Fresh frozen plasma transfusion fails to influence the hemostatic balance in critically ill patients with a coagulopathy

Müller, Marcella C.A.; Straat, Marleen; Meijers, Joost C. M.; Klinkspoor, J. H.; Jonge, Evert de; Arbous, M. Sesmu; Schultz, MJ; Vroom, Margreeth B.; Juffermans, Nicole P.

doi:10.1111/jth.12908

Cited by 69 publications

(51 citation statements)

References 31 publications

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“…During such a coagulopathy many coagulation factors are simultaneously reduced. This has been previously shown where coagulation factors and biomarkers were analysed in coagulopathic patients with INRs of 1.5–3 prior and post FFP administration [19]. Similar to our findings, these patients had a median prothrombin concentration of 34% of normal before FFP administration and also reduced concentrations of several other coagulation factors such as Factor X and fibrinogen.…”

Section: Discussionsupporting

confidence: 90%

Prothrombin time is predictive of low plasma prothrombin concentration and clinical outcome in patients with trauma hemorrhage: analyses of prospective observational cohort studies

Balendran

Lövgren

Hansson

et al. 2017

Scand J Trauma Resusc Emerg Med

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BackgroundFibrinogen and prothrombin have been suggested to become rate limiting in trauma associated coagulopathy. Administration of fibrinogen is now recommended, however, the importance of prothrombin to patient outcome is unknown.MethodsWe have utilized two trauma patient databases (database 1 n = 358 and database 2 n = 331) to investigate the relationship of plasma prothrombin concentration on clinical outcome and coagulation status. Database 1 has been used to assess the relationship of plasma prothrombin to administered packed red blood cells (PRBC), clinical outcome and coagulation biomarkers (Prothrombin Time (PT), ROTEM EXTEM Coagulation Time (CT) and Maximum Clot Firmness (MCF)). ROC analyses have been performed to investigate the ability of admission coagulation biomarkers to predict low prothrombin concentration (database 1), massive transfusion and 24 h mortality (database 1 and 2). The importance of prothrombin was further investigated in vitro by PT and ROTEM assays in the presence of a prothrombin neutralizing monoclonal antibody and following step-wise dilution.ResultsPatients who survived the first 24 h had higher admission prothrombin levels compared to those who died (94 vs.67 IU/dL). Patients with lower transfusion requirements within the first 24 h (≤10 units of PRBCs) also had higher admission prothrombin levels compared to patients with massive transfusion demands (>10 units of PRBCs) (95 vs.62 IU/dL). Admission PT, in comparison to admission ROTEM EXTEM CT and MCF, was found to be a better predictor of prothrombin concentration <60 IU/dL (AUC 0.94 in database 1), of massive transfusion (AUC 0.92 and 0.81 in database 1 and 2 respectively) and 24 h mortality (AUC 0.90 and 0.78 in database 1 and 2, respectively). In vitro experiments supported a critical role for prothrombin in coagulation and demonstrated that PT and ROTEM EXTEM CT are sensitive methods to measure low prothrombin concentration.DiscussionOur analyses suggest that prothrombin concentration at admission is predictive of mortality and transfusion and indicates that prothrombin and fibrinogen are rate limiting in coagulopathy.ConclusionsAdmission PT is predictive of low prothrombin concentration and clinical outcome. PT could therefore be used as a surrogate for prothrombin concentration and further evaluation of point-of-care devices for faster PT analysis is warranted.

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Section: Discussionsupporting

confidence: 90%

Prothrombin time is predictive of low plasma prothrombin concentration and clinical outcome in patients with trauma hemorrhage: analyses of prospective observational cohort studies

Balendran

Lövgren

Hansson

et al. 2017

Scand J Trauma Resusc Emerg Med

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“…3,6,7 In addition, plasma does not reliably correct mild-to-moderate elevations in INR or induce a more procoagulant state. 5,8–10 Perhaps most importantly, the assumption that mild-to-moderate elevations of INR confer increased bleeding risk lacks the support of robust experimental evidence. 3,11,12 Notably, plasma transfusion is not without risk.…”

Section: Introductionmentioning

confidence: 99%

Prophylactic Plasma Transfusion Is Not Associated With Decreased Red Blood Cell Requirements in Critically Ill Patients

Warner

Chandran

Jenkins

et al. 2017

Anesthesia &Amp; Analgesia

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Background Critically ill patients frequently receive plasma transfusion under the assumptions that abnormal coagulation test results confer increased risk of bleeding and that plasma transfusion will decrease this risk. However, the impact of prophylactic plasma transfusion remains poorly understood. The objective of this study was to determine the relationship between prophylactic plasma transfusion and bleeding complications in critically ill patients. Methods This is a retrospective cohort study of adults admitted to the ICU at a single academic institution between January 1, 2009 and December 31, 2013. Inclusion criteria included age ≥ 18 years and an International Normalized Ratio (INR) measured during ICU admission. Multivariable propensity-matched analyses were used to evaluate associations between prophylactic plasma transfusion and outcomes of interest with a primary outcome of red blood cell (RBC) transfusion in the ensuing 24 hours and secondary outcomes of hospital and ICU free days and mortality within 30 days of ICU discharge. Results A total of 27,561 patients were included in the investigation with 2,472 (9.0%) receiving plasma therapy and 1,105 (44.7%) for which plasma transfusion was prophylactic in nature. In multivariable propensity-matched analyses, patients receiving plasma had higher rates of RBC transfusion [OR: 4.3 (95% CI: 3.3 – 5.7), p < 0.001] and fewer hospital free days [estimated % increase: −11.0% (95% CI: −11.4, −10.6%), p < 0.001]. There were no significant differences in ICU free days or mortality. These findings appeared robust, persisting in multiple predefined sensitivity analyses. Conclusions Prophylactic administration of plasma in the critically ill was not associated with improved clinical outcomes. Further investigation examining the utility of plasma transfusion in this population is warranted.

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“…heparin therapy). 31 Hence, it is possible that in some patients this may paradoxically tip the hemostatic balance point towards a more anticoagulated state. Finally, there remains the very likely possibility of residual confounding despite careful statistical adjustments with plasma transfusion serving as a surrogate for a sicker patient.…”

Section: Discussionmentioning

confidence: 99%

Prophylactic Plasma Transfusion Before Interventional Radiology Procedures Is Not Associated With Reduced Bleeding Complications

Warner

Woodrum

Hanson

et al. 2016

Mayo Clinic Proceedings

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Objective To determine the association between prophylactic plasma transfusion and periprocedural RBC transfusion rates in patients with elevated INR values undergoing interventional radiology procedures. Patients and Methods In this retrospective cohort study, adult patients undergoing interventional radiology procedures with a preprocedural INR available within 30 days of the procedure during a study period of Jan 1st, 2009 to Dec 31st, 2013 were eligible for inclusion. Baseline characteristics, coagulation parameters, transfusion requirements, and procedural details were extracted. Univariate and multivariable propensity-matched analyses were used to assess the relationships between prophylactic plasma transfusion and the outcomes of interest, with a primary outcome assessed a priori of RBC transfusion occurring during the procedure or within the first 24 hours post-procedurally. Results A total of 18,204 study participants met inclusion criteria for this study, and 1,803 (9.9%) had an INR ≥ 1.5 prior to their procedure. Among these, 196 patients (10.9%) received prophylactic plasma transfusion with a median (interquartile range) time between plasma initiation and procedural start of 1.9 (1.1 – 3.2) hours. In multivariable propensity-matched analysis, plasma administration was associated with increased periprocedural RBC transfusions [OR (95% CI) = 2.20 (1.38 – 3.50); P<.001] and postprocedural ICU admission rates [OR (95% CI) = 2.11 (1.41 – 3.14); P<.001] compared to those who were not transfused preprocedurally. Similar relationships were seen at higher INR thresholds for plasma transfusion. Conclusion In patients undergoing interventional radiology procedures, preprocedural plasma transfusions given in the setting of elevated INR values were associated with increased periprocedural RBC transfusions. Additional research is needed to clarify this potential association between preprocedural plasma and periprocedural RBC transfusion.

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Fresh frozen plasma transfusion fails to influence the hemostatic balance in critically ill patients with a coagulopathy

Cited by 69 publications

References 31 publications

Prothrombin time is predictive of low plasma prothrombin concentration and clinical outcome in patients with trauma hemorrhage: analyses of prospective observational cohort studies

Prothrombin time is predictive of low plasma prothrombin concentration and clinical outcome in patients with trauma hemorrhage: analyses of prospective observational cohort studies

Prophylactic Plasma Transfusion Is Not Associated With Decreased Red Blood Cell Requirements in Critically Ill Patients

Prophylactic Plasma Transfusion Before Interventional Radiology Procedures Is Not Associated With Reduced Bleeding Complications

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