Currently, there are no studies published
on the effectiveness of PCC in trauma patients
on direct oral anticoagulants (DOACs). 46 However,
our experiences with major trauma patients
on DOACs revealed that high doses of PCC
(50U/kg body weight) are necessary to control
bleeding.
Risk of thromboembolic events
Joseph et al reported an incidence of
thromboembolic events in the range of 6% after
PCC administration in a heterogeneous group of
trauma patients. 47 Our group has shown that PCC
administration resulted in a substantial and
prolonged increase in endogenous thrombin
generation compared with patients who received
no coagulation therapy or fibrinogen concentrate
only. 48 PCCs are potent pro-coagulants and,
as such, the possibility of associated
thromboembolic complications should be
considered carefully. 49 Robust safety data
related to PCC use in TIC are still lacking.
Studies on the use of coagulation factor
concentrates in trauma
Data showing that fibrinogen supplementation
improves survival in trauma patients are still
limited. In a retrospective study the
administration of fibrinogen concentrate along
with PCC (4 factor concentrate) resulted in
favourable survival rates compared with those
predicted by both the trauma injury severity score
and the revised injury severity classification
score.6 Innerhofer et al compared FFP transfusion
versus coagulation factor concentrate (fibrinogen
concentrate first line, PCC and FXIII) replacement
in a cohort of major trauma patients. Significantly
fewer patients in the coagulation factor
concentrate group received massive transfusion
and fewer patients received ‘rescue’ therapy by
changing the treatment groups. However, the
primary outcome, which was multi-organ failure,
was not different between groups (the study was
stopped at 50% recruitment). 8 One study
compared a ROTEM-guided coagulation therapy
based on coagulation factor concentrates
(fibrinogen concentrate and PCC) with controls
from the German Trauma Registry, treated with
FFP. RBC and PC transfusions were avoided in
significantly higher proportions of patients in
the coagulation factor concentrate group.
However, no difference in mortality was
observed. 50
Conclusions
It remains unclear whether early substitution
of coagulation factor concentrate can improve
outcome in major trauma-related bleeding.
However, it has been clearly established that
coagulation factor concentrates allow rapid and
targeted supplementation of pro-coagulants, and
that the administration of fibrinogen concentrate
in cases of TIC effectively treats early and critical
fibrinogen depletion. Thus, fibrinogen
concentrate confers significant advantages in
both safety and speed of administration over
FFP transfusion for supplementation of
fibrinogen. In addition, PCCs effectively increase
the content of vitamin K-dependent coagulation
factors and is clearly superior compared with
FFP transfusion.
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