Blood Product Utilization Guidelines

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Plasma Transfusion Guidelines

Last update: March 20, 2020

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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.


  • 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


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