Higher intraoperative plasma transfusion volumes are associated with inferior perioperative outcomes

Plasma transfusion in critically Ill patients with abnormal coagulation tests before invasive procedures: A propensity-adjusted cohort study

OBJECTIVE

To evaluate the association between plasma transfusion and bleeding complications in critically ill patients with an elevated international normalized ratios undergoing invasive procedures.

METHODS

A retrospective study was conducted to evaluate a consecutive sample of critically ill adult patients undergoing invasive procedures (N = 487) with an international normalized ratio ≥ 1.5 between January 1, 2019 and December 31, 2019. Among the followed patients, 125 were excluded due to incomplete case records and 362 were finally included in this investigation. The exposure was whether plasma had been transfused within 24 h before the invasive procedure. The primary outcome was the occurrence of postprocedural bleeding complications. Secondary outcomes included transfusion of red blood cells within 24 h of the invasive procedure, and additional patient-important outcomes such as mortality and length of stay. Tests were performed with univariate and propensity-matched analyses.

RESULTS

Of the 362 study participants, 99 (27.3 %) received a preprocedural plasma transfusion. In the propensity score-matched analysis, the rate of the occurrence of postprocedural bleeding complications between two groups was not statistically different (OR, 0.605[95 % CI, 0.341-1.071]; P = .085). The rate of postoperative red blood cell transfusion in the plasma transfusion group was higher than that in the non-plasma transfusion group (35.5 % vs 21.5 %; P < .05). No statistically significant difference in mortality was observed between the two groups (29.0 % vs 31.6 %; P = .101).

CONCLUSIONS

Prophylactic plasma transfusion failed to reduce postprocedural bleeding complications in ill critically patients with a coagulopathy. Meanwhile, it was associated with increased red blood cell transfusion after invasive procedures. Findings suggest that abnormal preprocedural international normalized ratios should be managed more conservatively.

Association between perioperative plasma transfusion and in-hospital mortality in patients undergoing surgeries without massive transfusion: A nationwide retrospective cohort study

BACKGROUND

An aggressive plasma transfusion is associated with a decreased mortality in traumatic patients requiring massive transfusion (MT). However, it is controversial whether non-traumatic or non-massively transfused patients can benefit from high doses of plasma.

METHODS

We performed a nationwide retrospective cohort study using data from Hospital Quality Monitoring System, which collected anonymized inpatient medical records from 31 provinces in mainland China. We included the patients who had at least one record of surgical procedure and received red blood cell transfusion on the day of surgery from 2016 to 2018. We excluded those receiving MT or diagnosed with coagulopathy at admission. The exposure variable was the total volume of fresh frozen plasma (FFP) transfused, and the primary outcome was in-hospital mortality. The relationship between them was assessed using multivariable logistic regression model adjusting 15 potential confounders.

RESULTS

A total of 69319 patients were included, and 808 died among them. A 100-ml increase in FFP transfusion volume was associated with a higher in-hospital mortality (odds ratio 1.05, 95% confidence interval 1.04-1.06, p < 0.001) after controlling for the confounders. FFP transfusion volume was also associated with superficial surgical site infection, nosocomial infection, prolonged length of hospital stay, ventilation time, and acute respiratory distress syndrome. The significant association between FFP transfusion volume and in-hospital mortality was extended to the subgroups of cardiac surgery, vascular surgery, and thoracic or abdominal surgery.

CONCLUSIONS

A higher volume of perioperative FFP transfusion was associated with an increased in-hospital mortality and inferior postoperative outcomes in surgical patients without MT.

Intraoperative Plasma Transfusion Volumes and Outcomes in Cardiac Surgery

OBJECTIVE

Assess outcomes after intraoperative plasma transfusion in patients undergoing cardiac surgery.

DESIGN

Retrospective study of adult cardiac surgical between 2011 and 2015. Relationships between plasma transfusion volume, coagulation test values, and a primary outcome of early postoperative red blood cell (RBC) transfusion were assessed via multivariable regression analyses. Secondary outcomes included hospital mortality, intensive care unit and hospital-free days, intraoperative RBCs, estimated blood loss, and reoperation for bleeding.

SETTING

Academic tertiary referral center.

PARTICIPANTS

A total of 1,794 patients received intraoperative plasma transfusions during the study period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Higher plasma transfusion volumes were associated with worse clinical outcomes, with each 1-unit increase being associated with greater odds for postoperative RBCs [odds ratio (OR) 1.12 (confidence interval [CI] 1.04-1.20); p = 0.002], intraoperative [OR 1.85 (CI 1.69-2.03); p < 0.001], and fewer hospital-free days [mean -0.20 (-0.39, -0.01); p = 0.04]. Each 0.1 increase in pretransfusion International Normalized Ratio (INR) was associated with increased odds of postoperative and intraoperative RBCs, reoperation for bleeding, and fewer intensive care unit and hospital-free days. For given plasma volumes, patients achieving greater reduction in elevated pretransfusion INR values experienced more favorable outcomes.

CONCLUSIONS

In patients undergoing cardiac surgery who received intraoperative plasma transfusion, higher plasma transfusion volumes were associated with inferior clinical outcomes. Higher pretransfusion INR values also were associated with worse outcomes; however, those achieving a greater degree of INR correction after plasma transfusion demonstrated more favorable outcomes. Prospective studies related to plasma transfusion are needed to address this important topic.

Review of current transfusion therapy and blood banking practices

Transfusion Medicine is a dynamically evolving field. Recent high-quality research has reshaped the paradigms guiding blood transfusion. As increasing evidence supports the benefit of limiting transfusion, guidelines have been developed and disseminated into clinical practice governing optimal transfusion of red cells, platelets, plasma and cryoprecipitate. Concepts ranging from transfusion thresholds to prophylactic use to maximal storage time are addressed in guidelines. Patient blood management programs have developed to implement principles of patient safety through limiting transfusion in clinical practice. Data from National Hemovigilance Surveys showing dramatic declines in blood utilization over the past decade demonstrate the practical uptake of current principles guiding patient safety. In parallel with decreasing use of traditional blood products, the development of new technologies for blood transfusion such as freeze drying and cold storage has accelerated. Approaches to policy decision making to augment blood safety have also changed. Drivers of these changes include a deeper understanding of emerging threats and adverse events based on hemovigilance, and an increasing healthcare system expectation to align blood safety decision making with approaches used in other healthcare disciplines.