Abstract
The development of Prothrombin Complex Concentrates (PCCs) has led to better outcomes in patients receiving emergency reversal of warfarin. However, most published data describes the use of PCCs in the setting of major bleeding or emergent major surgery, with little information on neuraxial blockade. We describe a case of rapid warfarin reversal using PCC and subsequent surgery under spinal anaesthesia in an 87-year-old lady, for whom general anaesthesia was deemed high risk. Her international normalised ratio (INR) on the morning of surgery was 1.8, precluding neuraxial blockade; however, it was felt that given, the need for imminent surgery, immediate reversal of the warfarin was indicated. We administered a single dose of 23 units/kg PCC and 5 mg vitamin K. Her INR 1 hour following PCC was 1.2, and spinal anesthetic was administered. The patient then underwent excision of melanoma deposits from her leg and groin dissection. There were no complications, the patient recovered satisfactorily, and there were no thrombotic or hemorrhagic events at 30 days postoperatively. This case study demonstrates a novel use of PCCs; in certain patients, PCCs may be safely used for immediate reversal of warfarin to allow for neuraxial blockade, safer anaesthesia, and better outcomes.
Highlights
The development of Prothrombin Complex Concentrates (PCCs) has led to better outcomes in patients receiving emergency reversal of warfarin anticoagulation [1,2,3,4]
We describe a case of rapid warfarin reversal using PCC and subsequent surgery under spinal anaesthesia, with a good surgical outcome and no thrombotic or haemorrhagic events at 30 days
Her background history included atrial fibrillation which was rate controlled and required anticoagulation. Her background included mitral regurgitation, hypertension, and hypothyroidism. As her mobility was severely limited by osteoarthritis of the hip, it was difficult to clinically establish her exercise tolerance, and it was decided that she would be more suitable for neuraxial blockade than general anaesthesia
Summary
The development of Prothrombin Complex Concentrates (PCCs) has led to better outcomes in patients receiving emergency reversal of warfarin anticoagulation [1,2,3,4]. An 87-year-old lady was scheduled for urgent palliative removal of malignant melanoma and satellite lesions from her lower leg and ipsilateral groin dissection for metastatic disease Her background history included atrial fibrillation which was rate controlled (digoxin) and required anticoagulation (warfarin). Her background included mitral regurgitation, hypertension, and hypothyroidism As her mobility was severely limited by osteoarthritis of the hip, it was difficult to clinically establish her exercise tolerance, and it was decided that she would be more suitable for neuraxial blockade than general anaesthesia. She was instructed to discontinue warfarin for 4 days prior to her planned surgery, which she did. Postponing her surgery would have caused a delay of a number of days, due to the specifics of scheduling her case, and it was felt that, given the existing tumour burden, a delay of this magnitude was not acceptable
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