Newly Published
Review Article  |   August 2018
Prothrombin Complex Concentrates for Perioperative Vitamin K Antagonist and Non–vitamin K Anticoagulant Reversal
Author Notes
  • From the Department of Anesthesiology, Cardiothoracic Intensive Care Unit, Duke University School of Medicine, Durham, North Carolina (J.H.L.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (J.D.); Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany (T.S.); Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts (J.N.G.); and the Departments of Neurology and Surgery and Perioperative Care, Seton Dell Medical School Stroke Institute, Austin, Texas (T.J.M.).
  • Submitted for publication February 6, 2018. Accepted for publication July 10, 2018.
    Submitted for publication February 6, 2018. Accepted for publication July 10, 2018.×
  • Research Support: The authors had full editorial control and no additional financial support was received. Writing assistance was also provided with a grant from CSL Behring (Marburg, Germany).
    Research Support: The authors had full editorial control and no additional financial support was received. Writing assistance was also provided with a grant from CSL Behring (Marburg, Germany).×
  • Competing Interests: Dr. Levy serves on research and advisory committees for Boehringer-Ingelheim (Ingelheim am Rhein, Germany), CSL Behring (Marburg, Germany), Grifols (Barcelona, Spain), Instrumentation Laboratories (Bedford, Massachusetts), Janssen (Beerse, Belgium), Merck (Kenilworth, New Jersey), Octapharma (Lachen, Switzerland), and Portola (South San Francisco, California). Dr. Steiner has received a research grant form Octapharma, consultancy fees from Bayer (Leverkusen, Germany), BMS-Pfizer (New York, New York), Boehringer-Ingelheim, and Daiichi Sankyo (Tokyo, Japan), and speakers’ honoraria from Bayer, BMS-Pfizer, Boehringer-Ingelheim, and Daiichi Sankyo, and holds shares from Novo Nordisk (Bagsværd, Denmark). Dr. Goldstein has received research funding from Boehringer-Ingelheim, Pfizer (Groton, Connecticut), and Portola. Dr. Milling serves on research steering committees for Population Health Research Institute (Hamilton, Canada), Portola, Boehringer-Ingelheim, and CSL Behring, and a speakers’ bureau for Janssen. He has also received funding from the Seton Dell Medical School Stroke Institute (Austin, Texas) as a principal investigator; grant No. NHLBI K23 1K23HL127227-01A1. Dr. Douketis declares no competing interests.
    Competing Interests: Dr. Levy serves on research and advisory committees for Boehringer-Ingelheim (Ingelheim am Rhein, Germany), CSL Behring (Marburg, Germany), Grifols (Barcelona, Spain), Instrumentation Laboratories (Bedford, Massachusetts), Janssen (Beerse, Belgium), Merck (Kenilworth, New Jersey), Octapharma (Lachen, Switzerland), and Portola (South San Francisco, California). Dr. Steiner has received a research grant form Octapharma, consultancy fees from Bayer (Leverkusen, Germany), BMS-Pfizer (New York, New York), Boehringer-Ingelheim, and Daiichi Sankyo (Tokyo, Japan), and speakers’ honoraria from Bayer, BMS-Pfizer, Boehringer-Ingelheim, and Daiichi Sankyo, and holds shares from Novo Nordisk (Bagsværd, Denmark). Dr. Goldstein has received research funding from Boehringer-Ingelheim, Pfizer (Groton, Connecticut), and Portola. Dr. Milling serves on research steering committees for Population Health Research Institute (Hamilton, Canada), Portola, Boehringer-Ingelheim, and CSL Behring, and a speakers’ bureau for Janssen. He has also received funding from the Seton Dell Medical School Stroke Institute (Austin, Texas) as a principal investigator; grant No. NHLBI K23 1K23HL127227-01A1. Dr. Douketis declares no competing interests.×
  • Correspondence: Address correspondence to Dr. Levy: Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, 27710. Jerrold.levy@duke.edu. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Review Article / Coagulation and Transfusion
Review Article   |   August 2018
Prothrombin Complex Concentrates for Perioperative Vitamin K Antagonist and Non–vitamin K Anticoagulant Reversal
Anesthesiology Newly Published on August 28, 2018. doi:10.1097/ALN.0000000000002399
Anesthesiology Newly Published on August 28, 2018. doi:10.1097/ALN.0000000000002399
Abstract

Vitamin K antagonist therapy is associated with an increased bleeding risk, and clinicians often reverse anticoagulation in patients who require emergency surgical procedures. Current guidelines for rapid anticoagulation reversal for emergency surgery recommend four-factor prothrombin complex concentrate and vitamin K coadministration. The authors reviewed the current evidence on prothrombin complex concentrate treatment for vitamin K antagonist reversal in the perioperative setting, focusing on comparative studies and in the context of intracranial hemorrhage and cardiac surgery. The authors searched Cochrane Library and PubMed between January 2008 and December 2017 and retrieved 423 English-language papers, which they then screened for relevance to the perioperative setting; they identified 36 papers to include in this review. Prothrombin complex concentrate therapy was consistently shown to reduce international normalized ratio rapidly and control bleeding effectively. In comparative studies with plasma, prothrombin complex concentrate use was associated with a greater proportion of patients achieving target international normalized ratios rapidly, with improved hemostasis. No differences in thromboembolic event rates were seen between prothrombin complex concentrate and plasma, with prothrombin complex concentrate also demonstrating a lower risk of fluid overload events. Overall, the studies the authors reviewed support current recommendations favoring prothrombin complex concentrate therapy in patients requiring vitamin K antagonist reversal before emergency surgery.