An MD at Trauma mtg stated that he understood that the anticoagulants used in Frozen Plasma collection were a reason that the INR reversal with FP is difficult to achieve. I had never heard this, just wondering if anyone else has?

Never.  I would like to see a reference for this if it is true.  Donor blood doesn't clot due to the chelation of Ca, which should not, by itself, affect any routine coagulation assays or the patient's ability to clot.  But it does have all those other preservatives in it. Reversal of warfarin is still very common by transfusion of 2 units of thawed FFP.

Scott

We have had this discussion.  If you are transfusing to a number, you need to remember that the transfused plasma also has an INR value.

Ya.  But for two units of plasma, you are receiving only about 1/10th your blood volume.  Even if the factor levels for VII, IX, etc. were zero, this would have no effect on the patient's PT/INR test.  Likewise any warfarin in the product is not going to be a factor, especially since it takes hours and hours to have an effect on the recipient's liver.  Besides, if I am not mistaken, if you are on any kind of "blood thinner" your plasma is not going to be used for transfusion anyway.

Scott

We need Sunny Dzik on here!

What is all this INR stuff? We were not taught this 30 years ago. It means nothing to me!

The INR is a largely useless predictor of bleeding risk except for those on coumadin/warfarin, and not so good a predictor in those patients.  It is known that the range of 2-3 is a reasonably safe and effective one for anti-coagulation to prevent recurrent thrombosis (usually DVT or PE).  Beyond that, INR numbers like 6 or 12 tell us next to nothing except that factor VII is quite low, which may or may not be clinically important.  The INR of liquid plasma or FFP is around 1.6-1.8, and is not affected by the citrate anticoagulant, since exogenous excess calcium is added in the performance of the INR.  INRs of 1.5 to about 2.0 are not associated with substantial increases in bleeding, either spontaneous or procedure related, and do not need to be corrected at all, in my view, and this opinion is supported by an extensive observational literature.  FFP will not correct such an INR in any case, and thus represents risk without benefit.  Medical specialty society recommendations for INRs of 1.5 prior to procedures are without any evidence support whatever, and represent old, no longer valid expert opinion.

 

If an INR needs correction for any reason, factor concentrates are more effective and less likely to harm the patient than FFP. FFP should never be used to reverse warfarin/coumadin in my opinion, because of these efficacy and safety issues.  Unfortunately factor concentrates are also much more expensive than plasma/FFP.  However, this considers only the cost of the product, not the cost of any clinical complications such as thrombosis, volume overload, ICU admission, etc., not to mention death, all of which are more likely with plasma/FFP.  Meta-analyses of randomized trials of FFP vs. factor concentrate, demonstrate that FFP is associated with a two fold mortality increase. 'Nuf said.  One ICU admission for a few days can balance the increased costs of factor concentrates for the overall health system. Factor concentrates, preferably II, VII, IX, X concentrates that also contain some protein S and C; in the USA=Kcentra; in Europe=Beriplex are preferred over three factor concentrates, but both are superior to FFP.

The INR was never intended to predict bleeding risk, it was intended to normalize PT results from lab to lab in order to provide physicians a more standard indication of their patient's anticoagulation status.  There was a good presentation at AABB by Dr. Mary Townsend about this topic in the Blood Bank Mythbusters session.