Evaluation of appropriate usage of fresh frozen plasma: Results of a regional audit in Iran

BackgroundFresh frozen plasma (FFP) is a major source of coagulation factor replacement therapy for patients with clotting factor deficiency. Although FFP is readily available for use in clinical practice its administration isn’t without risk. Studies on the use of FFP reveal that it is often overused or inappropriately used. We undertook an audit to assess the appropriateness of FFP transfusion in Gorgan’s hospitals.MethodsThis was a retrospective, audit done at 5 hospitals in Gorgan city regarding the use of 1592 units of FFP issued to 346 patients from March 2006 to March 2007. The appropriateness of FFP transfusion was analyzed according to British Council for Standardization in Hematology (BCSH) Guidelines 2004.ResultsIn this audit we identified a high rate of inappropriate FFP usage (53% of transfusion episodes). Most ‘Inappropriate’ FFP usage occurred when there was active bleeding, with normal (or unmeasured) coagulation tests (30% of transfusion episodes). In only 66% of FFP-transfused patients were coagulation variable measured at any point in the hospital episode.ConclusionInappropriate usage of FFP is often seen in medical facility and the right solution is needed to curb the misuse of this component. Regular utilization audit can identify correctable errors in transfusion practices. Formal education programs and existing information on FFP use should be directed to professionals ordering FFP.     

Evaluation of using fresh frozen plasma for patients with cirrhosis at a tertiary healthcare center in Turkey: Strict transfusion policies are essential

AimManagement of blood transfusions is a critical issue, especially in cirrhotic patients, because of the absence of national policies in many countries. Fresh frozen plasma (FFP) is a common blood component misused excessively in various clinical situations and cirrhosis patients without any scientific rationale. We evaluated the FFP transfusions in patients with cirrhosis at our tertiary care hospital.Material and MethodThe cases with cirrhosis diagnosed between 2014 and 2020 were selected using the hospital database. The appropriateness of FFP transfusion was determined based on the Practice Guidance by the American Association for the Study of Liver Diseases and Italian guidelines.ResultTwo hundred and six liver cirrhosis patients were identified who received FFP transfusion. The median age was 63 (22–94). Of the 206 patients, 79 (38.3 %) were female, and 127 (61.7 %) were men. The most common causes of liver cirrhosis were alcohol (27.7 %). 45.6 % of the patients were in Child-Pugh Class C. We found 62.1 % of FFP replacements were inappropriately used. Most inappropriate use of FFP (22.8 %, n = 47) occurred to correct prolonged INR in the absence of bleeding.ConclusionTo avoid inappropriate usage of FFP, regular utilization reviews and formal education programs can be helpful. Our clinic has planned to arrange educational programs for physicians to use blood products appropriately and minimize transfusion-related side effects.     

Fresh frozen plasma transfusion in critically ill patients

OBJECTIVES: Although guidelines for fresh frozen plasma (FFP) use have been published, many transfusions are considered inappropriate. Current guidelines suggest few circumstances in which FFP transfusion to critically ill patients is warranted. The objectives of this study were to evaluate the consistency of Canadian guidelines for FFP administration to critically ill patients and to examine factors associated with inappropriate FFP transfusions. DESIGN: Retrospective cohort study. SETTING: 15-bed medical surgical intensive care unit in a teaching hospital. PATIENTS: 254 consecutive adults admitted during 1 yr expected to stay in intensive care for more than 72 hrs. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Patient demographics, illness severity, life support, intensive care and hospital length of stay, and survival were prospectively collected. All FFP orders were identified from the hospital laboratory information system. For each order, coagulation parameters, planned invasive interventions, recent or current bleeding, and bleeding severity were retrospectively collected. Three observers independently adjudicated whether transfusions were consistent with guidelines, inconsistent but appropriate for the intensive care context, or inappropriate. Of 254 patients, 76 (29.9%) received FFP, accounting for 225 orders to transfuse 547 units. Of 225 orders, 73 (32.4%) were consistent with guidelines, 45 (20.0%) were inconsistent but appropriate, and 107 (47.6%) were inappropriate. Considering transfusions clustered within patients, chance-independent agreement on whether transfusions were inappropriate or not was high (phi 0.73, 0.64-0.81). Independent determinants of inappropriate FFP were the presence of less severe coagulopathy as indicated by lower international normalized ratios (p < .0001) and the absence of bleeding (p < .0001) of planned invasive procedure (p = .0001). CONCLUSIONS: Critically ill patients frequently receive inappropriate FFP transfusions. Many transfusions may be appropriate for the intensive care setting, although they are inconsistent with expert recommendations, highlighting that further studies are needed to assess the effectiveness and safety of FFP transfusion in critical illness.     

Fresh frozen plasma transfusion in critically ill medical patients with coagulopathy

OBJECTIVE: Although restrictive red cell transfusion practice has become a standard of care in the critically ill, data on the use of fresh frozen plasma (FFP) are limited. We hypothesized that the practice of FFP transfusion in the medical intensive care unit is variable and that liberal use may not be associated with improved outcome. DESIGN: Retrospective cohort study. SETTING: A 24-bed medical intensive care unit in a tertiary referral center. PATIENTS: All patients admitted to a medical intensive care unit during a 5-month period who had abnormal coagulation defined as international normalized ratio (INR) of > or = 1.5-times normal. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We collected data on demographics, severity of illness as measured by Acute Physiology and Chronic Health Evaluation (APACHE) III scores, INR, bleeding episodes, and transfusion complications. We identified 115 patients with coagulopathy (INR of > or = 1.5) but without active bleeding. A total of 44 patients (38.3%) received FFP transfusion. INR was corrected in 16 of 44 patients (36%) who received transfusion. Median dose of FFP was 17 mL/kg in patients who had INR corrected vs. 10 mL/kg in those who did not (p = .018). There was no difference in age, sex, APACHE III scores, liver disease, Coumadin treatment, or INR level between those who did and did not receive FFP. Invasive procedures (68.2% vs. 40.8%, p = .004) and history of recent gastrointestinal bleeding (41% vs. 7%, p < .001) were more frequent in the group with transfusion. Although there was no difference in new bleeding episodes (6.8% in transfused vs. 2.8% in nontransfused group, p = .369), new onset acute lung injury was more frequent in the transfused group (18% vs. 4%, p = .021). Adjusted for severity of illness, hospital mortality and intensive care unit length of stay among survivors were not different between the two groups. CONCLUSION: The risk-benefit ratio of FFP transfusion in critically ill medical patients with coagulopathy may not be favorable. Randomized controlled trials evaluating restrictive vs. liberal FFP transfusion strategies are warranted.     

The use of fresh‐frozen plasma in England: high levels of inappropriate use in adults and children

BACKGROUND: Fresh‐frozen plasma (FFP) is given to patients across a range of clinical settings, frequently in association with abnormalities of standard coagulation tests. STUDY DESIGN AND METHODS: A UK‐wide study of FFP transfusion practice was undertaken to characterize the current patterns of administration and to evaluate the contribution of pretransfusion coagulation tests. RESULTS: A total of 4969 FFP transfusions given to patients in 190 hospitals were analyzed, of which 93.3% were in adults and 6.7% in children or infants. FFP transfusions to adults were given most frequently in intensive‐treatment or high‐dependency units (32%), in operating rooms or recovery (23%), or on medical wards (22%). In adult patients 43% of all FFP transfusions were given in the absence of documented bleeding, as prophylaxis for abnormal coagulation tests or before procedures or surgery. There was wide variation in international normalized ratio (INR) or prothrombin times before FFP administration; in 30.9% of patients where the main reason for transfusion was prophylactic in the absence of bleeding the INR was 1.5 or less. Changes in standard coagulation results after FFP administration were generally very small for adults and children. CONCLUSIONS: This study raises important questions about the clinical benefit of much of current FFP usage. It highlights the pressing need for better studies to inform and evaluate quantitative data for the effect of plasma on standard coagulation tests.     

A survey of physicians' reasons to transfuse plasma and platelets in the critically ill: a prospective single-centre cohort study

Data on the rationality of transfusion practice of fresh frozen plasma (FFP) and platelets in the critically ill are sparse and may contribute to efforts to reduce transfusion rates. To provide insight into determinants of the decision of intensive care unit (ICU)-physicians to transfuse, a survey study was performed. The reasons of ICU-physicians to transfuse FFP and platelets were determined during a 10-week period. Transfusion triggers were assessed, as well as correction of prolonged coagulation test results. Of 310 admissions, 44 patients (14%) received a transfusion of FFP and 35 patients (11%) received a platelet transfusion. In 67% patients, FFPs were transfused in bleeding patients and in 33% in non-bleeding patients. FFP was transfused at a prothrombin time (PT) of 19 s (17–22). After FFP transfusion, PT levels of 15–18, 18–20 and 20–26 s decreased with a median of 0.7, 1.9 and 3.5 s, respectively. On average, 3.2 FFP units were ordered, of which 28% was not transfused. The major reason to transfuse platelets was bleeding. Platelets were transfused at a platelet count of 95 (36–116) × 10⁹ L⁻¹ in bleeding and 13 (10–18) × 10⁹ L⁻¹ in non-bleeding patients. On average, 1.4 platelet units were ordered, of which 20% was not transfused. The agreement between physicians reporting a major bleeding and a definition of bleeding was poor ( κ < 0.10 for FFP and 0.20 for platelets). In conclusion, one-third of FFP transfusions was given to non-bleeding patients. FFP transfusion failed to normalize prolonged coagulation test results in the majority of the patients. Transfusion of platelets was restrictive in non-bleeding patients and liberal in bleeding patients. Education on indications of FFP transfusion and improved identification of bleeding may reduce transfusion rates.     

Appropriateness of fresh-frozen plasma usage in hospital settings: a meta-analysis of the impact of organizational interventions

BACKGROUND: Transfusions of fresh-frozen plasma (FFP) are a worldwide ever-growing practice. The most advanced health care organizations, to guarantee high-quality standards of interventions and safe procedures, should disseminate scientific evidence for promoting the appropriateness of transfusions and reducing avoidable risks.
STUDY DESIGN AND METHODS: We carried out a systematic review of scientific literature searching for studies focused on the implementation of different strategy of organizational interventions aimed at improving clinicians' practice.
RESULTS: Of 915 studies, 10 articles were included in our meta-analysis of risk of inappropriate transfusion after the implementation of an organizational intervention. The risk ratio of inappropriate transfusions before organizational interventions was 2.02 (95% confidence interval, 1.44-2.84) compared with after interventions.
CONCLUSION: The organizational interventions showed a positive impact on the reduction of rates of inappropriate FFP transfusion episodes.     

The appropriateness and physician compliance of platelet usage by a computerized transfusion decision support system in a medical center

BACKGROUND: The prescribing of inappropriate platelet (PLT) transfusions is always a significant problem. A computerized transfusion decision support system (CTDSS) has been used in Kaohsiung Medical University Hospital since September 2004. In this study, the physician compliance and appropriateness of PLT usage after using the CTDSS were investigated. STUDY DESIGN AND METHODS: A total of 5887 PLT transfusion episodes between January and December 2008 were reviewed including the demographic data and the “true reason” for each transfusion practice. The pre‐ and posttransfusion PLT counts were retrieved. The physician compliance, the appropriateness of PLT usage, and the PLT increments after transfusion were investigated. RESULTS: Physician compliance was 85.4%, and the appropriateness of PLT usage was 69.6%. The most commonly chosen indication from the CTDSS was “prophylactic use, PLT count ≤20 × 10⁹/L.” The highest inappropriate order rate was from the emergency department. More than half of the inappropriate episodes were from the surgery unit. The inappropriate rates were significant in terms of both different order sources and functional units (p < 0.0001). The posttransfusion PLT counts increased in two‐thirds of the episodes, and most of them were with the pretransfusion PLT counts of less than 50 × 10⁹/L. CONCLUSIONS: In Taiwan, the PLT concentration is too low‐priced and this might cause the overuse of blood components. Under the global budget of National Health Insurance, preventing the overuse of blood components might serve as one of the mechanism to improve medical quality. The CTDSS should be more powerful and effective to intervene in the appropriateness of transfusion practice.     

Why is fresh-frozen plasma transfused?

A three-part study to determine the reasons for fresh-frozen plasma (FFP) transfusions at hospitals in southeastern Wisconsin was conducted. During a 1-month period, hospital transfusion services reported that patients undergoing open-heart surgery received 42 percent, medical patients 26 percent, noncardiac surgery patients 23 percent, neonatal patients 1 percent, and other patients 7 percent of the FFP transfused. In the second phase of the study, the records of 102 patients receiving FFP during a 1-month period at two teaching hospitals were reviewed. Justification for the FFP transfusion was provided in the hospital chart for only 11 percent of the transfusion episodes, although abnormal results of coagulation studies or signs of hypovolemia were recorded for an additional 51 percent. Frequently, FFP and red cell (RBC) transfusions were given during the same transfusion episode. In the third phase of the study, clinicians completed a questionnaire specifying their "trigger" for prescribing FFP: bleeding (43% of episodes), abnormal coagulation studies (26%), signs/symptoms of hypovolemia (16%), and "other" (15%). They judged that the FFP transfusion was effective in 47 percent of transfusion episodes and ineffective in only 6 percent. These findings indicate that FFP is used mainly as a source of coagulation factor replacement in hospitals served by The Blood Center of Southeastern Wisconsin, that justification for FFP use rarely is provided in patient records, that both FFP and RBCs are frequently transfused together, and that clinicians believe FFP is beneficial for their patients. Educational efforts addressing appropriate use of FFP should be initiated.     

A simple automatized audit system for following and managing practices of platelet and plasma transfusions in a neonatal intensive care unit

During neonatal intensive care, blood components are often used in clinical situations where both their efficacy and safety lack solid justification. A practical system to continuously analyse actual transfusion practices is a prerequisite for improvements of quality in transfusion therapy. We hypothesized that such a system would reveal inappropriate variations in clinical decision making and offer a means for staff education and quality improvement and assurance. The study consisted of three 120-152-day periods (P I, P II and P III) between January 2000 and October 2001 and involved 543 new patient admissions (141 patients with birth weight < 1501 g) and 6227 days of patient care at a single tertiary level NICU. P I was a control with no intervention, P II was after technically introducing the computer system and, the last period, P III was after presenting and discussing the results of P I and P II at a staff meeting. Upon an order of platelet or fresh frozen plasma (FFP) unit from the blood bank, a computer-based audit system compared the last platelet count or prothrombin time [expressed as percentage of normal clotting activity, prothrombin time (PT-%)] to predefined criteria. In the case of exceeding the preset thresholds, the system required additional information and recorded the pretransfusion laboratory values for later analysis. Thirty-two per cent of platelet transfusions were given with pretransfusion platelet count >49 x 10(9) L(-1), and 60% of these transfusions (19% of all platelet transfusions) could not be clinically justified in retrospective chart review. There was no significant change in this practice from P II to P III. FFP transfusions were given with significantly different pretransfusion PT-% values during P II and P III. The proportions of FFP transfusions with pretransfusion PT-% > 49% were 7.8% and 0.9% during P II and P III, respectively (P < 0.0001). In chart review, none of the FFP transfusions with pretransfusion PT-% > 49% could be justified by clinical grounds. Inappropriate transfusions of both platelets and plasma remain a significant challenge for quality assurance of neonatal intensive care. Automated recording of pretransfusion platelet count and prothrombin time reliably identified the poorly justified transfusions and thus offered a practical resource-saving tool for quality assurance of transfusion in the NICU. A significant shift towards more appropriate use of plasma was demonstrated after implementation of the audit system.     

P12An Audit of Fresh Frozen Plasma Transfusion Use in the Royal Hospitals Trust (RGHT)

Allogeneic fresh frozen plasma (FFP) transfusions have increased in recent years, in the Royal Group of Hospitals Trust and in the UK as a whole. In the 2003 Serious Hazards of Transfusion report, FFP was the blood product most commonly attributed to the development of transfusion associated acute lung injury and a leading cause of transfusion related mortality. In the British Committee for Standards in Haematology (BCSH) guidelines there are few indications for FFP transfusion. Stainsby found that appropriateness of FFP transfusion in England varied from 62–92%.
Audit objectives (i) To assess the appropriateness of FFP transfusions in the RGHT against BCSH guidelines - 100% standard; and (ii) To assess the adequacy of documentation for FFP transfusion episodes re indication for transfusion and clinical effectiveness - 100% standard.
Method Data relating to FFP transfusion episodes between October 2004 and January 2005 inclusive, was extracted retrospectively from available patient notes by an SpR in haematology and a consultant anaesthetist. Anonymously completed proformas were jointly assessed for appropriateness of transfusion by the same investigators.
 

     

A critical survey of fresh-frozen plasma use

The use of 534 units of fresh-frozen plasma (FFP) during 160 transfusion episodes in 135 consecutive patients was reviewed. Only 27 percent of transfusions were indicated by a need for replacement of labile coagulation factors. Other uses included volume repletion (31%), intraoperative bleeding or massive transfusion without coagulopathy (19%), and miscellaneous indications unrelated to labile coagulation factors (23%). Data from other institutions and national sources support the hypothesis that much of the increase in FFP use over the last decade is related to decreases in whole blood availability rather than to use for labile coagulation factor replacement. The use of FFP and red cells as a substitute for, or in preference to, whole blood may have significant adverse implications in terms of the cost and safety of blood transfusion.     

Can mandatory pretransfusion approval programmes be improved?

SUMMARY. To improve the appropriateness of blood-component prescribing, a mandatory haematologist pretransfusion approval programme of all non-red-cell components was instituted. This was associated with a 33% decrease in the units of fresh frozen plasma (FFP) transfused. Platelet transfusions increased but utilization of both platelets and FFP are now the lowest of the six comparable blood transfusion regions in New Zealand.
A subsequent concurrent audit, using preset criteria, of FFP, cryoprecipitate and platelet usage over a 3-month period showed that further reductions in blood component usage could still be achieved, despite the continuing pretransfusion approval policy. This audit showed that 33% of FFP and 30% of cryoprecipitate units transfused were inappropriately given, despite prior haematologist approval.
Hospital transfusion practices can be improved by mandatory blood-component pretransfusion approval but concurrent auditing of this programme is required to identify and correct continuing inappropriate blood-component prescribing. Haematologists need to agree on blood-component indications prior to instituting a pretransfusion approval programme in order to provide optimal management.     

Prospective audit of cytomegalovirus-negative blood product utilization in haematology/oncology patients

The transfusion management of immunocompromised patients often requires special blood product use such as cytomegalovirus (CMV)-negative cellular products, which are more costly than standard blood products and occasionally in short supply. We audited the use of CMV-negative products in haematology/oncology patients to determine the appropriateness of their use. A concurrent-prospective audit was conducted of all orders for CMV-negative packed red blood cell (PRBC) and platelet products in 201 haematology/ oncology patients. Once CMV serostatus was determined, orders for inappropriate CMV-negative units were cancelled, and filled as CMV untested units. During the 21-month period of this audit, the rates of inappropriate transfusions decreased for PRBC from 73.2% to 14.3% (chi2 = 68.4, P<0.001) and for platelets from 68.1% to 10.6% (chi2 = 65.6, P<0.001). The median time to cancellation of inappropriate CMV-negative orders was 11 days. This audit resulted in estimated cost savings of $16500 over the 21-month duration. Inappropriate requests for scarce and expensive blood products are substantially reduced by concurrent-prospective auditing of transfusion practice, in a manner that is both simple and cost effective.     

Aminoglycosides in Critically Ill Septic Patients With Acute Kidney Injury Receiving Continuous Renal Replacement Therapy: A Multicenter,Observational Study

PurposeData on aminoglycoside stewardship in critically ill septic patients with acute kidney injury (AKI) needing continuous renal replacement therapy (CRRT) are scarce. The objectives of the study were to determine, during CRRT, the time window with low likelihood for safe reinjection and the proportion of inappropriate reinjection.MethodsA post hoc observational analysis of a multicenter randomized trial comparing the risk of hemodialysis catheter infection with ethanol lock vs placebo in critically ill patients with AKI was conducted. Eligible patients were adults in intensive care units from 6 French hospitals. Any patient with AKI needing CRRT and receiving an antimicrobial therapy for a septic episode occurring before (≤24 hours) or during CRRT was included. The aminoglycoside orders were left to the physicians’ discretion, but high dose once daily was the schedule of aminoglycoside administration.FindingsA total of 145 septic episodes treated by aminoglycosides were analyzed in patients receiving CRRT. A mean (SD) of 1.6 (0.8) amikacin and 1.8 (1.2) gentamicin administrations per patient were observed. During CRRT, C_max was 17.3 mg/L (interquartile range, 13.2-22.5 mg/L) for gentamicin and 50 mg/L (interquartile range, 43.7-76.6 mg/L) for amikacin. The plasma drug concentration at 24 hours (C_H24) was 2.3 mg/L (interquartile range, 1.6-3.2 mg/L) for gentamicin and 9.3 (interquartile range, 6.6-12.0 mg/L) for amikacin. Sixty-five C_min dosages remained above the reinjection threshold. Inappropriate reinjection was observed in 11 of 65 episodes (17%). Inappropriate reinjection (defined by, at the reinjection time, C_min dosages above the threshold; ie, C_min >2 mg/L for gentamicin and >5 mg/L for amikacin) was observed in 17% of analyzed episodes. Most patients did not need reinjection until approximately ≥30 hours after their initial administration.ImplicationsDuring CRRT, as indicated by the C_H24 value, which was higher than the recommended threshold, the interval to obtain a C_min low enough to allow for redosing aminoglycosides is significantly longer than 24 hours. This interval is not always respected and leads to an of inappropriate reinjection rate of 17%. ClinicalTrials.gov identifier: ISRCTNCT00875069.     

Analysis of Inpatient Use of Fresh Frozen Plasma and Other Therapies and Associated Outcomes in Patients with Major Bleeds from Vitamin K Antagonism

Objective

We conducted an observational study of outcomes and costs associated with fresh frozen plasma (FFP) use in patients receiving warfarin with intracerebral, gastrointestinal, or musculoskeletal bleeding.

Methods

Patients who had at least 1 International Classification of Diseases, Ninth Revision code indicative of anticoagulation history, received ≥1 unit FFP, and had patient costs >$0 were identified from a database of >600 US hospitals. The main outcome was transfusion of additional blood products (eg, cryoprecipitate, red blood cells, or platelets) or vitamin K. Further outcomes included administration of other bleeding-related therapies (eg, recombinant activated factor VII, albumin, or crystalloids), incidence of fluid overload, days in the intensive care unit, discharge status, and total hospital costs.

Results

The most frequently administered products were vitamin K and red blood cells, given to 55.6% to 61.0% and 19.2% to 29.3% of patients, respectively. The number of FFP units transfused correlated highly with fluid overload (r > 0.91) and was associated with inpatient mortality, nonhome discharge, and intensive care unit admittance. For both inpatient mortality and nonhome discharge, the odds ratio was significant when ≥4 units FFP were transfused (P < 0.05). A dose of >2 units FFP was associated with an increased probability of an intensive care unit stay (P < 0.05). Total costs were greater among patients receiving >2 units FFP compared with patients who received 1 unit FFP (P < 0.001), with a substantial increase in costs incurred when ≥4 units FFP were transfused.

Conclusions

In patients with warfarin-related bleeding, inpatient mortality, nonhome discharge, intensive care unit admission, and hospital costs were associated with the number of units of FFP transfused.     

Guidelines for the use of fresh frozen plasma

Fresh frozen plasma should only be used to treat bleeding episodes or prepare patients for surgery in certain defined situations. Definite indications for the use of FFP: 1. Replacement of single coagulation factor deficiencies, where a specific or combined factor concentrate is unavailable. 2. Immediate reversal or warfarin effect. 3. Acute disseminated intravascular coagulation (DIC). 4. Thrombotic thrombocytopenic purpura (TTP). Conditional uses: FFP only indicated in the presence of bleeding and disturbed coagulation: 1. Massive transfusion. 2. Liver disease. 3. cardiopulmonary bypass surgery. 4. Special paediatric indications. No justification for the use of FFP: 1. Hypovolaemia. 2. Plasma exchange procedures. 3. 'Formula' replacement. 4. Nutritional support. 5. Treatment of immunodeficiency states.     

Fresh frozen plasma reduces thrombin formation in newborn infants

Summary.  Background : Newborn infants undergoing intensive care are at risk of bleeding and thrombotic complications. Fresh frozen plasma (FFP) is used in hope of preventing these complications, despite poorly defined effects on the coagulation system and lack of proven clinical efficacy. Objectives and methods : We prospectively evaluated coagulopathy and the effect of standardized amount of FFP transfusion (10 mL kg⁻¹ + 4 mL in 2 h) on various coagulation markers in 33 newborn infants during the first 24 h of intensive care. Results : Increased levels of prothrombin fragment F1+2, thrombin–antithrombin complexes (TAT), and d -dimer were found prior to the transfusion in 97%, 81%, and 100% of the patients, respectively. FFP transfusion was associated with a decrease in F1+2 level in 26/32 (81%) of the patients. The extent of F1+2 decrease correlated with the pretransfusion F1+2 level ( R  = 0.65, P  < 0.0001). The patient series was divided into two groups according to increasing pretransfusional F1+2 level: Group 1 (preFFP F1+2 ≥ 2.35 n m , n  = 16), Group 2 (F1+2 <2.35 n m , n  = 16). In Group 1, F1+2 decreased on average 1.58 n m ( P  < 0.01) from the baseline during FFP transfusion but no significant change in the level of F1+2 during the transfusion was observed in Group 2. Pretransfusional levels of individual factors or prothrombin time (PT) did not correlate with the FFP-associated decrease in F1+2 level. Conclusions : In the patients with the highest pretransfusional thrombin formation, FFP had an acute thrombin-reducing effect. Pretransfusion thrombin generation markers, rather than PT or individual pro- and anticoagulants, may be helpful in identifying the patient who will have measurable coagulational effects induced by FFP.     

Reduction of Fresh Frozen Plasma Requirements by Perioperative Point-of-Care Coagulation Management with Early Calculated Goal-Directed Therapy

Background

Massive bleeding and transfusion of packed red blood cells (PRBC), fresh frozen plasma (FFP) and platelets are associated with increased morbidity, mortality and costs.

Patients and Methods

We analysed the transfusion requirements after implementation of point-of-care (POC) coagulation management algorithms based on early, calculated, goal-directed therapy with fibrinogen concentrate and prothrombin complex concentrate (PCC) in different perioperative settings (trauma surgery, visceral and transplant surgery (VTS), cardiovascular surgery (CVS) and general and surgical intensive care medicine) at 3 different hospitals (AUVA Trauma Centre Salzburg, University Hospital Innsbruck and University Hospital Essen) in 2 different countries (Austria and Germany).

Results

In all institutions, the implementation of POC coagulation management algorithms was associated with a reduction in the transfusion requirements for FFP by about 90% (Salzburg 94%, Innsbruck 88% and Essen 93%). Furthermore, PRBC transfusion was reduced by 8.4–62%. The incidence of intraoperative massive transfusion (≥10 U PRBC) could be more than halved in VTS and CVS (2.56 vs. 0.88%; p < 0.0001 and 2.50 vs. 1.06%; p = 0.0007, respectively). Platelet transfusion could be reduced by 21–72%, except in CVS where it increased by 115% due to a 5-fold increase in patients with dual antiplatelet therapy (2.7 vs. 13.7%; p < 0.0001).

Conclusions

The implementation of perioperative POC coagulation management algorithms based on early, calculated, goal-directed therapy with fibrinogen concentrate and PCC is associated with a reduction in the transfusion requirements for FFP, PRBC and platelets as well as with a reduced incidence of massive transfusion. Thus, the limited blood resources can be used more efficiently.