Cappabianca G, et al: Safety and efficacy of prothrombin complex concentrate as first-line treatment in bleeding after cardiac surgery.
Critical Care 2016; 20(5)
The authors analyzed data from their local experience utilizing prothrombin complex concentrate (PCC) as first-line coagulopathy treatment for bleeding following cardiac surgery with cardiopulmonary bypass (replacing fresh frozen plasma (FFP)). Study objectives were to examine: 1) the impact of PCC on hospital mortality, and 2) the effect of PCC on post-operative complications and blood transfusions. All consecutive patients undergoing isolated coronary artery bypass graft (CABG), valve surgery (± CABG), and proximal aortic procedures were included in this observational study. Decision for PCC transfusion was guided by point-of-care thromboelastography, prothrombin and activated partial thromboplastin times, and platelet count. Outcomes were compared with a historical series of patients who received FFP. Propensity score matching was utilized to compare groups.
Of 3454 patients (mean age 68 ± 10.8 years), one-to-one propensity score-matched analysis resulted in 225 pairs with similar baseline characteristics. Propensity score-adjusted multivariate analysis demonstrated that use of PCC was associated with a lower risk of red blood cell (RBC) transfusion (OR 0.50, 95% CI 0.31-0.80), decreased amount of RBC units (β, -1.42, 95% CI -2.06 to -0.77) and decreased risk of transfusion >2 RBC units (OR 0.53, 95% CI 0.38-0.73). However, patients receiving PCC had an increased risk of post-operative acute kidney injury (OR 1.44; 95% CI 1.02-2.05) and renal replacement therapy (OR 3.35, 95% CI 1.13-9.90). No difference between groups was observed in hospital mortality (9.3% vs. 8.4%, OR 1.51, 95% CI 0.84-2.72).
This study demonstrates that PCC instead of FFP does not impact mortality, but does reduce blood transfusion requirements. However, PCC use was also related to increased risk of post-operative acute kidney injury. The study has several limitations, and the potential benefits and harms associated with the use of PCC in cardiac surgery should be investigated in a randomized trial.
Jill M Cholette MD
Associate Professor of Pediatrics
Medical Director Pediatric Cardiac Care Center
University of Rochester, Golisano Children’s Hospital.