Optimizing Use of Fresh Frozen Plasma to Correct Coagulopathy in patients with Variceal Bleeding

From the 2018 HVPAA National Conference

Komal Patel (University Texas Southwestern Medical Center), Ravi Sarode (University Texas Southwestern Medical Center), Deepak Agrawal (University Texas Southwestern Medical Center)

Background

FFP is often given to correct elevated INR in patients with cirrhosis despite evidence that elevated INR does not correlate with risk of bleeding due to rebalanced hemostasis.  To optimize use of FFP at our institution we developed workflow whereby all FFP requests were reviewed by the hematology fellow.

Objectives

Determine usage of FFP in patients with variceal bleeding and see if it influences rebleeding rates

Methods

Retrospective review of medical records of patients who underwent endoscopy with banding for varcieal bleeds from June 2011 to August 2017. Information collected included – patient demographics, INR, rebleeding, number of units of FFP transfused, and post-transfusion INR.

Results

: 394 EGDs with banding were performed on patients with bleeding varices. Table 1 shows the number of FFP transfusions given for different presenting INR values. At the time of upper endoscopy, INR was ≤1.5 in 70.2%, 1.6-2.0 in 22.1%, 2.1-2.5 in 6.1%, ≥ 2.6 in 1.6% of patients. FFP was given in 28.7% of patients with an INR >1.5 and was associated with an increased bleeding rate. Four patients who received FFP rebled, with a rate of 12.1% vs. 0.0% in those without FFP (p = 9.02 x 10-11). After transfusion of 1-2 units, the INR decreased by a mean of 14.3% (range -20.0%- 61.3%). Transfusion of ≥ 2 units decreased the INR by a mean of 13.7% (range -5.0% – 27.3%). In the majority of cases, the INR continued to remain > 1.5 at the time of EGD.

Conclusion

FFP transfusions variably decrease INR values. Routine use of FFP in patients with variceal bleeds is unnecessary and may be associated with higher rebleeding rates. At our institution, review of FFP transfusions by transfusion fellows resulted in only approximately one-third of patients with INR > 1.5 receiving transfusions.

Implications for the Patient

1. Use of FFPs to correct INR in patients with cirrhosis is unnecessary

2. Screening requests for FFP results in optimizing usage of FFP

3. The guidelines for use of FFP in cirrhosis to correct INR should emphasize the lack of benefit of this practice.

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