24 should be administered concomitantly to sustain the effects of PCC . 18 In the case of intracranial haemorrhage , clinicians are unlikely to resume VKA therapy in the following two to four weeks after the event . Hospitals should have their own protocols regarding dosage , but these patients can receive a dose of 10mg IV vitamin K concomitantly with PCC , without concern for VKA refractoriness . Other patients requiring emergent major surgery may receive 3 – 5mg IV vitamin K , or 1 – 2mg IV in patients with a mechanical heart valve or LVAD . Concomitant vitamin K need not be given to patients undergoing INR reversal with PCC for minor invasive procedures .
Dosing of PCC for minor surgery and minor invasive procedures For patients undergoing minor surgeries or invasive procedures , such as line placement or thoracentesis , or for patients with LVAD or a mechanical heart valve , a higher INR goal of ≤2.0 may be used . Given the low added bleeding risk of many minor invasive procedures , there is evidence to support that they may be performed safely without any prior correction of INR . 23 However , if pre-procedure 4F-PCC is deemed necessary , a single low , fixed dose of 500 or 1000IU PCC will often achieve this goal , and concomitant vitamin K need not be given .
Conclusions In summary , VKA reversal is often required prior to surgery or invasive procedures to avoid excessive bleeding associated with anticoagulation . The urgency and bleeding risk of the procedure , as well as the patient-specific thromboembolic risk of VKA cessation , often determines the desired post-reversal INR and options for VKA reversal . In patients requiring major surgery , an INR of ≤1.5 should be achieved , but a higher INR goal of ≤2.0 may be used in patients undergoing minor surgeries or invasive procedures . Pre-operative management of VKA reversal can be accomplished using IV vitamin K administration and / or appropriate dose of 4F-PCC , and the VKA reversal method used depends on the type and urgency of surgical invention . If 4F-PCC is unavailable , then plasma can be used with the understanding that a large volume may have to be given , resulting in a much slower rate of VKA reversal . l
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Table 2 : 4F-PCC dosing for VKA reversal
Pre-treatment INR Dosage based on patient weight ( IU / kg )
2 to < 4 25 4 – 6 35 > 6 50
* Up to a maximum 100kg ; IU , international units
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