Background
Perioperative bleeding is costly, as the result is use of blood
products, pharmaceutical hemostatics, or repeat surgery. In complex
cardiac surgery, the cost of care for patients who are transfused
(receiving at least one unit of red blood cells, fresh frozen plasma,
platelets, or cryoprecipitate) is 133.2 % greater compared with those
not transfused.1
Two studies have found that PCC4 for warfarin reversal prior to heart
transplant displayed a reduced utilization of blood products. Further in
one of the retrospective studies, unrelated to anticoagulation at
baseline, there was a nonsignificant trend towards lower utilization of
blood transfusion when administering PCC4 at doses greater than 20
units/kilogram compared to 10-19.9 units/kilogram.2Every cardiothoracic surgery includes varying risk for blood loss and
consequences of blood product administration and even further, a two to
six times greater risk of mortality when performing a repeat
sternotomy.1 Increased bleeding risk translates to a
higher rate of blood transfusion and transfusion associated morbidity:
including pulmonary edema, right ventricular strain, increased
ventilator time, and increased length of stay (LOS) in the ICU.
Additionally, transfusion-related acute lung injury (TRALI) has an
estimated 2-4% incidence in cardiac surgery that carries significant
morbidity. TRALI typically has a twofold insult with an initial hyper
inflammatory immune mediated response followed by diffuse pulmonary
edema; it is the leading cause of transfusion-related morbidity and
mortality.2 Patients who receive more blood products
after surgery have greater risk adjusted pulmonary complications,
including TRALI, respiratory failure, acute respiratory distress
syndrome (ARDS), clinically described by the Berlin Criteriawhere the ratio of the partial pressure of oxygen (PaO2) to the fraction
of inspired oxygen (FiO2) is consistently less than 200-300 mmHg while
the positive end expiratory pressure (PEEP) is greater than or equal to
5 centimeters of water which leads to increased time on the ventilator.
Furthermore TRALI patients with and without RV overload, have higher
rates of reintubation.3,4 RV overload is an expensive
complication to treat, with resource intensive therapeutic options that
include inhaled nitric oxide (iNO) or pulmonary vasodilators such as
epoprostenol, both of which increase acuity and contribute to higher
cost of care. Limiting blood transfusion is important to the health
system stewardship efforts, firstly due to the critical shortage of
blood products in the United States that has been ongoing since the
COVID-19 pandemic began, and secondarily due to the overall cost to the
health system incurred from transfusion of blood products not solely
ascribed to product acquisition cost, but also to subsequent higher
acuity of care cost for patients after blood transfusion. Avoidance of
post-operative bleeding prevents volume overload, transfusion related
acute lung injury, and right ventricular heart
failure.1,3,7 This single center review sought to
assess the benefit of preemptive, intraoperative dosing administration
of PCC4 in cardiothoracic surgery patients with increased risk of
bleeding; the majority of cases (65%) being left ventricular assist
device (LVAD) and heart transplant.