Utilization of frozen plasma in <scp>O</scp>ntario: a provincewide audit reveals a high rate of inappropriate transfusions

Tinmouth, Alan; Thompson, Troy; Arnold, Donald M.; Callum, Jeannie; Gagliardi, Kate; Lauzon, Deborah; Owens, Wendy; Pinkerton, P. H.

doi:10.1111/trf.12231

Cited by 61 publications

(64 citation statements)

References 23 publications

(58 reference statements)

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“…A large proportion of these plasma units were administered preoperatively to surgical populations (10–13). Despite the frequent use of plasma transfusion, evidence-based indications are limited, with the primary indication being replacement of coagulation factor content in patients with active bleeding who have acquired coagulation factor deficiencies (13,19). Less frequently, plasma transfusion may be indicated in the setting of plasma exchange for such conditions as thrombotic thrombocytopenic purpura or in patients with congenital coagulation factor deficiencies when no specific coagulation factor concentrate exists.…”

Section: Discussionmentioning

confidence: 99%

“…Though these indications for plasma transfusion have been broadly endorsed (28), the more controversial issue of prophylactic plasma transfusion for nonbleeding patients with abnormal preprocedural coagulation screening tests is a matter of much debate (13,28). Indeed, plasma administration is still common in this clinical setting despite the dearth of data suggesting clinical benefit (12,13,28–30).…”

Section: Discussionmentioning

confidence: 99%

“…A large proportion of the plasma components are transfused in the perioperative environment (10–13). In that setting, plasma frequently is administered prophylactically, in the absence of significant active bleeding.…”

Section: Introductionmentioning

confidence: 99%

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

Jia

Brown

Clifford

et al. 2016

The Lancet Haematology

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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

Jia

Brown

Clifford

et al. 2016

The Lancet Haematology

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“…27,30 Despite published guidelines for FP transfusion, a recent five-day audit of FP utilization in 76 hospitals in Ontario found that, overall, only 29% of patients transfused with FP received optimal therapy, including both the correct dose and the appropriate indication for use. 31 The most common inappropriate uses for FP were for patients with an INR \ 1.5 or when administered to patients for warfarin reversal in the absence of bleeding. The most frequent indications for FP were to correct INR before surgery or for warfarin reversal.…”

Section: Contraindicationsmentioning

confidence: 99%

“…27,30 Malgré les directives publiées en matière de transfusion du PFC, un récent audit de cinq jours portant sur l'utilisation de PFC dans 76 hôpitaux ontariens a rapporté que globalement, seuls 29 % des patients transfusés avec du PFC ont reçu un traitement optimal, à la bonne dose et pour une indication reconnue. 31 Les utilisations inadaptées les plus courantes du PFC étaient liées à des patients avec un RIN \ 1,5, ou lorsqu'il était administré à des patients pour neutraliser la warfarine en l'absence de saignements. Les indications les plus fréquentes pour le PFC étaient la correction du RIN avant une chirurgie ou la neutralisation de la warfarine.…”

Section: Contre-indicationsunclassified

Reversal of warfarin anticoagulation for urgent surgical procedures

Curtis

Schweitzer

Vlymen

2015

Can J Anesth/J Can Anesth

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Purpose Patients treated with warfarin for therapeutic anticoagulation present a challenge for the perioperative management of urgent and emergent surgery. Anticoagulation must be reversed prior to most surgical procedures to prevent intraoperative bleeding. The purpose of this module is to review the options for urgent reversal of warfarin anticoagulation and the indications for each reversal agent. Selection of the appropriate agent is important to reduce unnecessary complications of treatment and to achieve optimal reversal of anticoagulation. Principal findings When urgent surgery is required for patients taking warfarin, intravenous vitamin K 1 should be used for procedures that can be delayed for six to 12 hr. Vitamin K 1 results in the activation of existing clotting factors rather than requiring the synthesis of new proteins, which allows for its relatively rapid onset of action. Intravenous vitamin K 1 acts more quickly than oral administration, with reversal of anticoagulation occurring within six to 12 hr vs 18-24 hr, respectively. If surgery cannot be delayed, prothrombin complex concentrates (PCCs) should be given, and intravenous vitamin K 1 should be infused concurrently to ensure sustained reversal of anticoagulation. The duration of action of both PCCs and plasma is six hours due to the short half-life of factor VII. Prothrombin complex concentrates contain small amounts of heparin and are contraindicated in patients with heparin-induced thrombocytopenia. Plasma should be used only if PCCs are unavailable or are contraindicated. Conclusion Reversal of warfarin anticoagulation can be achieved in a safe and timely manner when the appropriate agent is selected and administered correctly. Objectives of this Continuing Professional Development (CPD) module:After reading this module, the reader should be able to: 1. Identify the options for emergency reversal of warfarin anticoagulation; 2. Describe the dose, onset, and duration of action of agents that reverse warfarin anticoagulation; 3. List potential complications and contraindications of agents that reverse warfarin anticoagulation; 4. Choose the optimal agent for emergency reversal of warfarin anticoagulation, considering the timing of the operation and the risks and benefits of each agent.Despite increasing use of novel agents, warfarin remains the most widely prescribed oral anticoagulant in clinical use. A recent analysis of prescribing trends following regulatory approval for the newer agents showed that warfarin still accounted for over 75% of all the oral anticoagulants used. 1 Warfarin is indicated to reduce the risk of thromboembolic events in patients with atrial fibrillation, mechanical heart valves, and deep venous thrombosis, among other indications. Therefore, as the population ages, the use of anticoagulants, including warfarin, is projected to increase substantially.Patients treated with warfarin for therapeutic anticoagulation present a challenge for the perioperative management of urgent and emergent surgery. In order to...

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Prophylactic plasma transfusion for patients undergoing non-cardiac surgery

Huber

Stanworth

Dorée

et al. 2017

Cochrane Database of Systematic Reviews

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Utilization of frozen plasma in Ontario: a provincewide audit reveals a high rate of inappropriate transfusions

Abstract: This point-prevalence hospital audit revealed that transfusion of FP is frequently inappropriate. Focusing on reducing the two most common reasons for inappropriate FP transfusions could lead to a significant improvement in FP utilization.

Cited by 61 publications

References 23 publications

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

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

Reversal of warfarin anticoagulation for urgent surgical procedures

Prophylactic plasma transfusion for patients undergoing non-cardiac surgery

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