Consensus protocol for the emergency reversal of coumarin-induced anticoagulation

The management of haemorrhage or risk of haemorrhage in anticoagulated patients increasingly involves those providing services for haemophilia. This is particularly so in the use of prothrombin complex concentrates where experience of the use of these products exists almost entirely within haemophilia centres. As the majority of bleeding anticoagulated patients present to hospitals that do not have haemophila centres, and where there is little experience in the use of PCCs, there is clearly a need for practical guidelines to guide use of these products. Clinicians must be made aware of the potential benefits and risks of using concentrated coagulation factors prepared from large plasma pools.

A key aspects of the safe use of PCCs is the careful selection of the clinical indications for their use. Only those patients with or at risk from life-threatening haemorrhage should be treated. And where a licensed product is available, this should be used in preference to those that are not.

Data are lacking on the comparative efficacy of products containing factors II, VII, IX (FIX) and X against those lacking factor VII. There is evidence to show that factor VII levels may be extremely low in patients with high INRs, suggesting that overanticoagulated patients may benefit more from PCCs containing all four vitamin K-dependent factors.

The optimal dose of PCC required to reverse anticoagulation is not fully established but does depend on the degree of the coagulation defect. The experience of this group suggests that doses between 25 IU FIX/kg and 50 IU FIX/kg are effective.

We present a practical protocol for the use of PCC in reversal of coumarin-induced anticoagulation.