Plasma Transfusion Guidelines

Last update: March 20, 2020

Standard transfusion thresholds

• INR > 1.8 in a non-cirrhotic patient with a high-risk procedure planned
• INR > 2.5 in a cirrhotic patient with a high-risk procedure planned
• The intrinsic INR of plasma can be as high as 1.4-1.5, and it is not possible to get INR into the normal range with plasma
• Numerous studies have shown INR is not a good indicator of bleeding risk, especially in cirrhotic patients who have rebalanced hemostasis
• Please see the more specific procedural guidelines for high and low risk procedures for cirrhotic and non-cirrhotic patients
• Prolonged R time on TEG
• R is the time it takes for blood to clot. A prolonged R indicates a deficiency of clotting factors, and plasma is indicated
• Clinical coagulopathy with bleeding
• As part of a massive transfusion protocol (MTP)

Plasma transfusion not indicated

• Warfarin reversal
  • Prothrombin complex concentrate (PCC) should be used for urgent warfarin reversal
  • Vitamin K should be used for used for non-urgent warfarin reversal; IV vitamin K is more effective than oral vitamin K
• Volume expansion
• Correction of an elevated INR in stable, non-bleeding patients with no procedures

Emergency critical shortage transfusion thresholds

• During critical times of blood product shortage, the INR threshold for plasma transfusions will be increased. Clinicians may be asked to order a TEG to assess R time to confirm presence of functional clotting factor deficiency, and/or hang plasma right before a procedure and proceed.
• Every plasma unit ordered may be triaged by transfusion medicine.
• Outpatient transfusions may be stopped.
• Units may be split, and ½ units provided.
• Non-emergent cases requiring pre-procedure INR correction (such as interventional or endoscopic procedures) may need to be postponed.
• Plasma transfusions may be limited to only patients with life-threatening bleeding if necessary, to preserve a limited plasma inventory.

References

• Müller MCA et al. Transfusion of fresh-frozen plasma in critically ill patients with a coagulopathy before invasive procedures: a randomized clinical trial. Transfusion 2015;55:26-35
• Jia Qing et al. Prophylactic plasma transfusion for surgical patients with abnormal preoperative coagulation tests: a single institution propensity-adjusted cohort study. The Lancet Haematology 2016;3:e139-e148
• Yang Y et al. Is fresh-frozen plasma clinically effective? An update of a systematic review of randomized controlled trials. Transfusion 2012;52:1673-1686

Disclaimer

These documents and content on this website are guidelines during the COVID-19 pandemic. Because new information is released rapidly, these documents can be updated or changed at any time. These documents are in no way to be considered as a standard of care and the content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. The information in these documents is provided with no guarantees, accuracy, or timeliness. All content in these documents and website are for informational purposes only and do not constitute the providing of medical advice.