all associated with FFP.


PCC raises HGB and HCT more than FFP.
No, this does not occur in studies.


(Bonus) What factor does 4 factor PCC contain that exists in very low levels in 3 factor PCC?

Expand all answers
2
7
9
10

  1. Barton CA, Hom M, Johnson NB, Case J, Ran R, Schreiber M (2018). Protocolized warfarin reversal with 4-factor prothrombin complex concentrate versus 3-factor prothrombin complex concentrate with recombinant factor VIIa. American Journal of Surgery, 215(5):775.
  2. DeAngelo J, Jarrell D, Cosgrove R, Camamo J, Edwards C, Patanwala AE (2018). Comparison of 3-Factor Versus 4-Factor Prothrombin Complex Concentrate With Regard to Warfarin Reversal, Blood Product Use, and Costs. American Journal of Therapeutics, 25(3):e326-e332.

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