Eliminating international normalized ratio threshold for transfusion in pediatric patients with acute liver failure

Abstract

Introduction Transfusion protocols are not well‐studied for pediatric patients with acute liver failure (ALF). This study evaluates the utility of an international normalized ratio (INR)‐based transfusion threshold for these patients. Methods Forty‐four ALF pediatric patients from 2009 to 2018 were reviewed and divided into two groups: (a) a threshold group including patients between 2009 and 2015 who were transfused for an INR above 3.0, per institutional policy (n = 30), and (b) a post‐threshold group including patients after 2015 through 2018 who were transfused based on clinical judgment (n = 14). Preoperative INRs, preoperative transfusions, intraoperative transfusions, early reoperation, renal function, graft function and deaths were compared. Results Liver failure severity was similar between threshold and post‐threshold groups. Threshold patients had a lower average INR prior to transplantation, 2.8 (range 1.8‐3.8) vs 4.4 (range 2.1‐9.0), respectively (P = .01). Twenty‐six threshold patients (87%) received preoperative FFP compared with seven post‐threshold patients (50%, P = .0088). Two threshold patients (7%) received preoperative cryoprecipitate compared with five post‐threshold patients (36%, P = .014). The incidence of pre‐transplant bleeding, operative transfusions, and 1‐year patient and graft survival did not differ significantly. Conclusion Clinical judgment vs an INR‐based threshold for transfusions did not increase perioperative complications in children with ALF.

Transfusion Strategies for Hemostatic Blood Products in Critically Ill Children: A Narrative Review and Update on Expert Consensus Guidelines

“…80 Though INR is a prognostic indicator and/or a variable for transplantation consideration, as only reflecting procoagulant factors, it does not predict bleeding. 81 VET reflects whole blood's ability to clot, and is better assessment of bleeding risk, though its use in children with PALF has not been widely studied. 82 When considering plasma and/or platelet transfusions in children with PALF, one must exercise caution.…”