Increased risk of volume overload with plasma compared with four-factor prothrombin complex concentrate for urgent vitamin K antagonist reversal.
Immediate reversal of the anticoagulant effect of vitamin K antagonists can be achieved by administration of either plasma or prothrombin complex concentrates. When plasma is used for this purpose, high volumes are required to achieve a sufficient effect and this may be associated with a risk of volume overload. The extent of this disadvantage, however, has never been systematically assessed.
In this study, the incidence of volume overload and circumstances leading to this situation were studied in two randomised trials including 388 patients comparing plasma versus prothrombin complex concentrates for immediate reversal of vitamin K antagonist-induced anticoagulation. Volume overload occurred in 25 of 197 patients (12.7%) who received plasma versus 9 of 191 patients (4.7%) treated with prothrombin complex concentrate. In multivariate analysis, a history of congestive heart failure or renal insufficiency were independent predictors of volume overload.
This is one of the first studies that clearly demonstrates that administration of plasma for immediate reversal of vitamin K antagonists carries a risk of volume overload and establishes the incidence of this adverse effect in a systematic and controlled study. In real-life clinical practice, the risk of volume overload associated with plasma may even be larger as this analysis was done in a trial population with distinct exclusion criteria. If immediate reversal of anticoagulation is required, prothrombin complex concentrates are preferred over plasma to avoid this complication.
– Marcel Levi