The patient should be given 4-factor prothrombin complex concentrate (4f-PCC) in addition to intravenous vitamin K and fluids. He is experiencing major bleeding complicated by warfarin therapy and requires immediate anticoagulation reversal. 4f-PCC is a plasma-derived product that contains all four vitamin K–dependent coagulation factors (factors II, VII, IX, and X). Unlike fresh frozen plasma (FFP), 4f-PCC is stored at room temperature, does not require ABO typing, and can be infused quickly because of its small volume, thus reducing the time to delivery of therapy. Compared with FFP, 4f-PCC has been shown to more rapidly achieve hemostasis in patients with visible or musculoskeletal bleeding with less risk of fluid overload and no difference in thromboembolic events. This agent has therefore been approved by the FDA for urgent reversal of coagulation factor deficiencies related to vitamin K antagonist therapy for adult patients with acute major bleeding, as well as for adult patients in need of urgent surgery or an invasive procedure.
Activated factor VII (factor VIIa) has been evaluated in case series for the treatment of vitamin K antagonist–related bleeding. Although factor VIIa can correct the INR quickly in most instances, it is unclear if this is associated with achievement of optimal hemostasis considering factors II, IX, and X are not replaced with this agent. A low dose of factor VIIa may be used in conjunction with 3-factor PCCs (which contain very little factor VII) for treatment of major vitamin K antagonist–associated bleeding in situations when 4f-PCCs are not available and the patient has a contraindication to the use of FFP (for example, uncompensated heart failure).
Cryoprecipitate is rich in fibrinogen and is used to treat inherited or acquired fibrinogen deficiency or dysfibrinogenemia. It has no role in the management of vitamin K antagonist–related bleeding.
FFP can be used when 4f-PCC is not readily available. However, 4f-PCC is also less likely than FFP to induce transfusion-associated circulatory overload, an important consideration in patients with heart failure or transfusion-related acute lung injury. Furthermore, 4f-PCC goes through viral inactivation, which reduces the incidence of transfusion-transmitted infectious diseases.