Use of K-Centra in massive transfusion initiation

[Mabel Adams]

Is anyone considering using K-Centra, the new 4 factor PCC, at the beginning of a massive transfusion? At the start plasma may not yet be thawed and they might want something with lower fluid volume that they can get into the patient faster.  I know that big trauma centers are keeping thawed plasma ready at all times but smaller centers like we are that would have a hard time using up all that thawed plasma might benefit from using PCC (although I know it is expensive).  Just checking to see if anyone knows more about this concept.  I think they use it more readily in Europe than the US.

[Dansket]

From what I read, this drug is for warfarin-reversal.  Are you thinking about off-label use?

[Mabel Adams]

Well, it is approved for warfarin reversal in cases of major bleeding so that certainly fits some massive transfusions directly.  Doctors can choose to use it off-label so I was wondering if it is beginning to have a role in massive transfusion protocols in place of plasma.

[Auntie-D]

It is absolutely NOT recommended for MHP and specifically lists bleeding as a contraindications as it can initiate DIC.

[tbostock]

We are trying to utilize Kcentra and tranexamic acid here as part of our blood management program. We're thinking about Kcentra more for intracranial hemorrhages, and TXA for trauma/massive bleeds and knee replacements. I believe both will be used in trauma at some point.

It's been a battle here though. Keeps getting shut down in the Pharmacy committees because nobody knows enough about them yet.

[cthherbal]

We have implemented Transexamic acid for Orhopedic patients which has shown to decrease blood usage.

[tbostock]

 

We have implemented Transexamic acid for Orhopedic patients which has shown to decrease blood usage.

 

Are they using it topically or IV?

[Auntie-D]

Keeps getting shut down in the Pharmacy committees because nobody knows enough about them yet.

Or maybe they know more than you think-that it SHOULDNT be used...

[tbostock]

 

Or maybe they know more than you think-that it SHOULDNT be used...

 

The evidence is compelling that they are safe and effective, with very little risk of thrombosis when used as directed. You are certainly entitled to your opinion though.

[Auntie-D]

The evidence is compelling that they are safe and effective, with very little risk of thrombosis when used as directed. You are certainly entitled to your opinion though.

PCC is derived for the rapid reversal of warfarin and as a result contains heparin (up to 15iU/kg) - not exactly something you are wanting to be putting into someone who is massively bleeding. As there are no guidelines for volumes required there is the possibility of initiating DIC, and then there is the risk of HIT. The MDS for beriplex (the PCC) that we states that it is not advised for non-warfarin induced bleeding due to the risks mentioned above.

Giving plasma and cryo replaces all factors, not just 4 so is more likely to stop bleeding sooner, as well as reducing the risk of hypovolemic shock. Transfusing FFP and cryo also means that the medics know what is going in is of the same ratio as what is going in - which cannot happen with a mix of colloids and PCC.

Not just my opinion

http://onlinelibrary.wiley.com/store/10.1111/j.1538-7836.2010.04062.x/asset/j.1538-7836.2010.04062.x.pdf?v=1&t=ho92o2cpb211c92d

If you look at any studies for you will find that they specifically state that patients with DIC are excluded - hmm funny that...

I can think of a few reasons to use it for MHP - when there is severe liver disease, in extreme malnutrition and if there is the immediate need to prevent hypervolaemia. For the vast majority of MHP this is not an issue and 4:4:1:1 ratio of blood:plasma:cryo:platelets is the safest way to proceed.

Frozen products take 15 minutes to thaw - I have found that if it is put in the thawer immediately on receipt of the phone call, the staff will come over and grab 4 bags of flying squad blood and it will always be ready before they come back to the lab. There is no significant delay over administration - every trauma department I have ever seen will always use 4 blood before anything else to reduce the risk of brain/organ injury.

With PCC my biggest biggest concern (other than flooding a bleeding patient with heparin) is the significant risk of DIC - the possibility that this could cause further, and irreversible bleeding is not something I would be comfortable with.