title: Emergent reversal of vitamin K antagonists: addressing all the factors.
abstract: BACKGROUND
  Reversal of warfarin-induced coagulopathy after traumatic injury may be done exclusively with prothrombin complex concentrates (PCCs). No direct comparisons between different PCC regimens exist to guide clinical decision-making. Our institution has used 2 distinct PCC strategies for warfarin reversal; a 3-Factor PCC (Profilnine) combined with activated Factor VII (3F-PCC+rVIIa), and a 4-Factor PCC (Kcentra) given without additional factor supplementation.
  
  
  METHODS
  Retrospective review of all PCC administrations to trauma patients with acute bleeding who were taking warfarin before injury. Primary endpoints were international normalized ratio (INR) reduction, in-hospital mortality, and diagnosis of deep venous thrombosis (DVT).
  
  
  RESULTS
  Eighty-seven patients were identified from 2011 to 2015. Fifty-three were treated with 3F-PCC+rVIIa and 34 with 4F-PCC. Patient demographics, injury severity, and presenting laboratory data were similar. The 3F-PCC+rVIIa produced a lower median (IQR) INR postreversal compared with 4F-PCC (.75 (.69, 1.00) vs 1.28 (1.13, 1.36), P<.001). Both regimens were able to obtain an INR lower than 1.5 immediately after administration (3F+rVIIA 93.9% vs 4F 97.1%, P =.51). In the 4F-PCC group, there was a significant decrease in the incidence of DVT (2.9% vs 22.6%), P < .01), and a nonsignificant reduction in mortality (2.9% vs 17.0%, P = .08).
  
  
  CONCLUSIONS
  Use of 4F-PCC for warfarin reversal after traumatic hemorrhage is associated with a less severe decrease in INR, a significant reduction in DVT rates and a trend toward reduced mortality when compared with similar patients treated with 3F-PCC+rVIIa.
authors.affiliation: Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code L611, Portland, OR 97239, USA. Electronic address: damartin@alamedahealthsystem.org.
authors.forename: David T
authors.initials: DT
authors.lastname: Martin
authors.affiliation: Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code L611, Portland, OR 97239, USA.
authors.forename: Cassie A
authors.initials: CA
authors.lastname: Barton
authors.affiliation: Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code L611, Portland, OR 97239, USA.
authors.forename: Christopher
authors.initials: C
authors.lastname: Dodgion
authors.affiliation: Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code L611, Portland, OR 97239, USA.
authors.forename: Martin
authors.initials: M
authors.lastname: Schreiber
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001779:Blood Coagulation Factors / Q000627:therapeutic use*; D016009:Chi-Square Distribution; D015331:Cohort Studies; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D004338:Drug Combinations; D004630:Emergencies; D005164:Factor IX / Q000627:therapeutic use*; D005167:Factor VII / Q000627:therapeutic use*; D005170:Factor X / Q000627:therapeutic use*; D005260:Female; D005500:Follow-Up Studies; D006470:Hemorrhage / Q000139:chemically induced* / Q000150:complications / Q000188:drug therapy*; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D008875:Middle Aged; D011516:Prothrombin / Q000627:therapeutic use*; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D016896:Treatment Outcome; D014812:Vitamin K / Q000037:antagonists & inhibitors*; D014859:Warfarin / Q000009:adverse effects* / Q000627:therapeutic use; D014947:Wounds and Injuries / Q000150:complications / Q000175:diagnosis
chemical_list: D001779:Blood Coagulation Factors; D004338:Drug Combinations; D014812:Vitamin K; C025667:prothrombin complex concentrates; D014859:Warfarin; D005167:Factor VII; D011516:Prothrombin; D005164:Factor IX; D005170:Factor X; C000599051:Profilnine SD
keywords: Coagulopathy; Prothrombin complex concentrates; Traumatic hemorrhage; Warfarin