How Much Plasma Does It Take To Reverse Warfarin?

thetraumapro.com/2017/12/21/how-much-plasma-does-it-take-to-reverse-warfarin/

TheTraumaPro

For decades, plasma (with vitamin K) was the mainstay for reversing warfarin. Over the
past several years, prothrombin complex concentrates (PCC) have made inroads in the
management of this problem because of its sheer speed of action.

There are two problems with plasma. First, most hospitals still have only fresh frozen
plasma (FFP), and it takes 20-30 minutes to thaw. This adds some up-front time to
administration. Then, it takes time to infuse the 250cc or so of volume in each unit. This
may be 1 or 2 hours, depending on policy and patient tolerance of a bolus of colloid.

If it always just took one unit of plasma to correct the INR to a desirable range (typically
1.5-1.6), then the whole PCC conversation might be moot. You could potentially have the
INR corrected in 30-60 minutes depending on your patient’s cardiovascular system.

But how many does it really take? A group at Eastern Virginia Medical School in
Norfolk, VA looked at this problem and tried to come up with a mathematical formula.
They examined a year of warfarin reversal data at their hospital. Patients with severe
clotting disturbances (advanced cirrhosis, DIC) and those who received additional
products (PCC or activated Factor VII) were excluded.

Using data from nearly 1,000 patients, the following formula was derived and validated:

∆ INR = (0.57 · preINR) – 0.72

So a patient with an INR of 3.0 would be expected to show a decrease of 0.99 to about
2.0 after one unit. This formula can be used iteratively to figure out how many units will
drop the INR to the goal range.

I don’t know about you, but I hate doing math in the middle of a trauma
resuscitation. I need something quick and dirty. A physician from NYU Langone in NYC
commented on the article, and derived a nice little table to simplify the process. He
calculated the number of plasma units based on some common INR ranges, assuming
that the goal was to get it down under 1.5. Here is the table:

Bottom line: This is a nice little piece of information to tuck into your pocket or
phone. For patients inside the usual therapeutic values, it will take 2-3 units of
plasma to reverse. For your average older human with average comorbidities,
expect this to take 4-6 hours, not counting ordering, thawing, and delivery. If my
definitions of “life-threatening bleeding” are met (see below), your patient may
have significant adverse events during this time frame. So think very seriously
about using PCC instead.

Related posts:

1/2
 What’s the INR of FFP?
Life-threatening bleeding in the
anticoagulated patient

Reference: Fresh Frozen Plasma Dosing for

Warfarin Reversal: A Practical Formula.
Mayo Clin Proc 88(3):244-250, 2013.

2/2