Transfusion triggers for blood components

Defining Usage and Clinical Outcomes Following Perioperative Fresh Frozen Plasma and Platelet Administration in Spine Surgery Patients

STUDY DESIGN

This was a retrospective study.

OBJECTIVES

The main objectives of this study were to characterize the utilization of fresh frozen plasma (FFP) and platelets in spine surgery and the clinical outcomes following their administration.

SUMMARY OF BACKGROUND DATA

Blood component transfusion is often a crucial therapy during spine surgery. Little is known about the association between transfusion with FFP and/or platelets and perioperative morbidity in patients undergoing spine surgery.

MATERIALS AND METHODS

At a single large tertiary medical center, the surgical billing database was retrospectively queried for patients undergoing spinal surgery from 2008 to 2015. A univariate analysis compared patient characteristics for those who received FFP and/or platelets perioperatively and those who did not. To determine independent predictors of FFP and platelet administration and independent predictors of perioperative complications, both univariate and multivariate analyses were used.

RESULTS

In total, 6931 patients met inclusion criteria. One thousand seven (14.5%) patients received perioperative FFP transfusion and 432 (6.2%) received platelets. In multivariate analysis, Charlson Comorbidity Index (CCI) ≥4, preoperative hemoglobin <12 g/dL, preoperative international normalized ratio (INR) ≥1.7, higher estimated blood loss, and receipt of packed red blood cell or platelet transfusion were associated with perioperative FFP administration (all P≤0.001). More than half of all patients received FFP with an INR trigger of <1.7. Those who received perioperative FFP were more likely to experience infection, increased length of stay, and ischemic, respiratory, thrombotic, and renal complications (all P<0.0001). Perioperative FFP [odds ratio (OR): 2.43], platelet transfusion (OR: 1.81), American Society of Anesthesiologists (ASA) grade 3 or 4 (OR: 1.84), CCI≥4 (OR: 1.75), and receipt of packed red blood cells (OR: 1.73) were independent predictors of experiencing any complication (all P≤0.008).

CONCLUSIONS

The majority of patients were given FFP with a liberal INR trigger of >1.7. Perioperative FFP and platelet administration are independent predictors of perioperative complications following spine surgery.

Defining Transfusion Triggers and Utilization of Fresh Frozen Plasma and Platelets Among Patients Undergoing Hepatopancreaticobiliary and Colorectal Surgery

BACKGROUND

We sought to define the overall utilization of fresh frozen plasma (FFP) and platelets and the impact on perioperative outcomes among patients undergoing hepatopancreaticobiliary and colorectal resections, as well as analyze the utility of laboratory triggers in guiding transfusion practice.

METHODS

We identified 3027 patients undergoing pancreatic, hepatic, and colorectal resections between 2010 and 2013 at Johns Hopkins Hospital. Data on international normalized ratio (INR) and platelet counts that triggered the perioperative utilization of these non-RBC (red blood cell) products were obtained and analyzed.

RESULTS

Overall FFP and platelet transfusion rates were 8.9% and 3.8%, respectively. Mean INR and platelet triggers for FFP and platelet transfusions were 1.9 ± 1.3 and 60000 ± 44000, respectively. INR triggers varied depending on resection type, patient race, and comorbidity status (all P <0.05). Nearly one-half of patients (48.0%) received FFP in the postoperative period with an INR trigger less than 1.7. FFP transfusions were independently associated with an increased length of stay [odds ratio (OR) = 3.66], perioperative morbidity (OR = 3.96) and in-hospital mortality (OR = 91.85) (all P < 0.001). Similarly, patients receiving platelets were at increased risk for worse overall perioperative outcomes (all OR >1, P <0.001).

CONCLUSIONS

The utilization and indication of non-RBC components vary significantly across surgical specialties. Nearly one-half of patients transfused with FFP during the postoperative period had an INR of less than 1.7, indicating possible overutilization of these products. Furthermore, the use of FFP and platelets are associated with poorer perioperative outcomes. Further studies are needed to study the impact and management of a more restrictive use of FFP and platelets on surgical patients.

Clinical use of fresh-frozen plasma in neonatal intensive care unit

Recommendations for FFP use in neonates are based on a very limited amount of data, and not on well-designed randomized controlled trials. This retrospective study was performed to analyze our experience with FFP use in neonatal intensive care unit (NICU). From January 2006 until August 2011 a total of 80 neonates were identified as having been treated with FFP. The most common indication for FFP use was prolonged PT or aPTT, representing 32.8% of all usages of FFP. Following FFT treatment PT and aPTT normalized in 42% and 60% patients, respectively. Our results suggest that FFP were often used in acceptable indications in NICU.

Coagulation concepts update

OBJECTIVE

Since the previous comprehensive radiology review on coagulation concepts that was done in 1990, many studies have been published in the medical and surgical literature that can guide the approach of a radiology practice. The purpose of this article is to provide an analysis of these works, updating the radiologist on proper use and interpretation of coagulation assessment tools, medications that modify the hemostatic system, and the use of transfusions prior to interventions.

CONCLUSION

The basic tools for coagulation assessment have not changed; however, results from subspecialty research have suggested ways in which the use of these tools can be modified and streamlined to safely reduce time and expense for the patient and the health care system.

Update on Transfusion Medicine

Clinical pharmacists often participate on critical care teams that manage patients with bleeding emergencies. Although blood products are usually dispensed from the blood bank and not the pharmacy, pharmacists should be conversant in the language and trends of transfusion medicine, much like they are with other therapeutic agents. Toward that goal, this review provides a concise transfusion medicine tutorial, covering all commonly used blood products, including red blood cells, platelets, fresh frozen plasma, and plasma derivatives such as cryoprecipitate, prothrombin complex concentrates, and albumin. Usage patterns, the rationale for administering the various blood products, and studies that have attempted to determine appropriate criteria for ordering transfusions (transfusion triggers) are discussed. The benefits, risks, and several ongoing controversies that relate to the appropriateness and safety of blood product use are also summarized.