A national study of plasma use in critical care: clinical indications, dose and effect on prothrombin time

Simon J Stanworth, Timothy S Walsh, Robin J Prescott, Robert J Lee, Douglas M Watson, Duncan Wyncoll, Intensive Care Study of Coagulopathy (ISOC) investigators, Simon Stanworth, Tim Walsh, Douglas Watson, Heather Smethurst, Brian McClelland, Robert Lee, Robin Prescott, Caroline Maciver, Elizabeth Hutcheon, George Findlay, Gavin Lavery, Gillian Thompson, John McAteer, John Trinder, Jane Taylor, Steve Stott, Sian Roughton, Sally Hall, Heather Tennant, Wayne Wrathall, Lindsey Donaldson, Myles Cassidy, Sanjiv Chohan, Isabel Paterson, Sandra Morrow, Pauline Delaney, Lyndsey Berengler, Abigail McSherry, Marie Rankin, Kathleen McIlhatton, Mhairi Cairney, Lorna Hendry, Sheila Rea, Angela Hamill, Anna Barrett, Tracy Stillie, Moira Colton, Stephen Cole, Sally Crofts, Ian Mellor, Laura Kinloch, Kevin Rooney, Alana Kirkwood, Ewan Lindsey, Akuafo Agbenyega, Caroline Maciver, Fiona Frame, Tim Walsh, Alice Miller, Paul Nicholas, Laura Duffy, Chris Cairns, Paul Harrison, Gordon Peters, Stephan Dalchow, Jean Bruce, Kerry McIlhenny, Samantha Moultrie, Claire Battison, Louise Sinclair, Charles Wallis, Alexander Binning, Stephen Henderson, Marie Pollock, Ben Trumper, Tony Whitehouse, Mav Manji, Tracey Fleming, Sally Grier, Jasmeet Soar, Christine Mitchell-Inwang, Alisdair Short, Stuart Elliot, Andrew Bodenham, Judith Thornton, Stuart Murdoch, Adrian Wagstaff, Neil Soni, Gail Marshall, Andrew Ely, Maria Heeley, Tony Sherry, Katie Lei, John Smith, Laura Campbell, Duncan Wyncoll, Emma McClure, John Butler, Tony Dunne, Jane Eddleston, Dougal Atkinson, Sue Whitehead, Andrew Kilner, Jonathon Wallis, Simon Baudouin, Sue Whitehead, Jonathon Wallis, John Corcoran, Caroline Allen, Duncan Young, Julian Millo, Caroline Cawkill, Allison Hyson, Martin Tweeddale, Philip Young, Carys Jones, Linda Hosie, Carl Waldmann, Robert Lee, Robin Prescott, Simon Stanworth, Mike Patel, Caroline Hughes, Heather Smethurst, Douglas Watson, Hamish Davidson, Brian McClelland, Simon J Stanworth, Timothy S Walsh, Robin J Prescott, Robert J Lee, Douglas M Watson, Duncan Wyncoll, Intensive Care Study of Coagulopathy (ISOC) investigators, Simon Stanworth, Tim Walsh, Douglas Watson, Heather Smethurst, Brian McClelland, Robert Lee, Robin Prescott, Caroline Maciver, Elizabeth Hutcheon, George Findlay, Gavin Lavery, Gillian Thompson, John McAteer, John Trinder, Jane Taylor, Steve Stott, Sian Roughton, Sally Hall, Heather Tennant, Wayne Wrathall, Lindsey Donaldson, Myles Cassidy, Sanjiv Chohan, Isabel Paterson, Sandra Morrow, Pauline Delaney, Lyndsey Berengler, Abigail McSherry, Marie Rankin, Kathleen McIlhatton, Mhairi Cairney, Lorna Hendry, Sheila Rea, Angela Hamill, Anna Barrett, Tracy Stillie, Moira Colton, Stephen Cole, Sally Crofts, Ian Mellor, Laura Kinloch, Kevin Rooney, Alana Kirkwood, Ewan Lindsey, Akuafo Agbenyega, Caroline Maciver, Fiona Frame, Tim Walsh, Alice Miller, Paul Nicholas, Laura Duffy, Chris Cairns, Paul Harrison, Gordon Peters, Stephan Dalchow, Jean Bruce, Kerry McIlhenny, Samantha Moultrie, Claire Battison, Louise Sinclair, Charles Wallis, Alexander Binning, Stephen Henderson, Marie Pollock, Ben Trumper, Tony Whitehouse, Mav Manji, Tracey Fleming, Sally Grier, Jasmeet Soar, Christine Mitchell-Inwang, Alisdair Short, Stuart Elliot, Andrew Bodenham, Judith Thornton, Stuart Murdoch, Adrian Wagstaff, Neil Soni, Gail Marshall, Andrew Ely, Maria Heeley, Tony Sherry, Katie Lei, John Smith, Laura Campbell, Duncan Wyncoll, Emma McClure, John Butler, Tony Dunne, Jane Eddleston, Dougal Atkinson, Sue Whitehead, Andrew Kilner, Jonathon Wallis, Simon Baudouin, Sue Whitehead, Jonathon Wallis, John Corcoran, Caroline Allen, Duncan Young, Julian Millo, Caroline Cawkill, Allison Hyson, Martin Tweeddale, Philip Young, Carys Jones, Linda Hosie, Carl Waldmann, Robert Lee, Robin Prescott, Simon Stanworth, Mike Patel, Caroline Hughes, Heather Smethurst, Douglas Watson, Hamish Davidson, Brian McClelland

Abstract

Introduction: Fresh frozen plasma (FFP) is widely used, but few studies have described patterns of plasma use in critical care. We carried out a multicentre study of coagulopathy in intensive care units (ICUs) and here describe overall FFP utilisation in adult critical care, the indications for transfusions, factors indicating the doses used and the effects of FFP use on coagulation.

Methods: We conducted a prospective, multicentre, observational study of all patients sequentially admitted to 29 adult UK general ICUs over 8 weeks. Daily data throughout ICU admission were collected concerning coagulation, relevant clinical outcomes (including bleeding), coagulopathy (defined as international normalised ratio (INR) >1.5, or equivalent prothrombin time (PT)), FFP and cryoprecipitate use and indications for transfusion.

Results: Of 1,923 admissions, 12.7% received FFP in the ICU during 404 FFP treatment episodes (1,212 FFP units). Overall, 0.63 FFP units/ICU admission were transfused (0.11 units/ICU day). Reasons for FFP transfusion were bleeding (48%), preprocedural prophylaxis (15%) and prophylaxis without planned procedure (36%). Overall, the median FFP dose was 10.8 ml kg⁻¹, but doses varied widely (first to third quartile, 7.2 to 14.4 ml kg⁻¹). Thirty-one percent of FFP treatments were to patients without PT prolongation, and 41% were to patients without recorded bleeding and only mildly deranged INR (<2.5). Higher volumes of FFP were administered when the indication was bleeding (median doses: bleeding 11.1 ml kg⁻¹, preprocedural prophylaxis 9.8 ml kg⁻¹, prophylaxis without procedure 8.9 ml kg⁻¹; P = 0.009 across groups) and when the pretransfusion INR was higher (ranging from median dose 8.9 ml kg⁻¹ at INR ≤ 1.5 to 15.7 ml kg⁻¹ at INR >3; P < 0.001 across ranges). Regression analyses suggested bleeding was the strongest predictor of higher FFP dose. Pretransfusion INR was more frequently normal when the transfusion indication was bleeding. Overall, posttransfusion corrections of INR were consistently small unless the pretransfusion INR was >2.5, but administration during bleeding was associated with greater INR corrections.

Conclusions: There is wide variation in FFP use by ICU clinicians, and a high proportion of current FFP transfusions are of unproven clinical benefit. Better evidence from clinical trials could significantly alter patterns of use and modify current treatment costs.

Figures

Figure 1
Figure 1
Doses of fresh frozen plasma administered. Graphed histogram results summarising the range of doses of fresh frozen plasma (FFP) given in treatment episodes during intensive care unit (ICU) stay.
Figure 2
Figure 2
Effects of fresh frozen plasma on changes in international normalised ratio. Boxplot summarising the changes in international normalised ratio (INR), which are shown as medians (horizontal line), first and third quartiles (squares) and ranges (vertical lines) with outliers indicated by small circles or asterisks. The results are reported by reason for fresh frozen plasma (FFP) transfusion recorded by clinician (coagulopathy with bleeding, coagulopathy without bleeding or coagulopathy without bleeding prior to invasive procedure) for different levels of pretransfusion INR.

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