Background
Perioperative bleeding is costly, as the result is use of blood products, pharmaceutical hemostatics, or repeat surgery. In complex cardiac surgery, the cost of care for patients who are transfused (receiving at least one unit of red blood cells, fresh frozen plasma, platelets, or cryoprecipitate) is 133.2 % greater compared with those not transfused.1
Two studies have found that PCC4 for warfarin reversal prior to heart transplant displayed a reduced utilization of blood products. Further in one of the retrospective studies, unrelated to anticoagulation at baseline, there was a nonsignificant trend towards lower utilization of blood transfusion when administering PCC4 at doses greater than 20 units/kilogram compared to 10-19.9 units/kilogram.2Every cardiothoracic surgery includes varying risk for blood loss and consequences of blood product administration and even further, a two to six times greater risk of mortality when performing a repeat sternotomy.1 Increased bleeding risk translates to a higher rate of blood transfusion and transfusion associated morbidity: including pulmonary edema, right ventricular strain, increased ventilator time, and increased length of stay (LOS) in the ICU. Additionally, transfusion-related acute lung injury (TRALI) has an estimated 2-4% incidence in cardiac surgery that carries significant morbidity. TRALI typically has a twofold insult with an initial hyper inflammatory immune mediated response followed by diffuse pulmonary edema; it is the leading cause of transfusion-related morbidity and mortality.2 Patients who receive more blood products after surgery have greater risk adjusted pulmonary complications, including TRALI, respiratory failure, acute respiratory distress syndrome (ARDS), clinically described by the Berlin Criteriawhere the ratio of the partial pressure of oxygen (PaO2) to the fraction of inspired oxygen (FiO2) is consistently less than 200-300 mmHg while the positive end expiratory pressure (PEEP) is greater than or equal to 5 centimeters of water which leads to increased time on the ventilator. Furthermore TRALI patients with and without RV overload, have higher rates of reintubation.3,4 RV overload is an expensive complication to treat, with resource intensive therapeutic options that include inhaled nitric oxide (iNO) or pulmonary vasodilators such as epoprostenol, both of which increase acuity and contribute to higher cost of care. Limiting blood transfusion is important to the health system stewardship efforts, firstly due to the critical shortage of blood products in the United States that has been ongoing since the COVID-19 pandemic began, and secondarily due to the overall cost to the health system incurred from transfusion of blood products not solely ascribed to product acquisition cost, but also to subsequent higher acuity of care cost for patients after blood transfusion. Avoidance of post-operative bleeding prevents volume overload, transfusion related acute lung injury, and right ventricular heart failure.1,3,7 This single center review sought to assess the benefit of preemptive, intraoperative dosing administration of PCC4 in cardiothoracic surgery patients with increased risk of bleeding; the majority of cases (65%) being left ventricular assist device (LVAD) and heart transplant.