PCC Before Emergent LP

Although the true incidence of bleeding is unknown, there is likely an increased risk of spinal hematoma when performing a lumbar puncture (LP) in patients on vitamin K antagonists (eg, warfarin). A new study set out to determine the safety of prothrombin complex concentrate (PCC) when administered prior to emergent LP.

Setting

Tertiary care center’s neurologic Emergency Department (ED) in Germany (9,000 annual visits)

What They Did

• Retrospective database review of prospectively collected data for consecutive patients treated with PCC between December 2004 and June 2014
• Beriplex and Octaplex were used (both similar to KCentra in U.S.)
  • Primary Outcomes
    • INR ≤ 1.5 to normalize coagulation AND
    • Complications related to the LP or to administration of PCC

What They Found

• 37 patients (vitamin K antagonist was phenprocoumon)
• Median INR prior to PCC was 2.2 (IQR 1.8 to 2.9; 95% CI, 1.9 to 2.5)
• Median PCC dose was 1,000 IU
• Median INR after PCC was 1.3 (IQR 1.2 to 1.4; 95% CI, 1.2 to 1.3)
  • INR goal≤ 1.5 achieved in 33 of 37 patients
• Median time between start of PCC treatment and LP was 135 minutes
• Complications
  • No bleeding was observed
  • 2 of 37 patients experienced a thromboembolic event, though one was 15 days later

Application to ED Clinical Practice

• Study limited by retrospective design and lack of a control group; chart reviews typically underreport adverse events
• Majority of LPs were performed after patients were transferred to a neurologic or neurosurgical ward, limiting applicability to ED practice
• A clear INR threshold below which LPs can be safely performed is unknown

Bottom Line

Given the high cost of PCC in the U.S. and the limitations of this study, routine use of PCC before emergent LP in the ED cannot be recommended. Individual cases may be an exception.

References

Laible M, et al. Treatment With Prothrombin Complex Concentrate to Enable Emergency Lumbar Puncture in Patients Receiving Vitamin K Antagonists. Ann Emerg Med. 2016 Apr 14. [Epub ahead of print] PMID 27085368

Author: Bryan D. Hayes, PharmD

Attending Pharmacist, Emergency Medicine and Toxicology, Massachusetts General Hospital; Assistant Professor of EM, Harvard Medical School View all posts by Bryan D. Hayes, PharmD