Abstract
Prothrombin complex concentrate (PCC) is a term to describe pharmacological products that contain lyophilized, human plasma-derived vitamin K-dependent factors (F), FII, FVII, FIX, FX, and various amounts of proteins C and S. PCCs can be rapidly reconstituted in a small volume (20 ml for about 500 international units (IU)) at bedside and administered regardless of the patient’s blood type. PCCs are categorized as 4-factor PCC if they contain therapeutic amounts of FVII, and 3-factor PCC when FVII content is low. In addition, activated PCC which contains activated FVII and FX with prothrombin is available for factor VIII bypassing therapy in hemophilia patients with inhibitors. Currently, 4-factor PCC is approved for the management of bleeding in patients taking warfarin, but there has been increasing use of various PCCs in the treatment of acquired perioperative coagulopathy unrelated to warfarin therapy and in the management of bleeding due to novel oral anticoagulants. There is also an ongoing controversy about plasma transfusion and its potential hazards including transfusion-related lung injury (TRALI). Early fixed ratio plasma transfusion has been implemented in many trauma centers in the USA, whereas fibrinogen concentrate and PCC are preferred over plasma transfusion in some European centers.In this review, the rationales for including PCCs in the perioperative hemostatic management will be discussed in conjunction with plasma transfusion.
Highlights
Clinical management of severe bleeding in surgery and after trauma remains a major challenge
The FDA has approved the use of prothrombin complex concentrate (PCC) with therapeutic amounts of vitamin K-dependent factors for the management of bleeding in patients treated with warfarin [10]
Fassl et al reported that plasma usage was 33% in the thromboelastometry group compared to 65% in the control (P =0.005) while there was no difference in the use of fibrinogen and 4-factor PCC between the two groups in aortic surgery [35]
Summary
Clinical management of severe bleeding in surgery and after trauma remains a major challenge. The FDA has approved the use of prothrombin complex concentrate (PCC) with therapeutic amounts of vitamin K-dependent factors for the management of bleeding in patients treated with warfarin [10]. For the latter, prothrombin, FVII, FIX, and FX are the specific ‘targets’ of PCC for replacement. The abovementioned trauma and cardiac surgery studies suggested that factor concentrates can be effectively combined with allogeneic components using thromboelastometry-based protocols, resulting in reduced plasma transfusion [39]. It is speculated that transfused plasma prevents excessive hemodilution of procoagulant and anticoagulant proteins [63,64], making subsequent procoagulant interventions (PCC and rFVIIa) more effective and less thrombogenic [65]
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