Review Question - QID 104656

This patient on warfarin has serious bleeding with vital signs suggesting hypovolemia and an elevated INR. The best treatment for his coagulation abnormality is an infusion of fresh frozen plasma (FFP), which rapidly reverses the action of warfarin.

Warfarin is an anticoagulant that inhibits the hepatic synthesis of vitamin K dependent clotting factors. Like all anticoagulants, a common side effect is bleeding. Retroperitoneal bleeds can be one site of bleeding in patients on anticoagulant therapy. In cases with a life threatening bleed, the infusion of FFP, which contains all of the clotting factors, rapidly reverses the anticoagulant effect of warfarin and stops further bleeding. In cases of elevated INR without a life threatening bleed (or when titrating warfarin to achieve the correct dose), vitamin K can be used to reverse the effects of warfarin less rapidly. The effects of FFP are transient, so while it is important to immediately initiate FFP transfuion, vitamin K should also be given to counterat the long-term effects of warfarin.

Sharma et al. discuss the indications for the transfusion of blood products like FFP. Guidelines suggest a transfusion of FFP if the INR is greater than 1.6 and there is active bleeding, or a major bleed such as a large intracranial hemorrhage.

Tran et al. discuss the guidelines for the use of warfarin in Australia, and state that if available, a prothrombin complex concentrate (PCC) is preferable over FFP in emergency settings. PCCs have factors II, IX, X and low levels of VII, which are the vitamin K dependent factors affected by warfarin. As they only provide the necessary factors, PCCs are associated with fewer immune reactions as compared to FFP.

Incorrect Answers:
Answer 2: Protamine sulfate is used in the reversal of heparin, not warfain.
Answer 3-5: Vitamin K infusion or stopping warfarin would indeed reverse the anticoagulation, but this patient with an active bleed and vital sign abnormalities requires rapid reversal.