Additionally, plasma transfusion is indicated in the treatment of thrombotic thrombocytopenic purpura TTP , usually in conjunction with plasma exchange. Plasma should not be used for coagulation factor deficiencies for which a safer product is available, i.
As well, plasma should not be used for reversal of warfarin Coumadin anticoagulation. This can safely be achieved by giving Vitamin K or holding warfarin two to three days prior to a planned procedure. Plasma should not be used for volume expansion unless the patient also has a significant coagulopathy and is bleeding. The volume of one unit of plasma is mL. We recently presented the only paediatric data regarding current practice.
More than two thirds of paediatric intensivists would prescribe plasma transfusions to nonbleeding children. For these nonbleeding critically ill children, the median INR level that would trigger a plasma transfusion was 2.
This heterogeneity in plasma transfusion practice patterns probably indicates a need for stronger evidence on appropriate plasma transfusion thresholds. Once randomized, controlled trials will have provided the clinicians with the best transfusion strategies, these will have to be implemented.
It has been shown that systemic organizational interventions, such as educational campaigns or prospective audits of plasma requests, lead to a significant reduction in the inappropriate rate of plasma transfusions [ 38 ]. The following recommendations are based on international guidelines [ 1 , 30 , 39 , 40 ]. Thromboelastography, a recently incorporated method into ICU clinical practice, is performed with whole blood. It assesses the viscoelastic property of clot formation under low shear condition [ 41 ].
Thromboelastography-based algorithms reduce both transfusion requirements and blood loss in massively bleeding patients [ 42 ]. There is conflicting data regarding the predictive value of thromboelastography tests in patients with liver disease [ 43 , 44 ]. However, there is currently no data on its adequacy to evaluate the risk of bleeding in other situations, especially in a PICU setting.
Therefore, it has not yet been incorporated in plasma transfusion guidelines. Physicians also must recognise that coagulation tests are not well correlated to the risk of bleeding. In a recent meta-analysis of 25 studies, Segal et al. Compatibility testing is not required before plasma transfusion, unless large volumes are given.
Type AB plasma can be administered in severe and acute situations as a universal donor type if necessary. Normally, it takes 20 to 30 minutes to thaw FFP. Plasma also can be warmed in 7 minutes using a microwave oven; however, only ovens specifically constructed for this task can be used, as standard microwaves will destroy the function of most coagulation factors.
Thawed plasma must probably be used within 4 to 6 hours after release. A macroaggregate filter must be used to avoid infusing microcrystals of unthawed plasma. Current recommendations advise against the use of plasma for volume expansion, as it has been show that colloids are not superior to crystalloids [ 47 ], and plasma transfusions are associated with a worse clinical outcome [ 28 ].
Because a recent systematic review of 80 randomized, controlled trials did not find any significant benefit of prophylactic use of plasma transfusions [ 48 ], a prophylactic plasma transfusion strategy is not supported. However, most experts advocate prophylactic plasma transfusion in case of surgery or invasive procedures in patients with abnormal coagulation tests. Most experts suggest not waiting for coagulation tests before transfusing plasma units. The optimal RBC:plasma:platelet ratio is still unknown, but early use of plasma and platelets seems to be associated with improved outcome [ 49 ].
The use of rapid thromboelastography testing to guide plasma transfusion in massively bleeding patients, while still uncommon, is increasing over time. Thromboelastography-based algorithms reduce both transfusion requirements and blood loss in cardiac surgery, liver transplantation, and massive trauma. No recommendations in this population currently include thromboelastography thresholds for plasma transfusion. However, this strategy has never been adequately evaluated.
In children undergoing liver transplantation, plasma transfusions are associated with increased 1-year mortality [ 50 ]. Therefore, it seems reasonable to transfuse plasma only in the setting of a severe bleeding with abnormal coagulation tests.
Plasma also is often used to try to prevent bleeding before surgical procedures or invasive procedures in patients with abnormal coagulation tests. It has been shown that abnormal coagulations tests are not correlated with an increased risk of bleeding [ 45 ].
However, there are no data regarding this transfusion strategy. In patients with single clotting factor deficiency and active bleeding, experts recommend that plasma should only be transfused if specific concentrate is not obtainable.
Usually, this only applies to factor V deficiency. Plasma should only be used for the reversal of warfarin if there is evidence of severe bleeding or intracranial haemorrhage. If available, prothrombin complex is the first-choice treatment. The purpose of treatment of acute episodes is to halt progression of the oedema as quickly as possible.
The most efficient treatment is C1 inhibitor concentrate from donor blood, which must be administered intravenously. If C1-esterase inhibitor is not available, plasma transfusions can be used to treat these patients. In neonates, coagulation test have a wider normal range than in adult and therefore are even less correlated to the risk of bleeding. As for older children, there are no data to recommend prophylactic plasma transfusions. Plasma should not be used as volume replacement, because there is no advantage of colloids over crystalloids for this indication [ 47 ].
Plasma should not be used to correct abnormal INR or PTT in nonbleeding patients who have no planned surgery or invasive procedures, because there is no correlation between coagulation tests and risk of bleeding [ 45 ], but data show that plasma transfusions increase the risk of unfavourable outcome [ 27 , 28 ].
There are many unresolved questions regarding plasma transfusions. Apart from massively bleeding patients, it is still unknown which patients really benefit from plasma transfusions. Is it appropriate to give prophylactic plasma transfusions to patients with abnormal coagulation tests who will undergo surgery?
Should we transfuse plasma to patients who experience minor bleeding? Randomized, controlled trials on plasma transfusion strategies in these different clinical situations are warranted. Currently, it is unclear which coagulation test best reflects the risk of bleeding. Therefore, it is still unclear what the appropriate plasma transfusion triggers should be. Some experts suggest that thromboelastography tests are superior to classical coagulation tests. However, no studies have yet shown that a thromboelastography-based goal-directed transfusion strategy improves mortality in critically ill children.
Plasma transfusion is a common treatment for critical care patients. Although it clearly benefits some patients, such as those who are massively bleeding, epidemiological studies suggest that, in less dramatic situations, plasma transfusions are associated with worse outcome, both in adults and children.
Therefore, the decision to proceed with plasma transfusion must be based on individualized indications, while balancing the risks and benefits. Unfortunately, no randomized, controlled trial has yet addressed the appropriate plasma transfusion threshold. Despite current expert recommendations based on observational data, most physicians prescribe plasma transfusions according to their own believe and experiences.
This probably leads to many unnecessary transfusions and therefore preventable adverse events. Br J Haematol , 11— Article PubMed Google Scholar.
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Crit Care Med , — Transfusion , — Transfusion , 50SS. Transfus Med Hemother , 65— Transfusion , 52 Suppl 1 :9SS. Pediatrics , ee Zink K, Sambasivan C, Holcomb J, Chisholm G, Schreiber M: A high ratio of plasma and platelets to packed red blood cells in the first 6 hours of massive transfusion improves outcomes in a large multicenter study. Am J Surg , — Holland LL, Brooks JP: Toward rational fresh frozen plasma transfusion: the effect of plasma transfusion on coagulation test results.
Am J Clin Pathol , — Blood Rev , — Dzik WH: Leukoreduction of blood components. To determine whether use of a restrictive versus a liberal plasma transfusion threshold affects mortality or morbidity in critically ill patients, and to assess the clinical effects of different plasma transfusion thresholds in critically ill patients.
A search for studies was run on 15 August Randomised clinical trials that assessed the effects of two plasma transfusion strategies, using a restrictive and a liberal threshold of at least one coagulation test, in critically ill participants. Two review authors independently extracted data and assessed trial quality using the standard methods of the Cochrane Handbook for Systematic Reviews of Interventions. Of references identified by our search, none of the trials satisfied our predefined inclusion criteria.
No studies are included in this review. Authors' conclusions:. Search strategy:. Selection criteria:.
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