Prothrombin complex concentrate

So when a patient on warfarin is bleeding badly, we give both.

Four-factor PCC, prothrombin complex concentrate, replaces 2, 7, 9, and 10 right away.

And vitamin K keeps the liver making them.

Then we've got the direct agents.

Pradaxa has its own reversal agent, Praxabind, as well.

It's an antibody fragment that binds Pradaxa and nothing else.

So for a major bleed on Eliquis or Xarelto, we usually give four-factor PCC.

Okay, so again, see where almost every drug works, right? 10A or thrombin.

We don't always need to use reversal agents, but when we do have life-threatening bleeding and other measures are insufficient, it's important to know what these agents are, so let's go through each of them one by one.

For life-threatening bleeding on warfarin, what agent do you think we use? That's right, warfarin can be reversed with IV vitamin K plus four-factor prothrombin complex concentrate, or four-factor PCC.

Very good.

Four-factor PCC supplies clotting factors quickly, while vitamin K allows the liver to make functional factors again.

And if PCC is not available, then you can use fresh frozen plasma.

And what about the reversal agent for heparin? That's right, the reversal agent for heparin is protamine sulfate.

Very good.

Protamine sulfate works best against unfractionated heparin, but can also partially reverse anoxaparin as well.

You give IV vitamin K slowly, because if you rapidly administer it via IV, it's usually associated with some type of anaphylactoid reaction.

If it's urgent, like a patient on warfarin with an intracranial bleed who needs emergency surgery, you have to give four factor prothrombin complex concentrate, or PCC.

Now, four factor PCC contains the factors two, seven, nine, and 10, plus protein C and S. It's gonna replace exactly what warfarin took away.

It works within minutes, and it's a small volume.

Always give vitamin K along with it because the PCC is gonna wear off, and then the vitamin K is gonna provide that sustained reversal.

Well, what about FFP? We've heard of this before, giving FFP.

It does work, but it requires a really large volume, so it's gonna take time to thaw.

It carries some transfusion risks like volume overload, and it's also worth knowing that FFP usually can't bring the INR fully down to normal because FFP itself has an INR in the range of 1.4 to 1.6.