How does ffp affect inr

Plasma can be used for prophylaxis in patients with hereditary angioedema who are undergoing oral surgery. Prophylaxis will prevent attacks of angioedema which are commonly precipitated by dental procedures and head and neck surgery. Infusion of 2 units of FFP the day before and again just prior to the procedure is recommended. Although FFP is recommended for prophylaxis, its use for treatment of an angioedema attack has not been established.

Plasma transfusions have been reported to arrest attacks of angioedema. However, FFP could be hazardous because it contains complement factors C2 and C4 that may exacerbate the attack. FFP should be reserved for life threatening attacks.

Future treatment options include C1 Inhibitor concentrates that have been used for years in Europe and are currently under clinical investigation in the United States. FFP should not be used as a volume expander, as a nutritional supplement, for the treatment of bleeding in the absence of documented coagulopathy, or as a standing order following surgery or massive transfusion.

It is important to remember that transfusion of FFP is not free of risk. As with any other blood component, the decision to transfuse FFP should be based on predictable benefit and clinically necessity. Home Transfusion Plasma Transfusion Guidelines. Plasma Transfusion Guidelines. Pre-transfusion INR. Coagulation Defect. Liver disease — mild. Abnormal PT. Liver disease —moderate to severe. Acute DIC. Postoperative bleeding. Massive Transfusion.

Vitamin K deficiency, mild. PT factor VII. In these studies, the risk of bleeding between the 2 groups of patients undergoing the same procedure could be estimated [ 22 ]. Although the confidence intervals of some of these comparisons were relatively large due to the small number of patients in these studies, there was no significant difference in the risk of major bleeding between the patients who underwent these varied procedures with and without coagulopathies.

While further study is required, especially for coagulopathic patients undergoing kidney biopsy, overall it would appear that patients with mild coagulopathies undergoing various surgical procedures might not require normalization of their laboratory coagulation parameters with plasma to reduce their risk of bleeding.

The second meta-analysis can shed some light on the question, if plasma is administered to peri-surgical patients, does it have a beneficial effect in reducing transfusion requirements or surgical blood loss?

Stanworth and colleagues searched various medical publication databases looking exclusively for randomized controlled trials RCT where FFP was the therapeutic intervention [ 24 ]. While 57 such trials were identified, 19 were focused on surgical or potentially surgical patients; there were 11 studies based on cardiovascular surgery in children and adults, 3 studies on liver disease with or without GI bleeding, and 1 study each on warfarin reversal with intracerebral hemorrhage, massive transfusion, hip surgery, hysterectomy, and renal transplantation.

Most of these studies concluded that FFP administration did not reduce blood loss or transfusion requirements [ 24 ]. To explain why prophylactic plasma administration does not reduce peri-operative bleeding, consider a study of 22 non-trauma patients who received a total of 68 units of FFP mL units [ 4 ]. The average pre-transfusion INR was 1.

Furthermore, given that some FFP units can have INRs approaching that of these recipient's [ 4 ], it is not surprising that the decreases in the post-transfusion INRs were quite modest. Abdel-Wahab and colleagues studied FFP recipients from a wide variety of hospital wards, and with and an assortment of clinical diagnoses [ 25 ]. In this retrospective study, FFP units were transfused to recipients who had relatively low pre-transfusion INRs, 1.

It is not surprising that patients with lower INRs 1. The latter finding can be explained by considering that 1 unit of FFP approximately mL , when administered to a 70 kg recipient, translates into a dose of 3. Receipt of 2 units of FFP by a 70 kg recipient would amount to a dose of 6.

Furthermore, each recipient in this study received on average 2. Thus the low rate of correction could be attributable to the small volume of FFP transfused. Additionally, consider that the plasma volume of a 70 kg recipient with a Hct of 0. This might also explain the popular perception of the success of prophylactically administering plasma to recipients with modestly elevated INRs; when these patients tolerate the surgical procedure without excessive bleeding, this positive outcome is attributed to the administration of the plasma.

In reality, these recipients were unlikely to have had a coagulopthic bleed owing to their significant reserve of clotting factors even with their slightly elevated INR.

Another study of plasma recipients in Canada also found a minimal INR response when mildly coagulopathic patients were transfused with small quantities of FFP [ 26 ]. The indications for FFP ranged from pre-procedure prophylaxis, acute bleeding, or prophylactic reversal of a prolonged PT in non-bleeding recipients. The etiology of the cirrhosis in the majority of these patients was either alcohol use or a combination of Hepatitis C and alcohol use.

In this study, 27 healthy volunteers donated approximately 2. After they were anticoagulated to INRs between 1. The investigators then measured a series of pharmacokinetic parameters of factor VII, along with a PT.

At the end of the study period, all volunteers were given oral vitamin K which resulted in a complete reversal of their PT prolongation which should serve as a reminder that in situations when reversal of a coagulopathy is not urgent, non-human source medications such as vitamin K could be employed Fig. Furthermore, Holland et al. Another way to consider the effect of transfusing plasma to patients with an elevated INR is to remember that the response of a patient who is otherwise stable i.

This is depicted in Fig. These patients were not involved in trauma, not in the operating room, did not have DIC and were not treated with prothrombin complex concentrates PCC. Theoretical response to plasma transfusion based on a formula derived from a clinical study of adult plasma recipients [ 28 ].

The main predictor of the response to plasma transfusion is the pretransfusion INR. A small Welsh study extensively evaluated the laboratory parameters of hemostasis including factor levels, PT and PTT in ICU patients before and after receiving a median dose of either The routine administration of small quantities of plasma to peri-operative patients with minor coagulopathies probably confers very little hemostatic benefit and potentially subjects the recipients to numerous adverse reactions including volume overload and TRALI; conversely, higher doses of plasma than are currently recommended might be necessary to reverse a significant coagulopathy.

MHY is grateful to Drs. Darrell Triulzi and Jonathan Waters for thoughtful discussion and critical review of the manuscript, and to Dr. Walter Dzik for kindly providing Fig. Transfusion triggers. In: Waters J, ed. National Center for Biotechnology Information , U. Journal List Korean J Hematol v. Korean J Hematol. Usage of FFP in non-bleeding patients with acquired coagulation deficits is more often dictated by convention rather than rationally based approaches.

However, awareness of the harmful consequences of FFP usage must be underscored among healthcare providers. What is the take home message? Furthermore, elevation of INR does not predict bleeding in the setting of a procedure nor does prophylactic FFP transfusions result in fewer bleeding events. Guidelines for the administration of plasma, Accessed September 28, Fresh frozen plasma and platelet transfusion for nonbleeding patients in the intensive care unit: Benefit or harm?

Critical Care Medicine. Effect of plasma transfusions on the prothrombin time and clotting factors in liver disease. New England Journal of Medicine. Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities.

Toward rational fresh frozen plasma transfusion: the effect of plasma transfusion on coagulation test results. American Journal of Clinical Pathology. Clotting factor levels and the risk of diffuse microvascular bleeding in the massively transfused patient. British Journal of Haematology. Available at www. Prophylactic correction of the international normalized ratio in neurosurgery: a brief review of a brief literature. Journal of Neurosurgery.