Prothrombinex Use in Cardiac Surgery: Results of a 6 Month Audit

Abstract

Cardiac surgery continues to be associated with excessive perioperative bleeding due to poorly characterised haemostatic changes associated with cardiopulmonary bypass (CPB) and the trauma of major surgery. Blood component support varies between institutions and the recent introduction of recombinant VIIa promises to improve perioperative haemostasis, albeit at significant expense. Prothrombin complex concentrates (ProthrombinexTM-HT(PTX), CSL Australia) are utilised increasingly to correct excessive oral anticoagulation and have a number of advantages over FFP including greater coagulation factor concentration (particularly IX), reduced product volume and viral inactivation. There is no data on the use of PCCs in cardiac surgery. During a 6 month period (February – August 2003), 203 patients underwent cardiac surgery at Barwon Health of whom 60 received PTX during the intra-operative or post-operative period (45 M, 15 F; Mean age 68.7 years). 28 (47%) patients underwent simple procedures (either valvular or graft surgery alone) while the remaining 32 (53%) patients had complex surgery (emergency cases, graft/valves, double valves, Bentall’s or redos). PTX was employed following the use of standard blood component support when there was evidence of persistent bleeding and abnormal laboratory coagulation studies. 20 patients intra-operatively and 34 patients post-op required no PTX. The mean dose of PTX administered intra-operatively was 595 U (range 500–2000 U) and 240 U post-operatively (range 500–1000). PTX use was associated with documented improvements in bleeding and coagulation studies; mean INRs and APTTs pre- & post- PTX 1.7 > 1.3 and 65 s > 52s respectively. 33 (55%) patients were evaluated at 3 months through their physicians for evidence of prothrombotic sequelae. 8 patients were noted to have had potential prothrombotic complications (4 myocardial ischaemia, 1 pulmonary embolus, 1 CVA and 2 thrombophlebitis). Conclusion On the basis of this small study, PTX is a useful adjunct to standard blood component support in cardiac surgery and may defer the use of rVIIa in this setting.