Administration Of Fresh Frozen Plasma Research Articles

Comparison between Prothrombin Complex Concentrate (PCC) and Fresh Frozen Plasma (FFP) for the Urgent Reversal of Warfarin in Patients with Mechanical Heart Valves in a Tertiary Care Cardiac Center.

Fresh frozen plasma (FFP) and prothrombin complex concentrate (PCC) reverse oral anticoagulants such as Warfarin. We compared the standard dosage of FFP and PCC in terms of efficacy and safety for patients with mechanical heart valves undergoing interventional procedures while receiving Warfarin. Fifty patients were randomized (25 for each group) with mechanical heart valves [international normalized ratio (INR) >2.5]. FFP dosage was administered based on body weight (10-15 mL/Kg), while PCC dosage was administered based on both body weight and target INR. INR measurements were obtained at different time after PCC and FFP infusion. The mean ± SD of INR pre treatment was not significantly different between the PCC and FFP groups. However, over a 48-hour period following the administration of PCC and FFP, 76% of the patients in the PCC group and only 20% of the patients in the FFP group reached the INR target. Five (20%) patients in the PCC group received an additional dose of PCC, whereas 17 (68%) patients in the FFP group received a further dose of FFP (P=0.001). There was no significant difference between the two groups in Hb and Hct before and during a 48-hour period after PCC and FFP infusion. As regards safety monitoring and adverse drug reaction screening in the FFP group, the INR was high (INR > 2.5) in 86% of the patients. There was no report of hemorrhage in both groups. PCC reverses anticoagulation both effectively and safely while having the advantage of obviating the need to extra doses.

P0220 : JNK signaling activated by platelet-derived growth factor D (PDGF-D) stimulates secretion of vascular endothelial growth factor-C (VEGF-C) by cancer-associated fibroblasts to promote lymphangiogenesis and early metastasization in cholangiocarcinoma

Background and Aims: Prophylactic administration of platelets and fresh frozen plasma (FFP) is recommended in cirrhotic patients with low platelets/prolonged INR and esophageal varices (EV) that are submitted to endoscopic band ligation (EBL); however it is unknown if this measure prevents post-EBL bleeding. In this analysis we evaluated the outcome of patients undergoing EBL and the role of pre-procedure administration of blood products in this setting. Methods: Retrospective analysis of consecutive EBL procedures in patients with cirrhosis and EV performed at Hospital Clinic, Barcelona from 2010 to 2013. FFP and platelet transfusion were administered if INR was >1.5 and/or platelet count <50×109/L. Complications related to post-EBL bleeding and the relationship with administered blood products were recorded. Results: 516 EBL procedures were performed in 231 patients (70% male), etiology: HCV and alcohol (77%), median MELD 12, Child A/B/C (40/45/15%). EBL procedures were performed for primary (127, 25%) or secondary (290, 55%) prophylaxis and for acute variceal bleeding (AVB) (99, 20%). Median procedure per patient was 2 (1–3). Bleeding occurred in 25 procedures (4.8%). Bleeding complications were not different between Child A/B vs. Child C patients (p = 0.5) and occurred independently of cut-off values and FFP/platelet transfusion (Table 1). FFP and platelets were given in 41 (7.9%) and 39 (7.6%) procedures respectively. Multivariate analysis showed that MELD score (OR, 1.1; 95%CI, 1.0–1.2; p < 0.01) and AVB (OR, 3.4; 95%CI, 1.6–7.0;p < 0.01) emerged as a predictive factors for post-EVL bleeding. Conclusions: Pre-procedure administration of FFP and platelets in cirrhotic patients undergoing EBL does not confer a benefit as a prophylactic measure of post-EBL bleeding. Post-EBL bleeding is independent of pre-procedure cut-off values and FFP/platelet administration. MELD score and AVB are risk factors for post-EBL bleeding. Prospective studies are needed to determine the role of routine administration of blood products prior to EBL in patients with cirrhosis.

Use of prothrombin complex concentrate as an adjunct to fresh frozen plasma shortens time to craniotomy in traumatic brain injury patients.

The use of prothrombin complex concentrate (PCC) to reverse acquired (coagulopathy of trauma) and induced coagulopathy (preinjury warfarin use) is well defined. To compare outcomes in patients with traumatic brain injury without warfarin therapy receiving PCC as an adjunct to fresh frozen plasma (FFP) therapy compared with patients receiving FFP therapy alone. All patients with traumatic brain injury coagulopathy without warfarin therapy who received PCC (25 IU/kg) in conjunction with FFP or FFP alone at our Level I trauma center were reviewed. Coagulopathy was defined as an international normalized ratio >1.5. The groups (PCC + FFP vs FFP alone) were matched using propensity score matching on a 1:2 ratio for age, sex, Glasgow Coma Scale score, Injury Severity Score, head Abbreviated Injury Scale score, and international normalized ratio (INR) on presentation. The primary outcome measure was time to craniotomy. Secondary outcome measures were blood product requirements, cost of therapy, and mortality. A total of 1641 patients were reviewed, 222 of whom were included (PCC + FFP, 74; FFP, 148). The mean ± standard deviation age was 46.4 ± 21.7 years, the median (range) Glasgow Coma Scale score was 8 (3-12), and the mean ± standard deviation INR on presentation was 1.92 ± 0.6. PCC + FFP therapy was associated with an accelerated correction of INR (P = .001) and decrease in overall pack red blood cell (P = .035) and FFP (P = .041) administration requirement. Craniotomy was performed in 26.1% of patients (n = 58). Patients who received PCC + FFP therapy had faster time to craniotomy (P = .028) compared with patients who received FFP therapy alone. PCC as an adjunct to FFP decreases the time to craniotomy with faster correction of INR and concomitant decrease in the need for blood product requirement in patients with traumatic brain injury exclusive of prehospital warfarin therapy.

Does resuscitation with plasma increase the risk of venous thromboembolism?

Resuscitation with blood products improves survival in patients with traumatic hemorrhage. However, the risk of venous thromboembolic (VTE) complications associated with fresh frozen plasma (FFP) resuscitation is unknown. We hypothesized that a higher ratio of FFP to packed red blood cells (PRBCs) given during acute resuscitation increases the risk of VTE independent of severity of injury and shock. The records of patients admitted from April 2007 to December 2011 who had surveillance lower extremity duplex ultrasounds were retrospectively reviewed. Patients who received at least 1 U of PRBCs within 24 hours of admission were included. Patients who died without VTE were excluded. The relationship between FFP and VTE was evaluated using logistic regression. A total of 381 patients met inclusion criteria, of whom 77 (20.2%) developed VTE. In patients who required less than 4 U of PRBCs, increasing units of FFP were associated with an increasing risk for VTE, with each unit of FFP having an adjusted odds ratio of 1.27 (95% confidence interval, 1.04-1.54, p = 0.015). Conversely, in patients who required four or greater units of PRBCs, FFP in equal or greater ratios than PRBCs was not associated with VTE. Each unit of FFP increased VTE risk by 25% in patients who required less than 4 U of PRBCs. In patients who required 4 U or greater PRBCs, FFP administration conferred no increased risk of VTE. This suggests that FFP should be used cautiously when early hemodynamic stability can be achieved with less than 4 U of PRBCs. Care management study, level III.

Fresh frozen plasma resuscitation provides neuroprotection compared to normal saline in a large animal model of traumatic brain injury and polytrauma.

We have previously shown that early treatment with fresh frozen plasma (FFP) is neuroprotective in a swine model of hemorrhagic shock (HS) and traumatic brain injury (TBI). However, it remains unknown whether this strategy would be beneficial in a more clinical polytrauma model. Yorkshire swine (42-50 kg) were instrumented to measure hemodynamic parameters, brain oxygenation, and intracranial pressure (ICP) and subjected to computer-controlled TBI and multi-system trauma (rib fracture, soft-tissue damage, and liver injury) as well as combined free and controlled hemorrhage (40% blood volume). After 2 h of shock (mean arterial pressure, 30-35 mm Hg), animals were resuscitated with normal saline (NS; 3×volume) or FFP (1×volume; n=6/group). Six hours postresuscitation, brains were harvested and lesion size and swelling were evaluated. Levels of endothelial-derived vasodilator endothelial nitric oxide synthase (eNOS) and vasoconstrictor endothelin-1 (ET-1) were also measured. FFP resuscitation was associated with reduced brain lesion size (1005.8 vs. 2081.9 mm(3); p=0.01) as well as swelling (11.5% vs. 19.4%; p=0.02). Further, FFP-resuscitated animals had higher brain oxygenation as well as cerebral perfusion pressures. Levels of cerebral eNOS were higher in the FFP-treated group (852.9 vs. 816.4 ng/mL; p=0.03), but no differences in brain levels of ET-1 were observed. Early administration of FFP is neuroprotective in a complex, large animal model of polytrauma, hemorrhage, and TBI. This is associated with a favorable brain oxygenation and cerebral perfusion pressure profile as well as higher levels of endothelial-derived vasodilator eNOS, compared to normal saline resuscitation.

Restoration of Normal Prothrombin Time/International Normalized Ratio With Fresh Frozen Plasma in Hypocoagulable Patients.

Fresh frozen plasma (FFP) is an effective reversal agent for hypocoagulable patients. Its proven efficacy continues to prompt its usage as both a prophylactic and a therapeutic therapy. Although published guidelines encouraging the appropriate administration of FFP exist, overutilization continues. The purpose of these ex vivo studies was to determine the effects of succeeding volumes of FFP supplementation on hypocoagulable plasma prothrombin time/international normalized ratio (PT/INR). By analyzing the decline in PT/INR with varying volumes of FFP, a minimal required volume of FFP could be identified representing the optimal volume to administer while still providing therapeutic effect. A total of 497 plasma samples were screened for elevated PT/INR values and 50 samples were selected for inclusion in this experiment. The initial PTs/INRs ranged from 12.5 to 43.4 seconds/1.42 to 4.91. Subsequent declines in PT/INR values were analyzed following addition of 50, 100, and 150 µL of FFP to a fixed volume of 250 µL of plasma (26.4 ± 5.318 seconds/2.99 ± 0.603, 13.3 ± 1.077 seconds/1.51 ± 0.122, 11.2 ± 0.712 seconds/1.27 ± 0.081, and 10.3 ± 0.533 seconds/1.16 ± 0.06, respectively). A nonlinear relationship between decline in INR values and percentage of FFP supplementation was demonstrated. The greatest effect on INR was obtained after supplementation with 50 µL (49%). Doubling and tripling the volume of FFP lead to significantly lower declines in INR (16% and 8%, respectively). Analysis of variance indicated a statistical significance with subsequent volume supplementation of FFP, but marginal clinical benefits exist between the PTs/INRs obtainable with increased FFP volume administration.

Evaluation of a multi-center randomised clinical trial on prophylactic transfusion of fresh frozen plasma: implications for future trials.

Prophylactic use of fresh frozen plasma (FFP) in critically ill patients with a coagulopathy is common. However, a lack of evidence of efficacy has resulted in a call for trials on the benefit of FFP in these patients. To date, conducting a trial on this subject has not been successful. Recently, a multi-center randomised trial was stopped prematurely due to slow inclusion. To assess clinicians' opinions regarding a trial on prophylactic administration of FFP in coagulopathic critically ill patients who need to undergo an intervention. A survey among 55 intensivists who all participated in a randomised trial on the risks and benefits of FFP in critically ill patients. Response rate was 84%. Majority of respondents indicated that international normalised ratio (INR) should be assessed before insertion of a central venous catheter (CVC) (61%), chest tube (89%) or tracheostomy (91%). Reasons to withhold transfusion of FFP to non-bleeding critically ill patients are risk of transfusion-related acute lung injury (TRALI) (46%), fluid overload (39%) and allergic reaction (24%). Although, the majority of respondents expressed the opinion that the trial was clinically relevant, 56% indicated that ≥1 patient subgroups should have been excluded from participation. Intensivists express the need for more evidence on the prophylactic use of FFP in coagulopathic critically ill patients. However, lack of knowledge about FFP and personal beliefs about the preferable transfusion strategy among clinicians, resulted in premature termination of a clinical trial on this topic.

Red Blood Cell Storage Duration Is Associated with Various Clinical Outcomes in Pediatric Cardiac Surgery

Background: Recommendations on the use of fresh red blood cells (RBCs) in pediatric patients undergoing cardiac surgery are based on limited information. Furthermore, the RBC storage time cut-off of fresh units remains unknown. Methods: Data from 139 pediatric patients who underwent cardiac surgery and received RBCs from a single unit within 14 days of storage were analyzed. To identify the optimal cut-off storage time of RBCs for transfusion, multiple multivariate analyses aimed at different outcome parameters were performed. Results: 26 patients received RBC units stored for ≤3 days, while 126 patients received RBCs that were stored for 4-14 days. The latter group required more RBC transfusions and fresh frozen plasma (FFP) than the former group (19 vs. 25 ml/kg, p = 0.003 and 73% vs. 35%, p = 0.0006, respectively). In addition, the odds for the administration of FFP increased with the transfusion of RBCs stored for more than 4 days. The optimal cut-off for post-operative morbidity was observed with a storage time of ≤6 days for length of ventilation (p = 0.02) and peak of C-reactive protein (CRP; p = 0.008). Conclusions: The obtained results indicate that the hazard of blood transfusion increased with increasing storage time of RBCs. The results of this study suggest that transfusion of fresh RBCs with a storage time of ≤2 or 4 days (concerning transfusion requirements) or ≤6 days (concerning postoperative morbidity) may be beneficial in pediatric patients undergoing cardiac surgery. However, further prospective randomized studies are required in order to draw any final conclusions.

Peripartum anesthetic management of a parturient with inherited factor v deficiency.

Inherited Factor V deficiency is a rare bleeding disorder. We describe the genetic analysis and anesthetic management of a parturient with severe Factor V deficiency who presented in spontaneous labor. Good hemostatic conditions were obtained with prophylactic fresh frozen plasma administration of 10 mL/kg. Detailed genetic analysis by next-generation sequencing identified several relevant mutations in the coding part of the Factor V (F5) gene in our patient, her parents, and the newborn.

Mathematical Formula to Estimate Reversal of Coumadin Mediated Coagulopathy with Fresh Frozen Plasma Infusion

Purpose: Coumadin is one the top 20 drugs prescribed in the U.S. and is prone for multiple drug-to-drug interactions. The estimated annual number of emergency department visits for bleeding in these patients is close to 30,000 and gastrointestinal tract is the most common site of bleeding. Rashidi and colleagues developed a formula to estimate change in international normalized ratio (Delta INR) with fresh frozen plasma administration. In this study, we aim to validate the Rashidi formula to estimate Delta-INR in Coumadin mediated coagulopathy in patients presenting for GI bleeding. Methods: In this retrospective cohort study, we reviewed electronic medical records of consecutive cohort of patients presented to emergency department with gastrointestinal bleeding and required FFP administration. Patients with variceal bleeding, advanced liver failure and consumptive coagulopathy were excluded. We also excluded patients who had INR of less than 1.5 at the point of admission, or INR was not measured within 8 hours of FFP administration. Medical records were reviewed by three physician researchers (internal medicine residents). Data was collected using a predefined form which included age, gender, liver failure, disseminated intravascular coagulation, INR before FFP administration, number of FFP administered, INR within next 8 hours. The observed INR was considered gold standard. Formula predicted INR = (0.57 x PreFFP INR)-0.72. The correlation was tested using Pearson correlation coefficient. Statistical analysis was performed using JMP statistical package version 10 (SAS Inc., Cary, NC). Results: A total of 256 patients were enrolled. Mean age was 72 years (SD, 15 years). Median INR at admission was 2.26 (IQR 1.78-3.47). Median number of FFPs transfused was 2 (IQR 1-2) and 28 (11%) were transfused 3 units or more. Mean difference in predicted and post FFP observed INR was 0.14 (95% CI 0.07-0.20). On matched pair analysis, correlation between observed and predicted INR was significant, correlation 0.70 and two-tailed p value was <0.0001. Correlation was higher in cases where INR was checked with one unit of FFP transfusion compared to more than 1, (0.81 vs 0.67). Limitation: Retrospective study design. Time between FFP transfusion and INR check was variable. Conclusion: The predicted INR after FFP transfusion using this simple formula has excellent correlation with corrected INR, especially when checked after one unit FFP. Time of INR check after FFP transfusion might be the cause for variability and needs prospective evaluation of the formula.

Reference intervals for common coagulation tests of preterm infants (CME)

Fresh-frozen plasma (FFP) is sometimes administered to nonbleeding preterm neonates who are judged to be at risk for bleeding because they have abnormal coagulation tests. The benefits/risks of this practice are not well defined. One limitation to progress is lack of reference intervals for the common coagulation tests, thus limiting precision about whether coagulation tests are indeed abnormal. In a sequential observational study, fetal blood was drawn at preterm birth (≤ 34 weeks) from the umbilical vein near the placenta. Fibrinogen, prothrombin time, activated partial thromboplastin time, D-dimer, platelet (PLT) count, and mean PLT volume were measured. Reference intervals were constructed using 5th and 95th percentile values. Associations were then sought between abnormal coagulation values at birth and bleeding problems identified during the first week. Coagulation tests were drawn at 175 preterm deliveries and the results were organized into reference intervals by gestational age. No abnormal coagulation value, either alone or in combination, predicted hemorrhage (intraventricular, gastrointestinal, or pulmonary) during the first week. However, fibrinogen exceeding the 95th percentile was associated with evidence of in utero infection/inflammation (correlations with elevated C-reactive protein, p<0.01, and elevated immature to total neutrophil ratio, p<0.001). Abnormal coagulation values at preterm birth do not predict bleeding during the first week. This suggests to us that bleeding in the days after preterm birth is not generally the result of in utero coagulopathy. These findings bring into question the value of coagulation screening of nonbleeding preterm infants and prophylactic FFP administration to those with abnormal values.

A randomized controlled trial of fresh frozen plasma for treating venom‐induced consumption coagulopathy in cases of Australian snakebite (ASP‐18)

Venom-induced consumption coagulopathy (VICC) is a major effect of snake envenoming. To investigate whether fresh frozen plasma (FFP) given after antivenom resulted in more rapid correction of coagulation. This was a multicenter open-label randomized controlled trial in patients with VICC of FFP vs. no FFP within 4h of antivenom administration. Patients (>2years) recruited to the Australian snakebite project with VICC (International Normalized Ratio [INR]>3) were eligible. Patients were randomized 2:1 to receive FFP or no FFP. The primary outcome was the proportion with an INR of <2 at 6h after antivenom administration. Secondary outcomes included time from antivenom administration to discharge, adverse effects, major hemorrhage, and death. Of 70 eligible patients, 65 consented to be randomized: 41 to FFP, and 24 to no FFP. Six hours after antivenom administration, more patients randomized to FFP had an INR of <2 (30/41 [73%] vs. 6/24 [25%]; absolute difference, 48%; 95% confidence interval23-73%; P=0.0002). The median time from antivenom administration to discharge was similar (34h, range14-230h vs. 39h, range14-321h; P=0.44). Seven patients developed systemic hypersensitivity reactions after antivenom administration - two mild and one severe (FFP arm), and three mild and one severe (no FFP). One serious adverse event (intracranial hemorrhage and death) occurred in an FFP patient with pre-existing hypertension, who was hypertensive on admission, and developed a headache 6h after FFP administration. Posthoc analysis showed that the median time from bite to FFP administration was significantly shorter for non-responders to FFP than for responders (4.7h, interquartile range [IQR]4.2-6.7h vs. 7.3h, IQR6.1-8h; P=0.002). FFP administration after antivenom administration results in more rapid restoration of clotting function in most patients, but no decrease in discharge time. Early FFP administration (<6-8h) post-bite is less likely to be effective.

FFP:RBC Resuscitation Ratio and Post-Shock Fluid Uptake

To assess the effects of the fresh frozen plasma (FFP) to red blood cell (RBC) ratio and balanced electrolyte solution (BES) to RBC ratio during resuscitation of severely injured patients on the duration of the postoperative fluid uptake period (phase 2) as well as the fluid (BES) needs, weight gain, and hypoproteinemia in phase 2. The 316 patients were hypotensive (systolic blood pressure=81 mm Hg) and tachycardic (117/min), with an average shock time (systolic blood pressure 80 mm Hg) of 31 minutes in the operating room (OR); they received 14.2 RBC units, 854 mL of FFP, and 11.5 L of BES while in the OR. Phase 2 averaged 29.2 hours, where the patients gained 8.4 kg, had a serum albumin level of 2.6 g per day, and received 8.6 L of BES. The phase 2 time, BES needs, weight gain, and hypoproteinemia were correlated with systolic blood pressure, admission pulse rate, arterial pH, shock time, RBC, FFP, and BES; the FFP:RBC, BES:RBC, and BES: FFP ratios were given in the OR. Shock time had the best correlation with RBC, FFP, and BES administration in the OR as well as with phase 2 duration, BES needs, weight gain, and hypoproteinemia. There was no significant correlation with OR FFP: RBC, BES:RBC, or BES:FFP ratios and phase 2 hypoproteinemia or weight gain. The FFP:RBC ratio in the OR correlated directly with phase 2 duration and BES needs (P=.001); in contrast, the BES:RBC ratio in the OR correlated (P.001) inversely with phase 2 duration and BES needs. The severity of shock is best predicted by shock time and the RBC, FFP, and BES infusions in the OR. Contrary to recent reports, the FFP:RBC ratio in the OR correlates directly with duration and BES needs of phase 2, whereas the BES:RBC ratio correlates inversely with phase 2 duration and BES needs.

Unexpected Bronchial Anatomy Lesson

A 73-year-old woman presented with hemoptysis. Significant past medical history included paroxysmal atrial fibrillation, deep vein thrombosis of lower extremities, and recently diagnosed segmental pulmonary embolism on right upper lobe. The patient was being treated with warfarin. Her initial physical examination was unremarkable. Admission laboratory data showed an international normalized ratio of 3.9, which rapidly decreased to 1.5 after fresh frozen plasma administration. Chest radiograph showed no lung infiltrates or mass. Bronchoscopy was performed, and surprisingly, a large organized blood clot was visualized completely occluding the right main stem bronchi. No active bleed was noted. The blood clot was removed with a cryotherapy probe in a single attempt, providing us with an unexpected bronchial anatomy lesson (Figure 1). Further airway exam immediately after the clot removal Figure 1. (A) Blood clot removed in one piece from patient’s right bronchial tree. (B) Some form of tracheobronchial tree variation or anomaly has been reported to be found in 1 to 12% of patients (up to 70% in four more recent series) (1, 2). Therefore, the anatomy seen in these pictures cannot be generalized to all patients.

Factors associated with prophylactic plasma transfusion before vascular catheterization in non-bleeding critically ill adults with prolonged prothrombin time: a case–control study

Fresh-frozen plasma (FFP) is widely used in critically ill patients, despite a weak evidence base. Factors that influence the decision to transfuse FFP before intravascular catheter insertion are poorly described. We undertook a case-controlled study based on a prospective cohort study of 1923 admissions to 29 intensive care units in the UK. Non-bleeding patients with an international normalized ratio (INR) ≥1.5 who underwent intravascular catheterization, but no other invasive procedure, were identified. We compared patient characteristics, illness-related factors, and biochemical and haematological variables between patients who did or did not receive pre-procedural FFP. One hundred and eighty-six patients fulfilled the criteria; 26 received FFP during the 24 h before line insertion (cases) and 160 did not (controls). Factors associated with greater use of prophylactic FFP by clinicians were pre-existing chronic liver disease (P=0.01), higher serum bilirubin before procedure (P=0.01), lower platelet count (P=0.01), higher activated partial thromboplastin time (P=0.001), lower fibrinogen (P=0.01), and concurrent red cell transfusion despite the absence of bleeding (P=0.001). There was no difference in pre-procedural INR [median (1st, 3rd quartile) cases: 1.95 (1.85, 2.6); controls 1.8 (1.6, 2.3); P=0.19]. The mean FFP dose was 11.1 ml kg(-1) (sd 5.7 ml kg(-1)); 53.8% of cases were transfused <10 ml kg(-1). Chronic liver disease and more abnormal coagulation tests were associated with greater probability of pre-procedural FFP administration before vascular catheterization, whereas the severity of prothrombin time prolongation alone was not. FFP was more likely to be administered when red cells were also transfused, even in the absence of bleeding.

Does Early Administration of Fresh Frozen Plasma (FFP) in the Operating Room Decrease Blood Loss and Transfusion Needs?

Does Early Administration of Fresh Frozen Plasma (FFP) in the Operating Room Decrease Blood Loss and Transfusion Needs?

Fresh Frozen Plasma for Progressive and Refractory Angiotensin-Converting Enzyme Inhibitor-induced Angioedema

BackgroundAngioedema secondary to angiotensin-converting enzyme inhibitors (ACEI) is a commonly encountered problem in the Emergency Department (ED). The treatment of ACEI-induced edema with conventional methods such as epinephrine, steroids, and antihistamines is usually not effective. There is limited experience using bradykinin receptor blockers and fresh frozen plasma (FFP) as a treatment modality for ACEI-induced angioedema. ObjectiveTo emphasize alternative treatment option for ACEI-induced angioedema in the ED. Case ReportsWe report a case series of progressive and refractory presumed ACEI-induced angioedema that all improved in temporal association with administration of FFP, with a brief review of the literature. ConclusionThere was a temporal association between the administration of FFP and improvement in angioedema in seven cases of presumed ACEI-induced angioedema that were refractory to antihistamines, corticosteroids, and epinephrine.

O1-012 - The Efficacy of R-Thrombomodulin in Comparison with Dalteparin NA in 26 Patients with Hematological Malignancy Complicated by DIC

ABSTRACT Introduction Hematology malignancy is often complicated by many critical diseases including DIC. The resolution of DIC safely is one of the most important aspects in getting over hematological malignancy. We would like to report our comparative review of the administration of Recombinant Thrombomodulin (Recomodulin) versus Dalteparin Na (Fragmin) and this time, we would also report the possibility of reducing blood products such as fresh frozen plasma (FFP). Patient Thirteen patients (mean age 57.0 years, men/women 5/8, AML 7, APL 4, ALL 2) were administered recombinant thrombomodulin and 13 patients (mean age 50.5 years, men/women 8/5, AML 6, APL 4, ALL 3) were administered Dalteparin Na. Result The mean duration of therapies was 3.8 and 11.3 days, respectively. All patients has achieved DIC resolution, and the mean resolution time was 5.5 and 11.6 days (P = 0.020). The mean administration of FFP was 7.5 and 16.9 units (P = 0.091). The average of FDP, Fib, and JMHW DIC score has improved in both therapies. On the other hand, there were no changes in PT-INR and AT3. No bleeding and other adverse events were reported during both administration. Conclusion Recombinant thrombomodulin adminisitration is effective therapy rather than Dalteparin Na administration for patients with hematological malignancy and also tends to reduce the use of FFP.

Severe Pediatric Blunt Trauma—Successful ROTEM-Guided Hemostatic Therapy With Fibrinogen Concentrate and No Administration of Fresh Frozen Plasma or Platelets

Use of allogeneic blood products to treat pediatric trauma may be challenged, particularly in relation to safety. We report successful treatment of a child with severe abdominal and pelvic injuries with preemptive fibrinogen supplementation followed by rotational thromboelastometry (ROTEM)-guided, goal-directed hemostatic therapy. Fibrinogen concentrate was administered (total dose: 2 g), while transfusion of fresh frozen plasma and platelet concentrate was avoided. Activated partial thromboplastin time was prolonged and Quick values were low but ROTEM clotting time values remained normal, therefore, no thrombin-generating drugs were considered necessary. This case shows the potential for hemostatic treatment with coagulation factor concentrates to be applied to pediatric trauma.

Does risk-based coagulation screening predict intraventricular haemorrhage in extreme premature infants?

Intraventricular haemorrhage (IVH) continues to be a significant contributor to neonatal morbidity and mortality, especially in the extremely premature population (<26 weeks). The aims of the study were to test the hypothesis that risk-based coagulopathy screening could identify infants at risk of severe IVH/mortality, and whether preterm infants born at less than 26 weeks of gestation who received early (within first 48 h) fresh frozen plasma (FFP) had a lower incidence of IVH than those who did not. Chart review of preterm infants born less than 26-week gestation was conducted. The study compared two cohorts of infants who either had 'early' risk-based coagulopathy screening (within first 48 h, n = 47) or 'late' screening (n = 55). Baseline and clinical characteristics of the two cohorts were similar. 'Early' coagulopathy screening predicted infants at risk of severe IVH [relative risk (RR) 2.59, 95% confidence interval (CI) 1.18-5.67, P < 0.01] but not mortality (RR 1.2, 95% CI 0.79-1.94). FFP was administered significantly more in the 'early' screened cohort (P < 0.001); however, the incidence of IVH was similar in those who received early FFP administration than those who did not. 'Early' risk-based coagulopathy screening may identify preterm infants at risk of severe IVH; however, the study failed to show any benefit of early treatment of a coagulopathy with FFP in a small but high-risk population.