Ultra-rapid management of oral anticoagulant therapy-related surgical intracranial hemorrhage.
OBJECTIVE
Intracranial hemorrhage in patients receiving oral anticoagulant (OAC) therapy is associated with poor neurological outcome. Prothrombin complex concentrate (PCC) is the gold-standard therapy to normalize hemostasis but remains underused. Ultra-rapid reversal of anticoagulation could reduce the time to biological and surgical hemostasis, and might improve outcome. We report the use of bolus infusions of PCC to immediately reverse anticoagulation and allow for urgent neurosurgical care.


METHODS
Prospective, observational study.


METHODS
Neurosurgical intensive care unit, university hospital.


METHODS
Eighteen patients with OAC-associated intracranial hemorrhage requiring urgent neurosurgical intervention.


METHODS
All patients received 20 UI/kg of PCC as an intravenous bolus infusion (3 min) and 5 mg of enteral vitamin K. Surgery was started immediately, without waiting for blood sample results.


RESULTS
Serial blood samples were performed to assess prothrombin time. Coagulation was considered normal when the international normalized ratio was </= 1.5. All patients, including nine who were over-anticoagulated, had complete reversal of anticoagulation immediately after the bolus of PCC. No hemorrhagic or thrombotic adverse effect was observed intra- or postoperatively.


CONCLUSIONS
A bolus infusion of PCC completely reverses anticoagulation within 3 min. Neurosurgery can be performed immediately in OAC-related intracranial hemorrhage. This study shows that OAC-treated patients can be managed as rapidly as non-anticoagulated patients.
Vigué
Bernard
B
Département d'Anesthésie-Réanimation, AP-HP, Centre hospitalo-universitaire de Bicêtre, 78, rue du Général Leclerc, 94275, Le Kremlin-Bicêtre Cedex, France. bernard.vigue@bct.aphp.fr
Ract
Catherine
C
Tremey
Benjamin
B
Engrand
Nicolas
N
Leblanc
Pierre Etienne
PE
Decaux
Anne
A
Martin
Laurent
L
Benhamou
Dan
D
D000284:Administration, Oral; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects* / Q000037:antagonists & inhibitors; D001779:Blood Coagulation Factors / Q000008:administration & dosage / Q000627:therapeutic use*; D006801:Humans; D007262:Infusions, Intravenous; D019934:International Normalized Ratio; D020300:Intracranial Hemorrhages / Q000139:chemically induced* / Q000188:drug therapy; D008875:Middle Aged; D019635:Neurosurgical Procedures; D013997:Time Factors
D000925:Anticoagulants; D001779:Blood Coagulation Factors; C025667:prothrombin complex concentrates