Plavix

[DFALES]

Does anyone have a policy specifically regarding Plavix or Aspirin and Platelet Transfusions?

[David Saikin]

Usually questions regarding aspirin/Plavix are relegated to donors, not pts. Aspirin/plavix should not (I think) impact transfused plts as these antagonists are active in the pt's own plt maturation process.

[Stoogiesfreak]

We have had a couple of issues with physicians wanting platelets on hand for OR when patient's have been taking Plavix. As far as I can find out aspirin is a reversible reaction with regard to platelets, but Plavix is not. Once platelets have been "inactivated" by Plavix they will not reverse back to functional platelets as they will with aspirin.

The platelet count will be normal, but I have no idea how one would determine how many platelets are functional, and how many are not fully finctional. So far, we have gone with the physician requests. If this starts getting more common we will deal with it more agressively, but as of now we have only had this happen two or three times.

Good point!

John

[David Saikin]

I don't believe plts which have been "aspirinated" can be made functional again. I'd like to see the documentation for that.

[Stoogiesfreak]

David,

Oops! You are correct - my error. Got to typing too fast and not thinking!

Anyway, we do not have a policy as I said before, since we have only had this two or three times. We have found that the two or three requests for platelets on "hold" for OR have never used the platelets.

Thanks for pointing out my boo-boo.

John

[Deny Morlino]

We had an issue with a patient continuing to take Plavix prior to Ambulatory Surgery. On the date of surgery, the patient had discontinued the Plavix only two days prior. After surgery the patient continued to bleed, and the surgeon ordered platelets STAT. Being a small hospital we did not have any on hand. We were able to source the platelets and the patient was fine. In the follow-up to this situation, the package insert was researched. If I recall, the package insert recommended discontinuing use at least 5 days prior to elective surgery. The surgeons are all aware of this inclusion in the package insert now. As far as a policy specific to Plavix goes I don't think we have one.

[Stoogiesfreak]

That is what we have informed our physicians to do. It has seemed to work, we suggested five to seven days prior to a procedure. Since we haven't had the issue come up again we did not develop a specific policy either.

Our issue now is FFP - we have had a 100% increase over "normal" for the past two months.

Ideas??

John

[David Saikin]

It is difficult to stop the "empiric" use of FFP . . . I have not been able to. Many places I inspect also have issues with plasma usage. The best I can do is not thaw more than 2 without my Medical Director's approval or a new INR.

[Stoogiesfreak]

We do have in our policy not to thaw more than 2 FFP at a time. The strange thing about our recent usage is we have not destroyed a single unit. All have been used.

You are right, it is difficult to assess. We do have our QA department taking a look at it since this is a shift is usage we have not seen before.

How often do you obtain a new INR when a patient is using FFP. We do not have that in any policy that I know of. I don't think nursing does either. That is a great idea.

Thank you,

John

[tbostock]

Our policy, we give 2 FFP and then (unless a massive bleed) we require a repeat INR. We have found around 80% of the time 2 units is enough to correct the coagulopathy in a non actively-bleeding patient. If the INR is still above our criteria, they can order a third unit.

[Deny Morlino]

Additional questions. What is the time frame you use after the administration of the FP units (30 minutes, 1hr, etc.)? Have there been any studies to determine if there is any lag until the "full effectiveness" of the plasma administration is noticed? Just thinking aloud.

[tbostock]

We have always suggested at least an hour after transfusion. No specific studies that I am aware of.

[Malcolm Needs ☆]

George Garratty did one. I can't remember where it was published, but give me time and I'll try to get the little grey cells working.

[Deny Morlino]

Thanks. It is always nice to have a solid reference when you are looking to make changes or set a standard in place.

[Malcolm Needs ☆]

I hope I don't disappoint. What I meant was that George wrote a paper about the lag phase of FFP before it really works, rather than aspirin, plavix and FFP together.

[BLipkin]

My understanding of aspirin vs Plavix is such:

Aspirin disrupts the PLTs ability to adhere. If you can introduce non-aspirinated PLTs into circulation taht will adhere, the patient's aspirinated PLTs will then agrregate to them and form a plug. Thus is patients on aspirin who are bleeding, usually only one dose of platelets is sufficient to obtain hemostasis.

Plavix affetcs both the PLTs aherence and aggregation. The tricky part is, is if there is still free Plavix in the patient's plasma, and if transfused PLTs then get exposed to it before they can adhere/aggregate then they will effectively be non-functional. Therefore you will usually need mulitple doses of platelets to acheieve hemostasis- and there is really no good way to know what that magic number will be.

[Eagle Eye]

Our department has test called verify now which tests aspirin effect of plavix effect. Many time patient's platelet count is normal but verify now is abnormal then we issue up to two apheresis platelets. WHich seems to help the patients in OR and in controlling bleeding.

[Deny Morlino]

I hope I don't disappoint. What I meant was that George wrote a paper about the lag phase of FFP before it really works, rather than aspirin, plavix and FFP together.

Just the FP portion would be valuable as a guide to making recommendations to physicans and the transfusion committee. Anything woould be a help Malcolm. Thanks

[SMILLER]

The "Plavix" and "Aspirin" effects can be measured to some degree with analyzers such as the Dade PFA (aspirin and general functional screen) or the Accumetrics Verify Now (Plavix and aspirin). These are easy to use analyzers and I beleive the reimbursement is adequate.

We use them routinely here for surgeons who want to make sure their pre-op patients have no residual plavix or aspirin effect on their platelets before surgery.

The Accumetrics people also are pushing the idea that many patients on Plavix needs to be monitored empirically beyond a standard dosing regimen.

[Mabel Adams]

The worst are the brain bleeds on plavix. You just pour platelets (2-4 apheresis units in my experience) into them until you soak up enough of the plavix so the plts can plug holes. By then there is usually so much brain damage that they often don't survive. If they do, they are seriously incapacitated. I wish there were a plavix antidote. A few years back I tried to research appropriate treatment of those on plavix that are bleeding or need surgery and it was amazing how little I could come up with. Basically, throw plts at them.

And next we will get Pradaxa which also has no antidote. Sigh.

[BBK710]

Our department has test called verify now which tests aspirin effect of plavix effect. Many time patient's platelet count is normal but verify now is abnormal then we issue up to two apheresis platelets. WHich seems to help the patients in OR and in controlling bleeding.

We also do this platelet function test using verify now. If a physician orders platelets for an OR procedure because the patient is on Plavix or asprin we will not order platelets (we do not store platelets) until they have had the testing done and the testing show a specific level of platelet inhibition. Our medical director will contact the surgeon if the testing has not been ordered.