Prothrombin complex concentrate administration timing in warfarin-associated intracranial hemorrhage.

INTRODUCTION: Guidelines recommend "rapid" and "urgent" reversal of anticoagulation for warfarin-associated intracranial hemorrhage (ICH) treatment; however, they do not specify goals for time-to-administration. There are limited studies evaluating time to reversal, or international normalized ratio (INR) correction, on hematoma expansion and outcomes in intervals of <4 h. The purpose of this study was to evaluate the association of 4-factor prothrombin concentrate (4F-PCC) time-to-administration on rates of achieving effective hemostasis, determined by hematoma expansion, for treatment of warfarin-associated ICH. METHODS: This was a retrospective, observational, single center study performed at a large community teaching hospital. Patients were stratified into three groups based on time of CT diagnosis of ICH to administration of 4F-PCC: <45 min, 45-90 min, and >90 min. The primary outcome was rates of achieving effective hemostasis in each group defined as a ≤20% increase in hematoma volume as estimated by a radiologist. RESULTS: A total of 227 patients were screened for inclusion with ultimately 39 being included. Baseline characteristics were similar between groups. The primary outcome was not significantly different among groups stratified by time to 4F-PCC administration of <45 min, 45-90 min, and >90 min (85.7% vs 73.3% vs 90%, p value 0.514). There was no difference among secondary outcomes between groups including in-hospital mortality, hospital length of stay (LOS), and intensive care unit LOS. CONCLUSION: There was no association with time-to-administration of 4F-PCC on rates of hemostasis achievement, defined as hematoma expansion of ≤20%, identified in this study.

Pharmacoeconomic impact of an alternative workflow process for stroke.

OBJECTIVE: The objective of this study was to evaluate a new multidisciplinary process in which intravenous alteplase (tPA) waste, used for acute ischemic stroke (AIS), was salvaged in an attempt to maximize cost effectiveness without impacting door-to-needle (DTN) administration times. DESIGN: This was a retrospective cohort between May 2017 and February 2018. The primary endpoint evaluated for this study was the total tPA salvaged and total cost savings in U.S. dollars. Secondary endpoints evaluated included overall DTN time in minutes. SETTING: Emergency department of a primary stroke center. PATIENTS: A convenience sample of sequential adult (>18 years) patients who received tPA in the ED for AIS were included for analysis. INTERVENTIONS: New stroke process which involved bedside mixing of tPA and salvaging of excess waste in the main central pharmacy. MEASUREMENTS AND MAIN RESULTS: A total of 50 patients were included in the final analysis. There were 25 patients included in the new process and old process groups respectively. A total of 605 mg of alteplase was salvaged from 25 patients in the new process group which was associated with an estimated cost savings of over $120,000 annually. Patients in the new process group had statistically faster average (52 min vs. 60 min; p = 0.01) and median (50 min vs. 58 min; p = 0.03) DTN administration times. CONCLUSION: Preliminary data, in this pilot study, utilizing a multidisciplinary model for tPA administration led to significant cost savings of tPA and decreases in overall DTN administration times.

A Case of Ivermectin-Induced Warfarin Toxicity: First Published Report.

Here, we present the case of a patient who developed a large hematoma under his tongue while taking concomitant warfarin and ivermectin. Ivermectin has been shown to interfere with vitamin K-dependent clotting factors II, V, VII, and X. However, all the data to date have been from in vivo data with little to no reports on its effects on humans. To our knowledge, this is the first case report to present such a case.