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471: EFFICACY AND SAFETY OF 4F-PCC VS. FFP FOR WARFARIN REVERSAL IN EMERGENT SURGERY/INVASIVE PROCEDURE

Learning Objectives: Coagulopathy defects and excessive bleeding may occur during surgery, especially in cardiac surgery. Cardiopulmonary bypass causes alterations to the coagulation system, platelet activation, and platelet destruction. Approximately 15–20% of cardiac surgery patients can receive more than 80% of the blood products transfused while intraoperatively. Pharmacological agents are recommended to limit blood transfusions including erythropoietin stimulating agents, aminocaproic acid, tranexemic acid, and desmopressin. Human fibrinogen concentrate was approved by the Food and Drug Administration in 2009 for the treatment of acute bleeding in patients with congenital fibrinogen deficiency. An in vitro study observed a statistically significant increase in fibrinogen levels and clot firmness. The Society of Thoracic Surgeons (STS) Blood Conservation guidelines recommend the use of human fibrinogen concentrate for clot stabilization after cardiac procedures requiring cardiopulmonary bypass when other routine blood conservation measures prove unsatisfactory. Methods: We present a case of a 67-year old male, 62 kg, post cardiac surgery patient who received human fibrinogen concentrate for excessive bleeding immediately post surgery. The patient’s surgery closure time was at 1330 and blood loss was noted as 140 ml at 1430, 330 ml at 1530, and 90 ml at 1630 from the chest tube (CT). A thromboelastography (TEG) was obtained and resulted with functional fibrinogen MA of 12.4 mm (normal 15–32 mm) and fibrogen level (FLEV) of 226 mg/dL (normal 278–581 mg/dL). A serum fibrinogen was also obtained and was 210 mg/dL (normal 200–450 mg/dL). He received aminocaproic acid 5 grams intravenously (IV) once at 1437 and phytonadione 5 mg IV once at 1515. Minimal resolution of the bleeding was observed, and human fibrinogen concentrate was ordered at 70 mg/kg (4356 mg) IV once administered at 1600. Bleeding resolved immediately and the post-administration TEG was MA 17.6 mm and FLEV 321 mg/dL and CT output decreased to 50 ml/hr for the next 12 hours. He was discharged to a cardiac rehabilitation facility within 3 days. Results: The institution has developed a criteria for use for this novel therapy, recombinant human concentrate, for cardiac surgery patients and specific administration guidelines were provided to the nurses and pharmacists.