SCA Lecture, March 2014: When should I give platelets and plasma?
Stephen A. Esper, MD, MBA
Ian J. Welsby, MB BS
Specific Guidelines1-3
Fresh Frozen Plasma (FFP):
STS/SCA
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Plasma transfusion is reasonable in patients with serious bleeding in context of multiple
or single coagulation factor deficiencies when safer fractionated products are not
available.
For urgent warfarin reversal, administration of prothrombin complex concentrate
(PCC) is preferred, but plasma transfusion is reasonable when adequate levels of Factor
VII are not present in PCC.
Transfusion of plasma may be considered as part of a massive transfusion algorithm in
bleeding patients requiring substantial amounts of red-blood cells.
Prophylactic use of plasma in cardiac operations in the absence of coagulopathy is not
indicated, does not reduce blood loss and exposes patients to unnecessary risks and
complications of allogeneic blood component transfusion.
Plasma is not indicated for warfarin reversal or treatment of elevated international
normalized ratio in the absence of bleeding.
ASA
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FFP should be given in doses calculated to achieve a minimum of 30% of plasma factor
concentration (10-15 mg/kg FFP). Urgent reversal of warfarin anticoagulation may
suffice with 58- ml/kg.
Correct excessive microvascular bleeding in the presence of prothrombin time (PT)
greater than 1.5 times normal or INR greater than 2.0, or a prothromboplastin time
(aPTT) greater than 2 times normal.
Correct excessive microvascular bleeding secondary to coagulation factor deficiency in
patients transfused with more than one blood volume (70 cc/kg)
Urgent reversal of warfarin therapy
Correct known coagulation factor deficiencies when specific concentrates are
unavailable
Heparin resistance
European2,4
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Recommend against the use of FFP for pre-procedural correction of mild to moderately
elevated INR.
FFP may be used if no other fibrinogen source is available.
Discuss the Italian guidelines that recommend transfusion of FFP when prolonged PT
and aPTT (>1.5 times normal) as a trigger, or blind FFP administration if tests cannot be
performed in a reasonable time.4
FFP prepared from units of whole blood and that obtained by apheresis are equivalent
in terms of haemostasis and side effects
In cardiovascular surgery, the routine use of apheresis procedures in the immediate
pre-operative period, in order to produce platelet concentrates or units of FFP from
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apheresis is not recommended because the documented superiority of benefits
compared to the possible risks for the patient is marginal, because it is often impossible
to produce therapeutic doses of autologous blood components and because of the costs
of the procedure itself
The main indication for transfusion of FFP is correction of deficiencies of clotting
factors for which a specific concentrate is not available, in patients with ongoing
bleeding18.
In the presence of acute or chronic liver disease and ongoing bleeding, DIC or active
bleeding
Adverse reactions to the transfusion of fresh-frozen plasma
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The acute adverse reactions to transfusion therapy with FFP are mild allergic reactions
(urticaria) or severe, anaphylactic allergic reactions, TRALI, febrile reactions, citrate
toxicity and circulatory overload18.
Platelets:
STS/SCA
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In patients requiring longer CPB times (2 to 3 hours), maintenance of higher and/or
patient-specific heparin concentrations during CPB may be considered to reduce
hemostatic system activation, reduce consumption of platelets and coagulation proteins,
and to reduce blood transfusion.
For extracorporeal membrane oxygenation: Maintain platelet count of greater than
80,000 to 100,00/mcL with transfusion.
Use of intraoperative platelet plasmapheresis is reasonable to assist with blood
conservation strategies as part of a multimodality program in high-risk patients if an
adequate platelet yield can be reliably obtained.
Preoperative hematocrit and platelet count are indicated for risk prediction and
abnormalities in these variables are amenable to intervention.
Patients who have thrombocytopenia (_50,000/mm2), who are hyperresponsive to
aspirin or other antiplatelet drugs as manifested by abnormal platelet function tests or
prolonged bleeding time, or who have known qualitative platelet defects represent a
high-risk group for bleeding. Maximum blood conservation interventions during
cardiac procedures are reasonable in these high-risk patients.
Use of 1-deamino-8-D-arginine vasopressin (DDAVP) may be reasonable to attenuate
excessive bleeding and transfusion in certain patients with demonstrable and specific
platelet dysfunction known to respond to this agent (eg, uremic or CPB-induced platelet
dysfunction, type I von Willebrand’s disease).
ASA
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In a bleeding patient, platelets should be administered when the count is below 50,000
cells/mm3
Platelet count is rarely indicated when greater than 100x109/L and is usually indicated
when the count is below 50x109 in the presence of excessive bleeding.
Determination of whether patients with intermediary platelet counts should require
therapy, including prophylactic therapy, should be based on potential for platelet
dysfunction, anticipated or ongoing bleeding, and the risk of bleeding into a confined
space.
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If a platelet count cannot be done in a timely fashion in the presence of excessive
microvascular bleeding, platelets may be given if thrombocytopenia is suspected.
Prophylactic transfusion of platelets for heparin-induced thrombocytopenia, idiopathic
thrombocytopenic purpura, and thrombotic thrombocytopenic purpura is ineffective
and rarely indicated.
Point of Care Testing:
Thromboelastography (TEG)
Rotational Thromboelastometry (ROTEM)
Functional Platelets
Activated Clotting Time (ACT)
European Guidelines:
5.1.7 Are patient outcomes improved by algorithms that incorporate coagulation monitoring
for perioperative haemostatic management?
 Recommend the application of transfusion algorithms incorporating predefined
intervention triggers to guide haemostatic intervention during intraoperative bleeding.
1B
 Recommend the application of transfusion algorithms incorporating predefined
intervention triggers based on POC coagulation monitoring assays to guide haemostatic
intervention during cardiovascular surgery. 1C
Article on Point of Care Testing:
Hemostatic therapy based on point of care testing reduced patient exposure to allogenic blood
products and provided significant benefits with respect to clinical outcomes.
Weber CF and Gorlinger K et al. Point of Care Testing: A Prospective, Randomized Trial of
Efficacy in Coagulopathic Cardiac Surgery Patients. Anesthesiology. 2012;117:531-547.
Risk of Transfusion:
 Transfusion Related Acute Lung Injury (TRALI)
 Acute Immune Hemolytic Reaction
 Delayed Hemolysis
 Graft-versus-host disease
 Allergic reaction and anaphylaxis
 Fever
 Infections
o Hepatitis B
o Hepatitis C
o HIV
o Bacterial Contamination
1. Ferraris et al. 2011 Update to The Society of Thoracic Surgeons and the Society of
Cardiovascular Anesthesiologists Blood Conservation Clinical Practice Guidelines.
Annals of Thoracic Surgery. 2011;91:944-82
2. Kozek-Langenecker SA et al. Management of severe perioperative bleeding, Guidelines
from the European Society of Anesthesiology. European Journal of Anaesthesiology.
2013;30:270-382.
3. American Society of Anesthesiology Task Force on Perioperative Blood Transfusion.
Practice Guidelines for Perioperative Blood Transfusion and Adjuvant Therapies.
Anesthesiology. 2006. 105;1:198-208.
4. Liumbruno GM, Bennardello F, Lattanzio A, et al. Recommendations for the transfusion
management of patients in the peri-operative period. II. The intra-operative period.
Blood Transfus 2011; 9:189–217.