Fresh Frozen Plasma and Platelet Transfusion for nonbleeding patients in the intensive care unit: Be

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Fresh Frozen Plasma and Platelet Transfusion for
nonbleeding patients in the intensive care unit
Benefit or Harm?
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• Ognjen Gajic, MD Walter H. Dzik, MD Pearl Toy,
  MD
• Crit Care Med 2006 Vol. 34, No. 5 (Suppl.)
• Presented by R1 ???
• Supervised by Dr. ???

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Introduction

• For critically ill patients with normovolemic
  anemia ? restrictive red blood cell (RBC)
  transfusion strategy
• How about FFP and platelet to critically ill
  patients?
• Appropriate indication
• Risk-benefit profile of prophylactic use of FFP
  and platelet transfusions solely on the basis of
  abnormal laboratory test results in the absence
  of active bleeding is not known.

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Introduction

• National Library of Medicine PubMed database
• Handsearching of the references and contacting
  experts in the field
• Evidence for the efficacy and safety
• prophylactic use of non-RBC products, FFP and
  platelet transfusions, in critically ill patients
  with abnormal coagulation tests or
  thrombocytopenia who do not have active bleeding.

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Fresh Frozen Plasma

• Intensive care patient with abnormal coagulation
  test result
• Twin Assumptions evidence ?
• These tests predict bleeding risk
• Transfusion will reduce that risk
• In the absence of active bleeding, NOT indicated
• Correct hypovolemia (Br J Haematol 2004)
• Supratherapeutic Coumadin effect (7th ACCP
  Conference)
• Adverse effects
• allergic reactions
• transfusion-related acute lung injury (TRALI)
• transfusion-related circulatory overload (TACO)

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Fresh Frozen Plasma

• Bleeding ? massively transfused
• FFP is used to treat dilutional coagulopathy
• Nonbleeding ? very little evidence !!!
• Correcting coagulation abnormalities
• Preventing bleeding complications
• Prophylactic use in preventing bleeding of
  invasive procedure

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Fresh Frozen Plasma

• Abnormal coagulation test Bleeding
  complications?
• Specific factor concentrations remain adequate to
  prevent microvascular bleeding.
• Standard recommended dose of FFP fails to correct
  the coagulation deficit in a majority of
  critically ill patients.
• Spector et al., 1966 large volumes of FFP result
  in only transient (2- to 4-hr) corrections in
  some coagulation factors in patients with liver
  disease
• Thromboelastography (TEG) may predict
  microvascular bleeding with higher accuracy, its
  use has been limited to patients undergoing liver
  transplantation. Further studies

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Fresh Frozen Plasma

• Numerous studies have shown that invasive
  procedures can be done safely in patients with
  mildly abnormal pre-procedure laboratory test
  results by skilled physicians who frequently
  perform these procedures.
• Some published guidelines currently define
  invasive procedure as one of the indications for
  FFP transfusion, we have not found supporting
  evidence for this practice with regard to the
  commonly performed critical care procedures.

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Fresh Frozen Plasma

• Absence of evidence-based guidelines
• Wide variability in practice, particularly before
  invasive procedures
• Dara et al., 2006
• Retrospective cohort of critically ill medical
  patients with abnormal INRs
• More adverse effects rather than benefit with
  liberal use
• 115 patients with INR values 1.5 but without
  active bleeding
• 44 (38.3) received FFP transfusion INR was
  corrected in only 16 (36)
• No difference in new bleeding episodes
• (6.8 transfused vs. 2.8 nontransfused p
  .369)
• New-onset acute lung injury was more frequent in
  transfused group
• (18 transfused vs. 4 nontransfused p .021)
• Current practice of FFP transfusion is likely to
  expose patients to transfusion risks with little
  or no documented benefit

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Platelet Transfusion

• Thrombocytopenia
• Common problem in the intensive care unit (ICU)
• Associated with adverse outcomes
• Platelet transfusions to correct
  thrombocytopenia
• Active bleeding
• Invasive procedure
• Prevent spontaneous bleeding (1020 x 109/L)
• Contraindications
• Heparin-induced thrombocytopenia (HIP)
• Thrombotic thrombocytopenic purpura (TTP)
• Bleeding ? massively transfused
• PLT is used to treat dilutional thrombocytopenia

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Platelet Transfusion

• American Society of Clinical Oncology guidelines
  for PLT transfusion
• Oncology patients limited / no bone marrow
  hematopoietic reserve
• Critically ill patients normal bone marrow
  function
• Normal marrow function, the risk of bleeding from
  thrombocytopenia may be lower, as has been
  established for patients with immune
  thrombocytopenia.
• Patients with abnormal platelet function (uremia)
  or associated coagulation abnormalities would
  have a higher risk of bleeding for an equivalent
  degree of thrombocytopenia.
• In the subset of patients with increased
  consumption (fever, disseminated intravascular
  coagulation) in addition to decreased production,
  the risk of bleeding rises further.

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Platelet Transfusion

• Risks of platelet transfusions
• Bacterial contamination
• Allergic reactions
• Febrile reactions
• Venous thromboembolism
• TRALI
• TACO
• For oncology patients, a restrictive transfusion
  threshold of 10 x 109/L has been recommended to
  prevent spontaneous bleeding.
• In the presence of sepsis, antibiotic use, or
  concurrent abnormalities in hemostasis, cancer
  treatment guidelines suggest a higher threshold
  of 20 x 109/L.

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Platelet Transfusion

• Limited data support the safety of central line
  placement, thoracocentesis, paracentesis, and
  liver biopsy in thrombocytopenic patients, but
  the exact threshold for transfusion has not been
  identified.
• In a recent large series, children with severe
  thrombocytopenia safely underwent lumbar puncture
  without platelet transfusion, regardless of
  platelet count. Whether or not such results may
  be extrapolated to adults is currently unknown.

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Platelet Transfusion

• Salman et al. (personal communication)
• 6-month audit of three ICUs at Mayo Clinic
• 117 patients with severe thrombocytopenia without
  active bleeding
• 90 (76) of whom received a platelet transfusion
• Bleeding complications were extremely rare
  regardless of transfusion
• Complications were not uncommon
• (6/90, or 8 2 TRALI, 2 allergic, 2 febrile).
• Degree of thrombocytopenia (p lt .01)
  postoperative state (p .01) but not the need
  for an invasive procedure (p .88) as predictors
  of platelet transfusion in the ICU.

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CONCLUSION

• FFP and platelet transfusion in critically ill
  patients
• Current representative guidelines for both are
  weak
• Few small randomized, controlled trials largely
  on anecdotal experience
• FFP laboratory tests that are not likely to
  reflect the risk of bleeding
• Platelet guidelines for cancer chemotherapy
  patients, even though different in mechanisms,
  risks, and consequences of thrombocytopenia
• Randomized trials comparing restrictive vs.
  liberal transfusion policies for non-RBC products
  for critically ill patients are warranted,
• especially non-bleeding patients before invasive
  procedures

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Thanks for your attention