Use Of Fresh Frozen Plasma Research Articles

Early Aggressive Use of Fresh Frozen Plasma Does Not Improve Outcome in Critically Injured Trauma Patients

Recent data from Iraq supporting early aggressive use of fresh frozen plasma (FFP) in a 1:1 ratio to packed red blood cells (PRBCs) has led many civilian trauma centers to adopt this resource intensive strategy. Prospective data were collected on 806 consecutive trauma patients admitted to the intensive care unit over 2 years. Patients were stratified by PRBC:FFP transfusion ratio over the first 24 hours. Stepwise regression models were performed controlling for age, gender, mechanism of injury, injury severity, and acute physiology and chronic health evaluation (APACHE) 2 score to determine if early aggressive use of PRBC:FFP improved outcome. Seventy-seven percent of patients were male (N = 617) and 85% sustained blunt injury (n = 680). Mean age, injury severity score (ISS), and APACHE score were 43 +/- 20 years, 29 +/- 13, and 13 +/- 7, respectively. Mean number of PRBCs and FFP transfused were 7.7 +/- 12 U, 6 U, and 5 +/- 12 U, respectively. Three hundred sixty-five (45%) patients were transfused in the first 24 hours. Sixty-eight percent (n = 250) of them received both PRBCs and FFP. Analyzing these patients by stepwise regression controlling for all significant variables, the PRBC:FFP ratio did not predict intensive care unit days, hospital days, or mortality even in patients who received massive transfusion (> or = 10 U). Furthermore, there was no significant difference in outcome when comparing patients who had a 1:1 PRBC:FFP ratio with those who did not receive any FFP. Early and aggressive use of FFP does not improve outcome after civilian injury. This may reflect inherent differences compared with military injury; however, this practice should be reevaluated.

Audit of the clinical use of fresh-frozen plasma in Umbria: study design and results of the pilot phase.

Fresh-frozen plasma (FFP) is unanimously recognised by international guidelines as the blood component of choice for the management of acute haemorrhage when accompanied by disorders of haemostasis, for disseminated intravascular coagulation in the presence of haemorrhage, for rare bleeding disorders when specific clotting factor concentrates are not available and for thrombotic thrombocytopenic purpura. The literature, however, reports a high percentage of inappropriate requests for FFP. This article presents the results of a pilot study of clinical auditing of the use of FFP in the Region of Umbria (Italy). This study was based on the examination of the requests for FFP made in April 2006 to four Immunotransfusion Services (ITS) in Umbria and of the clinical records of the patients receiving transfusions. The following indicators were identified and evaluated: completeness of the request, appropriateness of the indication and the dose, completeness of the records in the clinical charts, adverse events, in-hospital morbidity and mortality, efficacy of the treatment (evaluated by analysing the changes between pre- and post-transfusion coagulation test results) and, as an indicator of the process, the correspondence between data in the paper request form and in the computerised database. The data were extracted from the ITS databases, from the paper request forms and from the patients' clinical records. Two hundred and twenty-one requests (615 units of FFP) for 109 patients and 92.8% of the related clinical records were examined. The patients were admitted in medical (22.9%), surgical (51.4%) and critical care units (25.7%). In 50.7% of the cases, the completeness of the data in the individual requests was good (65-80% of the fields filled in). The indication was appropriate in 31.5% of the requests evaluated (56.1% of the total), with no difference related to different requesters. The dosage was appropriate in 62.7% of the requests evaluated (62% of the total). A comparison of pre- and posttransfusion laboratory data showed a significant correction of pathological values (p=0.02) only for the International Normalised Ratio (INR). Critical areas that should be targeted by interventions to improve plasma usage are those related to the appropriateness of the indication, the completeness of the data entered in the request forms and the data recorded in the clinical charts.

Use of fresh‐frozen plasma at Royal Darwin Hospital: a retrospective audit

The aim of the study was to assess the appropriateness of use of fresh-frozen plasma (FFP) at Royal Darwin Hospital against the National Health and Medical Research Council and Australian and New Zealand Society for Blood Transfusion guidelines. A retrospective review of blood product request forms, online pathology storage system data, pathology records and clinical notes between 1 January 2006 and 31 December 2006 was carried out. The appropriateness of requests was assessed against existing guidelines. The percentage of appropriate and inappropriate FFP transfusions was obtained. Six hundred and forty-eight of 950 units (68%) of FFP were used with an appropriate indication as per National Health and Medical Research Council/Australian and New Zealand Society for Blood Transfusion guidelines. Of the remaining units, 14% (137 units) was given without a clear indication and a decision of appropriateness could not be established for 17% (165 units) because of inadequate clinical or pathology information (e.g. coagulation results). Multiple issues around prescribing practice were identified. There is significant use of FFP at Royal Darwin Hospital without clear clinical indication. The employment of a transfusion nurse to monitor use of FFP (and other blood products) and provide education is aimed at improving transfusion efficiency and patient safety.

Red blood cell to plasma ratios transfused during massive transfusion are associated with mortality in severe multiply injury: a retrospective analysis from the Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie

To test whether an acute transfusion practice of packed red blood cells (pRBC) : fresh-frozen plasma (FFP) 1 : 1 would be associated with reduced mortality in acute bleeding multiply injury. Retrospective analysis using the TR-DGU database (Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie 2002-2006) on primary admissions with substantial injury (Injury Severity Score > 16) and massive transfusion (> 10 pRBCs). Seven hundred thirteen patients were divided into three groups according to the pRBC : FFP ratio transfused, that is, (i) pRBC : FFP > 1.1; (ii) pRBC : FFP 0.9-1.1 (1 : 1); and (iii) pRBC : FFP < 0.9, and mortality rates were compared. Four hundred ninety-seven (69.7%) of patients were male, the mean age was 40.1 (+/- 18.3) years. Injury characteristics and pathophysiological state upon emergency room arrival were comparable between groups. Out of 713, 484 patients had undergone massive transfusion with pRBC : FFP > 1.1, 114 with pRBC : FFP 0.9-1.1 (1 : 1), and 115 with pRBC : FFP < 0.9 ratios. Acute mortality (< 6 h) rates for pRBC : FFP > 1.1, pRBC : FFP 0.9-1.1 (1 : 1), and pRBC : FFP < 0.9 ratios were 24.6, 9.6 and 3.5% (P < 0.0001), 24-h mortality rates were 32.6, 16.7 and 11.3% (P < 0.0001), and 30-day mortality rates were 45.5, 35.1 and 24.3% (P < 0.001). The frequency for septic complications and organ failure was higher in the pRBC : FFP 0.9-1.1 (1 : 1) group, ventilator days and length of stays for intensive care unit and overall in-hospital were highest in the pRBC : FFP < 0.9 ratio group (P < 0.0005). An association between pRBC : FFP transfusion ratios and mortality to favour early aggressive FFP administration was observed. Further investigation is necessary prior to recommending routine 1 : 1 or more aggressive FFP use in exsanguinating patients.

The neonatal coagulation system and the vitamin K deficiency bleeding – a mini review

Coagulation factors do not cross the placental barrier but are synthesized independently by the conceptus. At birth, activities of the vitamin K dependent factors II, VII, IX, and X and the concentrations of the contact factors XI and XII are reduced to about 50% of normal adult values. The levels of the factors V, VIII, XIII, and fibrinogen are similar to adult values. Plasma concentrations of the naturally occurring anticoagulant proteins (antithrombin, protein C, and protein S) are significantly lower at birth than during the adult years. Plasminogen is reduced by approximately 50%. Platelet counts are within the normal range, regarding function, however, neonatal platelets seem to be hyporeactive. The von Willebrand factor contains large multimers and its concentration is increased. Properties and functions of vitamin K as well as requirement and plasma concentrations in newborns are reviewed. Regarding vitamin K deficiency bleeding (VKDB), the classical nomenclature is used: "early" (presenting within the first 24 h of life), "classical" (day 1-7 after birth), and "late" (8 days to 6 months). After the presentation of the history of vitamin K prophylaxis, vitamin K levels are described as can be expected after the administration of prophylactic doses at various routes. Subsequently, the actual schedule of vitamin K prophylaxis as recommended by the "Osterreichische Gesellschaft für Kinder- und Jugendheilkunde" is given as follows: i) the oral treatment of healthy full-term babies and orally fed preterm babies, ii) the parenteral treatment of small preterm and sick full-term babies, and iii) the treatment of mothers under medication with enzyme-inducing drugs with vitamin K during the last 15-30 days of pregnancy. The regimes of prophylactic vitamin K treatment of different countries are also given. Finally, the therapeutic use of vitamin K is addressed; the potential use of fresh-frozen plasma, prothrombin complex preparations, and recombinant factor VIIa is discussed.

The good use of plasma. A critical analysis of five international guidelines.

The clinical use of fresh-frozen plasma (FFP) is progressively increasing both nationally and internationally, despite the fact that many studies have shown the weaknesses of the indications for its use. Guidelines on the good use of plasma have, therefore, been adopted in various countries. The aim of the present study was to analyse some of the existing guidelines on the good use of plasma, applying a scientifically validated method, as a preliminary step in the implementation of Regional guidelines. Abibliographic search (1990-2006) was conducted in databases, websites, and the archives of scientific societies. Relevant articles were recovered in full. The selected guidelines were evaluated using theAGREE instrument, which assesses the completeness and structural quality of the guidelines and, in some aspects, the contents of the recommendations. The project, co-ordinated by the Regional Centre for Co-ordination and Compensation (CRCC) and carried out by four Services of Immunohaematology and Transfusion (SIT) in Umbria, was funded by the Region of Umbria and approved by the four health care institutions involved. The bibliographic search yielded 3067 abstracts of which 239 were considered relevant. The analysis of these led to the recovery of 11 guidelines, among which five were selected: those from the British Committee for Standards in Haematology, theAgence Française de Securité Sanitaire de Produits de Sante, the Canadian Members of the Expert Working Group, the American Society of Anesthesiologists Task Force on Blood Component Therapy and the National Health and Medical Research Council (NHMRC)/Australasian Society of Blood Transfusion. None of the guidelines analysed obtained a score higher than 50% in all the domains of the AGREE score. There was no evidence of a tendency to improvement over time in the guidelines analysed. Objective evaluation of the guidelines analysed could provide the starting point for the subsequent production of similar documents.

Recommendations from the Tuscan Transfusion System on the appropriate use of solvent/detergent-inactivated fresh-frozen plasma.

The availability of methods and systems for inactivating pathogens in fresh-frozen plasma (FFP) for clinical use raises the question of whether and, if so, to what extent, these treatments, notoriously used to reduce the risk of post-transfusion infections, should be introduced. The level of transfusion safety guaranteed by selecting donors on the basis of their clinical features and personal history, combined with serological tests and genomic amplification to screen for transmissible infections, is very high, while there are adverse events associated with transfusions that, given their morbidity and mortality, deserve greater attention1–4. The current level of transfusion safety makes the cost-benefit ratio of introducing the use of pathogen-inactivated FFP unfavourable, even in the most economically developed countries, if the benefit is measured only in relation to the residual risk of infection5–14. Furthermore, cost-efficacy analyses show that the use of further economic resources, to improve the already high level of transfusion safety, must be justified by in-depth evaluations of the particular epidemiological context; in this way it is possible to avoid the paradox that the allocation of resources, withheld from other areas in which epidemiological findings suggest a more appropriate use, could even lower the overall safety of transfusions9. Between 2004 and 2005, the Transfusion System of the Region of Tuscany carried out an experimental project for the production of contract manufacturing apheresis plasma to be sent to industry for pathogen inactivation with solvent/detergent (S/D). The aim of this project was to obtain locally-collected pathogen-inactivated plasma for clinical use in the Region and involved all the structures constituting the Region’s Transfusion System: 15 Services of Immunohaematology and Transfusion Medicine and their peripheral branches, represented by 25 Transfusion Sections. After a thorough analysis of the characteristics that could make S/D FFP superior to standard FFP, in 2005 the Regional Blood Transfusion Co-ordinating Centre (RBTCC) drew up proposed recommendations for the use of this blood component, which had recently become available (albeit to a limited extent and at a relatively high cost), with the dual aim of reaching a consensus on its clinical utilization and of supplying an instrument to guide appropriate usage of the product. The recommendations, revised in May 2007 by a regional working group coordinated by the Technical Committee of the RBTCC, were kept at a low grade given the lack of studies that were methodologically adequate to provide higher levels of evidence. The expected benefits of spreading and using the recommendations on the correct use of S/D FFP within the Region are more appropriate use of this blood component and a contribution to Regional self-sufficiency in plasma derivatives, possibly as a consequence of the reduced consumption of plasma for clinical use.

The use of Fresh Frozen Plasma (FFP) in 2007 in France

After a more than four-fold decrease in Fresh Frozen Plasma (FFP) consumption in the nineties in France, probably due to the consequences of HIV epidemics, the use of FFP is again increasing in recent years but at a slower rate. In the surgical and trauma area, recent data suggest that guidelines for the use of FFP may need to be modified. Indeed, contrary to traditional beliefs and guidelines, several studies evaluating conditions with severe hemorrhage (very often associated with coagulation abnormalities) have shown that early use of FFP may be associated with better patient outcome. This has indeed been shown in emergency major vascular surgery and in trauma patients. Although there is a trend to favor a larger use of FFP in specific circumstances (i.e., major hemorrhage), reasons to better control administration of FFP remain. Several audits have indeed shown that the rate of inappropriate FFP transfusion remains high, from 20 to almost 100% of cases. Moreover, FFP continues to be used in patients who may be better treated with other strategies. The best example is the frequently inappropriate use of FFP in bleeding patients with excess anticoagulation from vitamin K antagonists. Even recent studies have shown that prothrombin complex administration is efficient, safe and provides very rapid reversal. Many physicians continue however to administer FFP as a first line treatment with notably increasing the risk of fluid overload, delayed efficacy and increased risk of transfusion-related acute lung injury (TRALI).

Warfarin reversal emerging as the major indication for fresh frozen plasma use at a tertiary care hospital

Because of the increase in the use of warfarin in the population in recent years, reversal of warfarin-related coagulopathy has become common in daily hospital practice. Transfusion of fresh frozen plasma (FFP) is the preferred treatment method for urgent warfarin reversal in the USA. We have undertaken a 1-month audit of FFP usage to ascertain the impact of warfarin use on the consumption of FFP. Sixty percent of the 376 units of FFP that were transfused during the study month were used to reverse warfarin effects. The most common reason to reverse warfarin was bleeding. Thirty-three percent of the units were used for the treatment of other coagulopathies, 7% were used in therapeutic plasmapheresis, and <1% was transfused empirically. One hundred and eighteen patients received FFP during the study month. The study population consisted mostly of elderly patients (65%); however, the warfarin reversing patients consisted disproportionately more of elderly patients (75%) compared with patients receiving FFP for other reasons (46%) (P = 0.0032). Warfarin reversal emerged as the major indication for FFP use in this study. Blood banks of hospitals serving a predominantly elderly patient population should anticipate a higher consumption of FFP. Careful monitoring of warfarin therapy, stringent implementation of the warfarin reversal guidelines, and the introduction of newer products for warfarin reversal would help reduce the consumption of FFP.

Tuscan study on the appropriateness of fresh-frozen plasma transfusion (TuSAPlaT).

The considerable increase in the consumption of fresh-frozen plasma (FFP) recorded in 2002 in the Region of Tuscany made it necessary to check the appropriateness of the use of this blood component in all transfusion facilities in the Tuscan network. From July 1, 2003 to December 31, 2005, the Regional Blood Transfusion Coordinating Centre carried out an audit on the clinical use of FFP in the 40 structures included in the Tuscan transfusion network. The study had two complementary parts: a review of guidelines on the use of FFP and the involvement of Hospital Transfusion Committees in evaluating the outcome of the audit and in the consequent local policy decisions and in educating clinicians. The data from all 40 of the regional transfusion structures were analysed. The audit, which was initially retrospective, gradually became prospective. The percentage clinical use of FFP decreased, compared to 2002, in each of the 3 years of the study: a) 2003: - 8.92%; b) 2004: - 2.11%; c) 2005: -1.97%. The inappropriate requests for plasma decreased from 27% to 22.7% of the total. It was possible to classify the inappropriate requests for plasma on the basis of homogeneous, regionally defined criteria. The most frequent inappropriate indication (60.7% of the total) was the use of plasma in the case of haemorrhage in patients with a normal PT and/or PTT or unavailable results. Each hospital revised its own guidelines between 2004 and 2005 and the Hospital Transfusion Committees set up appropriate educational and behavioural interventions. The capacity of transfusion facilities to make data on the use of blood components available systematically and continuously is an essential feature of clinical governance; systematic clinical auditing increases the level of appropriate behaviours in the transfusion sector, contemporaneously contributing to self-sufficiency in transfusion products, and may direct research towards those clinical settings at greatest risk of inappropriate use of transfusion therapy with FFP.

Justifying the clinical use of fresh frozen plasma - an audit.

To determine the appropriateness of fresh frozen plasma (FFP), uses in various haematological and clinical disorders, with reference to the British Committee for Standards in Haematology (BCSH) guidelines through an audit. Descriptive study. Department of Haematology and Transfusion Medicine, Shalamar Hospital, Lahore, from June 2001 to June 2004. The data was collected from June 2001 to June 2004 from the request forms ordered by the clinicians for the transfusion of FFP at the Department of Haematology and Transfusion Medicine, Shlamar Hospital, Lahore. A total of 2075 healthy blood donors donated their whole blood for the preparation of fresh frozen plasma (FFP). All blood donors were screened for anti HCV, HBsAg, VDRL and HIV. Those 2075 FFP units were prepared on high-speed centrifuge and were rapidly stored at -30oC freezer. A total of 587 patients were transfused 2075 units of FFP for various clinical disorders. The percentage of FFP units, transfused appropriately and inappropriately, as defined by BCSH guidelines, was estimated. Out of 2075 FFP units, 335 (24.41%) FFP units were transfused to patients suffering from bleeding due to disseminated intravascular coagulation (DIC), 306 (22.30%) units used for massive transfusion and surgical bleeding, 236 (17.20%) units for bleeding due to chronic liver disease, 202 (14.72%) units used to control bleeding due to coagulation factor deficiencies, 84(6.12%) units for thromobotic thrombocytopenic purpura (TTP), 75(5.46%) units prior to liver biopsy to correct prolonged prothrombin time (PT), 72(5.24%) units for haemorrhage due to haemolytic disease of newborn (HDN) and 62(4.51%) units to control bleeding due to warfarin overdosage, 425(60.45%) units used for nutritional support and hypovolaemia replacement, 131(18.63%) units for the reversal of prolonged INR in the absence of bleeding due to warfarin, 92 (13.08%) units used in ICU to correct prolonged PT without bleeding due to Vitamin K deficiency and 55(7.82%) units for chronic liver disease (CLD) to correct prolonged PT and APTT in the absence of bleeding. In summary, 1372 (66.12%) FFP units were appropriately and 703 (33. 88 %) were inappropriately used. In conclusion, 33.88% FFP was inappropriately used mainly due to lack of awareness of international guidelines and ignorance of risks.

Reliability of the technologist and today's technology

The increased morbidity and mortality associated with liberal blood product usage have been convincingly demonstrated. The clinical problems they pose have prompted development of more restrictive evidence-based transfusion criteria. Education alone has a limited impact on the adoption of these criteria into practice. New York Methodist Hospital undertook a proactive approach to reduce unnecessary transfusions.In November 2008, an interventional monitoring program to ensure adherence to transfusion criteria for packed red blood cells (PRBC), platelets, fresh frozen plasma (FFP), and cryoprecipitate transfusions was started. Blood bank technologists routinely monitored transfusion requests against a list of established criteria and experienced clinicians reviewed and adjudicated transfusion requests when the blood bank technologist's action was appealed.Transfusion usage decreased sharply in Year 1 (November 2008-October 2009) and continued to decrease in Year 2 (November 2009-October 2010). PRBC use decreased by 30.1% and 37.7%, with a 47.6% decrease in multi-unit transfusions; platelet use decreased by 24.3% and 41.2%; fresh frozen plasma use decreased by 41.8% and 31.1%; and cryoprecipitate use decreased by 38.7% and 56.1% during monitoring Years 1 and 2, respectively. Decreases occurred despite a 4.0% increase in hospital admissions during the monitoring years. The decreased blood product usage was accompanied by 28.6% reduction in complications. A 26.1% decrease in blood product requests from Year 1 to Year 2 suggested a practice change by the ordering physicians themselves. The total cost of blood products decreased by $2,235,676.We established a successful method to reduce transfusions of all blood products using strict adherence to evidence-based criteria and continuous monitoring. Our model translates into improved patient safety by decreasing the number of unnecessary transfusions. This also led to a significant reduction in hospital expenses.

Use of Recombinant Factor VIIa for Hip Surgery in a Patient with Factor-VII Deficiency

F actor-VII deficiency is a rare autosomal recessive disorder affecting approximately one in 500,000 persons1. The risk of bleeding complications depends on the factor-VII level, and patients with factor-VII activities of 5% are mildly affected2. As a result of its short half-life of six hours, factor-VII-replacement strategies require frequent infusions of factor preparations. Historically, options for treatment of or prophylaxis against bleeding in factor-VII-deficient patients included use of fresh-frozen plasma and plasma-derived concentrates of vitamin K-dependent coagulation factors (prothrombin complex concentrates). Potential complications associated with these products include infection with blood-borne pathogens as well as volume overload with fresh-frozen plasma and thrombotic events with prothrombin complex concentrates. Recombinant activated factor VII (recombinant factor VIIa) (NovoSeven; Novo Nordisk, Bagsvaerd, Denmark) was approved by the United States Food and Drug Administration (FDA) in 1999 for treatment of bleeding in patients with hemophilia A or B who have inhibitors to factors VIII and IX, respectively. On the basis of limited clinical experience, recombinant factor VIIa appears to also have beneficial hemostatic effects in bleeding situations complicated by coagulopathies due to liver disease, massive hemorrhage, qualitative and quantitative platelet disorders, oral anticoagulation, and congenital factor-VII deficiency3,4. We present a case of off-label use of recombinant factor VIIa to prevent perioperative bleeding complications in association with a major hip procedure in a patient with congenital factor-VII deficiency. The patient's wife granted permission for us to submit data concerning the case for publication, as the patient had died of chronic cardiac disease. I n 2003, a seventy-six-year-old man had major bleeding after a primary right …

A prospective audit of transfusion requests in a tertiary care hospital for the use of fresh frozen plasma

Aims and Background:Like any other drug, therapeutic use of fresh frozen plasma (FFP) has its own side effects, adverse reactions and risks involved. Overall use of FFP has been on the increase in most tertiary care hospitals. Since the guidelines for FFP use in a clinical setting are not well defined, the present study aims at defining the appropriateness of use of FFP in the light of its risks and benefits as a drug.Materials and Methods:We carried out a prospective survey of 821 transfusion orders for 2,915 units of fresh frozen plasma components in our hospital over a 4-month period and recorded indication for transfusion and the number of components requested.Results:Five hundred seventy-three (69.8%) of transfusion requests affecting 2,202 (75.54%) units of FFP were appropriately indicated, while 248 (30.2%) of FFP requests were inappropriately indicated. The majority of fresh frozen plasma requests used were for surgical bleeding (22.77%) because of the deranged coagulation profile before surgery in most of the patients. It was followed by liver disease and transplantation (12.54%). Out of 821 patients, 586 were male and 235 were female.Conclusion:Inappropriate requests accounted for 30.2% of the total FFP requests in patients who had normal coagulation parameters. Regular audits, appropriate training of medical staff, conducting regular CMEs are the measures being incorporated in our hospital to rationalize the use of blood components.

Intraoperative fresh-frozen plasma versus human albumin in craniofacial surgery − A pilot study comparing coagulation profiles in infants younger than 12 months

The transfusion of fresh-frozen plasma (FFP) is suggested to minimize dilution coagulopathy when applied instead of colloids during paediatric craniofacial surgery (pCFS). We prospectively compared plasmatic haemostaseologic function between volume replacement with FFPs versus human albumin (HA) in a pilot study. Thirty infants with primary craniosynostosis were scheduled for pCFS. In 15 of those, FFPs were available from the identical donor as for packed red blood cells (pRBC), and were thus employed for intraoperative volume replacement. The remaining 15 infants were infused with HA-5% instead. Haemoglobin(Hb)-values, global coagulation parameters (activated partial thromboplastin time-aPTT; prothrombin time-PT), selected clotting factors (F) (VIII, XI, XIII), antithrombin-AT, fibrinolytic factors (fibrinogen; plasminogen; alpha2-antiplasmin-alpha2A), and activation parameters (thrombin-antithrombin-complex-TAT; plasmin-antiplasmin-complex-PAP; D-dimers) were assessed and compared between both groups after induction of anaesthesia, before transfusion of pRBC, and at the end of surgery. Patients and treatment characteristics were balanced between both groups. Prolongation of aPTT and decreases of PT, FXI, FXIII, AT3, and fibrinolytic factors were more pronounced in the HA-group. Increases in F VIII activity, activation parameters, and the course of Hb-values were similar among both groups. There was no difference regarding clinical endpoints (peri-/postoperative pRBC-transfusions, postoperative blood loss). In conclusion, the application of HA was associated with a more distinct dilution of procoagulant factors, AT3, and fibrinolytic factors than the use of FFPs. However, the course of activation markers suggested a similar extent of clotting and fibrinolytic activation with the use of both transfusion regimens, and there were no differences with regard to clinical endpoints.

Population‐based audit of fresh‐frozen plasma transfusion practices

In contrast to decreasing red blood cell (RBC) consumption in Finland, the use of fresh-frozen plasma (FFP) has been increasing since the 1990s, suggesting that FFP use may not always be optimal. To improve transfusion practices, knowledge of current FFP use and regional, national, and international comparison is necessary. Nine (of 21) Finnish hospital districts participated. Data concerning FFP-transfused patients in the years 2002 and 2003 were collected from existing computerized medical records into a yearly updated database as part of a Finnish benchmarking project on blood component use. Data included 11,590 FFP-transfused patients and 60,240 FFP units (71.2% of Finnish FFP use) delivered to Finnish hospitals during the study period. FFP was transfused most often to surgery patients (62.8% of FFP transfusion hospital visits) with blood circulatory system problems (32.3% of surgically treated and FFP-transfused patients). In only 65.9 percent of FFP-transfused patients were coagulation variables measured at any point in the hospital episode, and FFP was usually transfused in paired doses. Mean FFP use in Finland is comparable to other countries. Although overall FFP use in Finland is similar to that of international figures, it does not ensure best practice. Perioperative staff, being the largest FFP user, should be encouraged to dose FFP based on coagulation variables and body weight. Improvement efforts should be directed to patient groups transfused with large amounts of FFP.

P12 An Audit of Fresh Frozen Plasma Transfusion Use in the Royal Hospitals Trust (RGHT)

Allogeneic fresh frozen plasma (FFP) transfusions have increased in recent years, in the Royal Group of Hospitals Trust and in the UK as a whole. In the 2003 Serious Hazards of Transfusion report, FFP was the blood product most commonly attributed to the development of transfusion associated acute lung injury and a leading cause of transfusion related mortality. In the British Committee for Standards in Haematology (BCSH) guidelines there are few indications for FFP transfusion. Stainsby found that appropriateness of FFP transfusion in England varied from 62–92%.Audit objectives (i) To assess the appropriateness of FFP transfusions in the RGHT against BCSH guidelines ‐ 100% standard; and (ii) To assess the adequacy of documentation for FFP transfusion episodes re indication for transfusion and clinical effectiveness ‐ 100% standard.Method Data relating to FFP transfusion episodes between October 2004 and January 2005 inclusive, was extracted retrospectively from available patient notes by an SpR in haematology and a consultant anaesthetist. Anonymously completed proformas were jointly assessed for appropriateness of transfusion by the same investigators. FFP transfusion episodes Appropriate Inappropriate 137 episodes (114 patients) 93 (68%) 44 (32%) Reversal of warfarin effect, bleeding not severe or absent 16 Hepatic disease induced coagulopathy, no bleeding 6 Heparin/antiplatelet induced coagulopathy, with bleeding 4 Other causes of coagulopathy without bleeding 13 Ongoing blood loss, normal coagulation screen 4 Normal coagulation screen, no evidence of bleeding 1 Clinical documentation Present Absent Statement re indication for FFP transfusion 73 (53%) 64 (47%) Statement re clinical effectiveness of transfusion 52 (38%) 85 (62%) Conclusion and Recommendations A significant number of FFP transfusions are inappropriate, based on recent BCSH guidance. Documentation in clinical notes concerning the indication and response to FFP transfusion is frequently lacking. Appropriateness of FFP transfusion and associated clinical documentation should be improved by staff education and greater awareness of BCSH guidelines. Education should also include appropriate monitoring and management of bleeding secondary to warfarin or antiplatelet therapy. FFP transfusions should be re‐audited 1 year hence. Guidelines for the use of fresh‐frozen plasma, cryoprecipitate and cryosupernatant. The British Society for Haematology 2004, 126: 11–28 Stainsby D. Audit of the Appropriate Use of Fresh Frozen Plasma, National Blood Service, May 2002.

Aprotinin is useful as a hemostatic agent in cardiopulmonary surgery: yes.

Aprotinin is useful as a hemostatic agent in cardiopulmonary surgery: yes.

Abstracts for the British Congenital Cardiac Association Annual Meeting: The Barbican, London, 24–25 November 2005: Oral Presentations: Perioperative red cell salvage in paediatric cardiac surgery

Objective: In recent years blood transfusion has become a debated health care issue. To minimise exposure to infectious agents and reduce bank blood transfusion requirements, leucocyte filtration and perioperative red cell salvage (RCS) are increasingly used in paediatric patients. We hypothesised RCS would reduce the need for additional blood products in children following cardiopulmonary bypass (CPB). Methods: Patients undergoing routine or emergency cardiac surgery requiring CPB over a study period of 3 months were included prospectively in the analysis. Haemoglobin, platelet count, coagulation screen and heparin levels were performed before, immediately after surgery and 24 hours later. RCS was performed in theatre according to surgical and anaesthetic preference. Red cells were salvaged from the surgical site, anticoagulated, washed and following resuspension in saline reinfused into the patient within 4 hours. The incidence of post-operative bleeding (&gt;10 ml/kg/hr) was recorded, as was the need for additional red blood cells, platelets and fresh frozen plasma (FFP). The need for blood products was at the discretion of the consultant intensivist. Statistical analysis was performed using student t-test and Chi squared methods. Significance was accepted as p &lt; 0.05. Results: Thirty-five consecutive patients (34.54 ± 43.55 months, 13.48 ± 14.39 kg) were included in the analysis. A total of 17 infants &lt;12 months were included, 9/24 who received RCS and 8/11 who did not (p 0.052). Cyanotic heart disease was seen in 40%. RCS was performed in 24 of 35 patients, who were significantly older (44.2 ± 44.1 vs. 13.6 ± 25.5, p 0.02) and heavier (16.6 ± 16.2 vs. 6.7 ± 4.7, p 0.01). No difference was seen in the prevalence of cyanosis between the two groups. Post-operative bleeding was seen in 21% who underwent RCS and 40% in those who did not (p 0.33). The need for additional red blood cells was significantly reduced in those who received RCS, 37.5% vs. 91%, p 0.003, as was the use of FFP, 8.3% vs. 45.5%, p 0.02. There was no difference in the need for platelet transfusion, p 0.2. Discussion: In this study RCS was performed on 68.5% of children following CPB. RCS significantly reduced the need for further blood and FFP transfusion, although this was not related to post-operative bleeding. This has important implications for both exposure to infectious agents and health economics. That children who underwent RCS were older and heavier may be related to the complexity of surgery and CPB in younger patients, although infants were represented in both groups. A further analysis of potential health and economic benefits in a homogenous group is needed.

Fresh frozen plasma and platelet transfusion for nonbleeding patients in the intensive care unit: Benefit or harm?

Whereas restrictive red cell transfusion has become a standard of care for the critically ill, evidenced-based indications for use of other blood components such as fresh frozen plasma (FFP) and platelet transfusions are limited. We searched the National Library of Medicine PubMed database as well as references of retrieved articles and summarized the current evidence for the use of FFP and platelet transfusions in critically ill patients. Routine coagulation tests are poor determinants of bleeding risk in critically ill patients with coagulopathy. FFP transfusion has limited efficacy and is associated with significant morbidity in critically ill patients, in particular, pulmonary edema and acute lung injury. Routine minimally invasive critical care procedures can be safely performed by experienced clinicians in the setting of mildly abnormal coagulation test results, and there is no evidence that FFP transfusion alters the risk of bleeding. For platelet transfusion, the American Society of Clinical Oncology has developed practice guidelines designed for oncology patients. However, because the pathophysiology of thrombocytopenia in critically ill patients often differs from that of thrombocytopenia in oncology patients, published guidelines for oncology patients may not be applicable. Because the risk-benefit ratio of a liberal FFP or platelet transfusion strategy for critically ill patients may not be favorable, randomized controlled trials are warranted for evaluating a restrictive vs. liberal FFP or platelet transfusion strategy for nonbleeding patients in the intensive care unit.