KKidd Posted May 4, 2011 Share Posted May 4, 2011 Does anyone have a protocol for plasma transfusion regarding repeating the PT/INR? I would love to see us implement a protocol to check the INR after 2 units. Of course this would not include traumas. Thanks!!:confused::confused::confused::confused: Link to comment Share on other sites More sharing options...
David Saikin Posted May 5, 2011 Share Posted May 5, 2011 Unfortunately NO. I try to bully my docs when they use plasma "empirically". My Medical Director is only here 2 half days/week (if I'm lucky). I do not thaw more than 2 at one time . . . if they want more than that I make them contact the Director and he can tell me to thaw more (if they don't want to do an INR after 2u). This seems to be a problem in most places I inspect too. YOU ARE NOT ALONE! Link to comment Share on other sites More sharing options...
Malcolm Needs ☆ Posted May 5, 2011 Share Posted May 5, 2011 Unfortunately NO. I try to bully my docs when they use plasma "empirically". My Medical Director is only here 2 half days/week (if I'm lucky). I do not thaw more than 2 at one time . . . if they want more than that I make them contact the Director and he can tell me to thaw more (if they don't want to do an INR after 2u). This seems to be a problem in most places I inspect too. YOU ARE NOT ALONE!Just as a matter of interest, David, in the UK, the Guidelines do not talk of units of FFP, but rather of a minimum initial dose of 12-15mL/Kg body weight. Link to comment Share on other sites More sharing options...
David Saikin Posted May 5, 2011 Share Posted May 5, 2011 Just as a matter of interest, David, in the UK, the Guidelines do not talk of units of FFP, but rather of a minimum initial dose of 12-15mL/Kg body weight.I believe that is how our docs are supposed to calculate the dose BUT I believe only a few do so (notably the docs in Emergency) Link to comment Share on other sites More sharing options...
tbostock Posted May 5, 2011 Share Posted May 5, 2011 Our policy is that they can give 2 units of plasma for the following:INR >1.5 with active bleeding or pre-opAPTT >60 sec with active bleeding or pre-opImmediate reversal of Coumadin effect for immediate hemostasisAbnormal bleeding/oozing intra-op with suspected coagulopathyMassive bleedActive intracranial hemorrhageDocumented coag factor deficiency: factor assay less than 25% with active bleeding or pre-opAfter 2 units (unless a massive bleed), they have to repeat the INR/APTT and patient has to qualify to get more units, then they are given 1 at a time. Link to comment Share on other sites More sharing options...
Malcolm Needs ☆ Posted May 5, 2011 Share Posted May 5, 2011 I may well be talking out of turn here Terri, so please forgive me if you think I am, but, these days, an awful lot of folk tend to give more FFP to prevent coagulopathy, especially in the case of a massive bleed, as prevention has been found to be better than trying to catch up after the fact with more FFP, particularly as it would seem from some of the latest studies that FFP may take some time to "work", rather in the same way that stored red cells need time to recover in the circulation before they can carry an optimum amount of oxygen. Link to comment Share on other sites More sharing options...
tbostock Posted May 5, 2011 Share Posted May 5, 2011 Correct, that is why we don't ask that for massive bleeds. We have a massive transfusion protocol that uses a 1:1 ratio of red cells to plasma to correct coagulopathy. Also for intracranial hemorrhages...we don't play around with them.On the more routine cases, we're just trying to prevent overtransfusion of plasma. We've found here that even with very high INRs, without active bleeding, two units of FFP usually do the trick (probably about 80% of the time). Link to comment Share on other sites More sharing options...
Mabel Adams Posted May 7, 2011 Share Posted May 7, 2011 I sure wish someone would come up with some good evidence-based FFP transfusion guidelines. It's hard to argue with the docs that want to make the INR normal no matter what it takes when we don't have really strong science to back us up. About the only strong science there is is in the area of massive transfusion. Link to comment Share on other sites More sharing options...
EDibble Posted May 7, 2011 Share Posted May 7, 2011 We have seen a great improvement in FFP utilization here. Almost always, patients getting FFP (outside of the OR) are also given Vitamin K injections. This seems to have reduced the number of units of FFP given. Link to comment Share on other sites More sharing options...
Angie Redd Posted March 27, 2012 Share Posted March 27, 2012 What time frame do you check the PT/INR after the 2 units of FFP are given? Is there a appropriate time that effectivness could be monitored similar to 1 hr for RBC's? Link to comment Share on other sites More sharing options...
ElinF Posted April 9, 2012 Share Posted April 9, 2012 We are looking into this at our facility as well. Our current policy states to talk to the pathologist if more than 4 units are ordered. (but does that get done at 2 in the morning...no) We had a patient recently transfused with 6 units before a recheck and I don't think her PT was that high to begin with. It just seemed excessive. I would have probably suggested it after 3 at least 4 had I been here and involved. I was more worried about overload, but that is apporx 1200 mL of fluid over 2 and 1/2 hours. I guess that is not unheard of... I don't know what the best thing to do is and then where is the reference for that? Link to comment Share on other sites More sharing options...
Malcolm Needs ☆ Posted April 10, 2012 Share Posted April 10, 2012 UK Guidelines suggest that a minimum of 12 to 15mL/Kg body weight is given as a starter, and you would be surprised how many times that means that more than 2 units of FFP are required.If anything, we have a problem in that, on a regular basis, too little FFP is requested for the patient's body weight. I, incidentally, after the choclate eggs for Easter, would require a minimum of about 10 units!!!!!!!!!!!!!!!!!!!!!!!! Link to comment Share on other sites More sharing options...
mollyredone Posted April 10, 2012 Share Posted April 10, 2012 Elin, wow does that hit home for me today! Over the weekend we had a patient with an INR of 9, a HGB of 11 and a PLT of 21. ER ordered 4 FFP, and gave them. I believe they did a PT then, with an INR of 2. On the floor, the dr ordered 4 more FFP, 1 cryo (FBG<50) and PPH. They drew a CBC from a line and got a HGB of 4, so they also ordered 4 PRBC, with two on keep-ahead. In less than 12 hours the pt got 1 cryo, 1 PPH, 8 FFP and 7 PRBC and then died. Link to comment Share on other sites More sharing options...
Malcolm Needs ☆ Posted April 10, 2012 Share Posted April 10, 2012 Elin, wow does that hit home for me today! Over the weekend we had a patient with an INR of 9, a HGB of 11 and a PLT of 21. ER ordered 4 FFP, and gave them. I believe they did a PT then, with an INR of 2. On the floor, the dr ordered 4 more FFP, 1 cryo (FBG<50) and PPH. They drew a CBC from a line and got a HGB of 4, so they also ordered 4 PRBC, with two on keep-ahead. In less than 12 hours the pt got 1 cryo, 1 PPH, 8 FFP and 7 PRBC and then died.TACO. Link to comment Share on other sites More sharing options...
mollyredone Posted April 10, 2012 Share Posted April 10, 2012 (edited) Malcolm, first you're talking about chocolate eggs, now you're talking about TACOs! You're making me hungry! No, seriously, that situation over the weekend will be discussed in utilization review! Edited April 10, 2012 by mollyredone Link to comment Share on other sites More sharing options...
Deny Morlino Posted April 12, 2012 Share Posted April 12, 2012 TACO.That was exactly the first thought that came to mind when I was looking at the number of units involved. Link to comment Share on other sites More sharing options...
ElinF Posted April 13, 2012 Share Posted April 13, 2012 TACO.I worry about taco, but I sometime I don't think they know what that is... Don't forget about the hgb people! Link to comment Share on other sites More sharing options...
Malcolm Needs ☆ Posted April 13, 2012 Share Posted April 13, 2012 But the Hb was probably 11 (the 4 came from a line). However, to a certain extent the Hb is irrelevant, because it is circulatory overload - not red cell overload. The overload can be caused by "liquid" blood components just as much as cellular blood components. Link to comment Share on other sites More sharing options...
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