Choosing Wisely:

Don’t transfuse plasma to correct a laboratory value; treat the clinical status of the patient.

Rationale and Comments: Plasma transfusion to a patient with an international normalized ratio of less than 1.6 has minimal effect, and transfusion for international normalized ratio values between 1.6 and 2 should be carefully considered. Since a mildly elevated international normalized ratio is usually not associated with spontaneous hemorrhage and doesn’t increase the risk of bleeding during routine invasive procedures, excessive transfusion of plasma is unnecessary and increases the risk of transfusion-associated circulatory overload, which is a leading cause of transfusion associated morbidity and mortality. Judicious use of vitamin K and/or prothrombin complex concentrate following evidence-based clinical practice guidelines should also be considered to avoid unnecessary transfusion.
Sponsoring Organizations:
  • American Society for Clinical Pathology
  • Sources:
  • Expert consensus
  • Disciplines:
  • Hematologic
  • References: • Triulzi D, Gottschall J, Murphy E, et. al. A multicenter study of plasma use in the United States. Transfusion. 2015;55:1313-1319.
    • Shah N, Baker SA, Spain D, et.al. Real-time clinical decision support decreases inappropriate plasma transfusion. Am J Clin Pathol. 2017;148(2):154-160.
    • Alcorn K, Ramsey G, Souers R, Lehman CM. Appropriateness of plasma transfusion: a College of American Pathologists Q-probes study of guidelines, waste, and serious adverse events. Arch Pathol Lab Med. 2017;141:396-401.
    • Holland LL, Brooks JP. Toward rational fresh frozen plasma transfusion: the effect of plasma transfusion on coagulation test results. Am J Clin Pathol. 2006;126:133-139.
    • Roback JD, Caldwell S, Carson J, et. al. Evidence-based practice guidelines for plasma transfusion. Transfusion. 2010;50:1227-1239.
    • Fatalities Reported to FDA Following Blood Collection and Transfusion Annual Summary for FY2016. [accessed Mar 20, 2018]. Available from: https://www.fda.gov/downloads/BiologicsBloodVaccines/SafetyAvailability/ReportaProblem/TransfusionDonationFatalities/UCM598243.pdf
    • Garcia DA, Crowther MA. Reversal of warfarin: case-based practice recommendations. Circulation. 2012;125:2944-2967.
    • Gorlin J, Kinney S, Fung MK, et al. Prothrombin complex concentrate for emergent reversal of warfarin: an international survey of hospital protocols. Vox Sanguinis. 2017;112(6):595-597.

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