Pre-emptive intraoperative administration of PCC4 in cardiac surgery patients at high risk of bleeding: A pilot study.

BACKGROUND: Four-factor prothrombin complex (PCC4), a concentrate of factors II, VII, IX, and X and proteins C and S, has been used selectively for reversal of oral anticoagulation before surgery. There is data to support PCC4 as opposed to supplemental fresh frozen plasma (FFP) to manage postoperative bleeding following cardiac surgery. The preemptive, intraoperative use of PCC4 in cardiothoracic surgery has not been studied though it may prevent postoperative bleeding, the need for blood transfusion and the risk of transfusion-related acute lung injury, volume overload, and right ventricular (RV) heart failure. The purpose of this study is to evaluate the intraoperative administration of PCC4 to decrease bleeding and lower the rate of blood transfusion. METHODS: A single institution retrospective chart review was conducted from May 2020 to November 2021 of patients who received PCC4 intraoperatively during cardiothoracic surgery of high-risk variety. Patients were evaluated for the type of surgery, demographics, baseline anticoagulation, PCC4 dose, type and quantity of blood transfusion within 72 hours (h) postoperatively, chest tube output, the incidence of RV failure, hypersensitivity reactions, acute kidney injury (AKI), thrombosis, acute lung injury, and mortality within 45 days of the operative dose of PCC4. RESULTS: Thirty-five patients received PCC4 at a mean dose of 2920 units (U). Sixty-five percent of cases were left ventricular assist devices (LVADs) or heart transplants. The protocol is to use PCC4 30 units (U)/kg immediately after the completion of protamine administration. Inclusion criteria are cardiothoracic surgery with increased risk of postoperative right heart failure commonly secondary to blood product transfusion, or cardiothoracic surgery associated with increased risk of bleeding, including heart transplant, LVAD implant, aortic dissection, and redo sternotomy (e.g., coronary artery bypass). Total chest tube output was recorded as a mean of 757 ml for 24 h after surgery (32 ml/h). Overall median event rates of FFP and red blood cell (RBC) transfusions were 0 (interquartile range [IQR]: 0-3 U) and 4 (IQR: 2-5 U). Overall, 43% and 89% of cases received FFP and RBC, respectively. There was one occurrence of RV failure, one occurrence of AKI requiring renal replacement therapy, one occurrence of venoarterial extracorporeal membrane oxygenation, one occurrence of venous thromboembolism related to a central venous access line, and one death unrelated to surgery or PCC4 that was attributed to advanced heart failure not amenable to advanced therapies. CONCLUSION: Overall patients received a low rate of blood transfusion, had minimal chest tube output, and there was a small incidence of right heart failure. Patients did not have an increased risk of adverse effects such as AKI or venous thromboembolism. A randomized controlled clinical trial comparing the observed dose and timing of PCC4 versus routine postoperative bleeding management with blood product transfusion is recommended.

Measuring personality and emotional functioning in multiple sclerosis: a cautionary note.

Changes in personality and emotional status are common in individuals with multiple sclerosis (MS). The purpose of this study was to examine results based on the MMPI-2 before and following application of a statistical correction procedure (Gass, 1992). This was done to help determine changes in scale score elevations when items containing actual physical symptoms are identified and statistically removed. Twenty-eight participants with MS were administered the MMPI-2, then retested 1 year later. Stability of MMPI-2 scores over time was demonstrated. Results showed that when the correction procedure was applied to the MMPI-2, eight standard clinical scale scores dropped an average of 6.66 T-score points. Significant differences were obtained between standard MMPI-2 scored profiles and corrected profiles on Scales 1-3 and 8. Cautious interpretation of MMPI-2 results for neurological samples was indicated. This study extended prototypic research by using patients with MS, examining the stability of results over time (1 year), and introducing a more reliable method of deriving standard T-scores in the correction procedure.

Personality testing and epilepsy: comparison of two MMPI-2 correction procedures.

The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) is widely used for assessing psychopathology. However, its reliability in people with neurologic disease has been questioned. This concern is especially true for epilepsy, a disease with symptoms, i.e., seizures, that frequently include experiences likely to suggest psychopathology. Correction procedures, in which select items are removed and the test is rescored, may improve MMPI-2 specificity. The MMPI-2 was administered to 27 subjects with epilepsy, and the results were compared before and after application of three correction procedures: rational, statistical, and combined. The statistical correction resulted in clinically significant T-score changes (> or = 5 points) in two MMPI-2 clinical scales, while a combined correction procedure produced clinically significant changes in three scales. In the subgroup of patients with intractable epilepsy, two noncorrected scale T-scores > or = 65 fell to the normal range with both the statistical and combined procedures. These results suggest cautious interpretation of standard MMPI-2 scores in patients with epilepsy.