Prophylactic plasma transfusion for surgical patients with abnormal preoperative coagulation tests: a single-institution propensity-adjusted cohort study

Abstract

Background Perioperative hemorrhage negatively impacts patient outcomes and results in substantial health care resource consumption. Plasma transfusions are frequently administered to address abnormal preoperative coagulation tests, with the hope of mitigating bleeding complications. This study aimed to evaluate the associations between preoperative plasma transfusion and bleeding complications in patients with elevated international normalized ratios undergoing noncardiac surgery. Methods An observational comparative effectiveness research study evaluating a consecutive sample of adult patients undergoing noncardiac surgery (N=14,743) with preoperative international normalized ratios ≥ 1.5 between January 1, 2008, and December 31, 2011. Among the patients, 1,234 (8.4%) had an international normalized ratio ≥ 1.5 and were included in this investigation. Exposure of interest was transfusion of preoperative plasma for an elevated international normalized ratio. Primary outcome was World Health Organization grade 3 bleeding in the early perioperative period. Secondary outcomes included blood loss, reoperation for bleeding, and additional patient-important outcomes including death and lengths of stay. Hypotheses were tested with univariate and propensity-matched analyses. Multiple sensitivity analyses were performed to further evaluate the robustness of study findings. Findings Of 1,234 study participants, 139 (11.3%) received a preoperative plasma transfusion. Those who received plasma had a higher rate of perioperative (52.5% vs 32.0%; P < .0001) and intraoperative (40.3% vs 24.5%; P < .0001) red blood cell transfusion, as well as an increased rate of reoperation for bleeding (11.5% vs 4.5%; P = .0005). The increased rate of perioperative red blood cell transfusion stayed in the propensity-matched analyses (OR, 1.75 [95% CI, 1.09–2.81]; P= .0210). Results from multiple sensitivity analyses were qualitatively similar. Interpretation Preoperative plasma transfusion for elevated international normalized ratios was associated with an increased rate of perioperative bleeding complications. Findings were robust in the sensitivity analyses, suggestive that more conservative management of abnormal preoperative international normalized ratios is warranted. Funding Department of Anesthesiology and Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, Minnesota; National Institutes of Health, Grant Number: R01 HL121232-01.

Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology

“…However, more recent studies have shown quite the reverse; that there is often a prothrombotic state, and transfusion of FFP has been described as usually unnecessary, ineffective and potentially hazardous. [139][140][141][142][143][144][145] A recent Cochrane review concluded that there is uncertainty about the utility and safety of prophylactic FFP use. 146 Thus, use of FFP is rarely indicated.…”

Higher intraoperative plasma transfusion volumes are associated with inferior perioperative outcomes

“…38 Similarly, multiple investigations have observed higher rates of bleeding complications in patients that receive prophylactic plasma transfusion for the management of elevated INR values in the absence of clinical bleeding. 39–41 …”

“…38 Similarly, multiple investigations have observed higher rates of bleeding complications in patients that receive prophylactic plasma transfusion for the management of elevated INR values in the absence of clinical bleeding. [39][40][41] As another study limitation, plasma transfusion volumes were modest (median, 8.9 mL/kg), and hence "suboptimal" plasma dosing may have affected study results. Furthermore, most transfusions were administered with INR values less than 2 and hence within the range of potentially "preserved" hemostasis.…”

Hemostatic Complications in Hepatobiliary Surgery

“…95 Whereas the evidence for the benefits of blood products in perioperative medicine is low, the supporting evidence for transfusion-related complications including transfusion associated lung injury, transfusion-associated circulatory overload, and infectious complications are increasingly acknowledged. 62 As in other types of surgery, 96,97 transfusion of blood products during liver surgery and liver transplantation has been associated with increased morbidity and mortality. 4 Our current practice is in general one of wait-and-see approach to start blood product transfusion only in actively bleeding patients with evidence of hemostatic abnormalities.…”