Save the FFP, Save the World

This is a trial that does a couple things I really love: it nails inappropriate usage of the International Normalized Ratio to the wall, while simultaneously offering a viable alternative.

The INR is intended for one thing and one thing only: monitoring anticoagulation with warfarin. The INR, as a proxy for the PT, has instead been utilized as a pointless and misleading instrument for screening adults for previously undiagnosed coagulopathy. The PT, in the correct, narrow clinical context, has value – the INR does not.

This trial beautifully illustrates this point. These are patients with severe cirrhosis and end-stage liver disease undergoing invasive procedures. With thirty patients in each group, they were randomized to either standard pre-procedure prophylactic transfusion per-protocol based on INR guidelines, or the necessity of blood product was determined via thromboelastography. In the standard care group, the mean INR was 2.01, and, thus, per protocol, the typical patient received an appropriate dose of 4 units of FFP for “correction”. In the TEG group, only a handful of patients were deemed to actually have a coagulopathy for which FFP was indicated. No patients in the TEG-guided cohort had procedure-related bleeding and identical numbers of patients needed red cell transfusions.

Transfusions are expensive and dangerous: transfusion-related circulatory overload, transfusion-related lung injury, various incompatabilities and allergic reactions are not terribly infrequent. They should be avoided whenever possible, and this study beautifully illustrates the disutility of the INR for screening for bleeding risk. ESLD patients have elevated INRs from their inability to synthesize Vitamin K-dependent clotting factors, but they also do not synthesize Protein C and S, and there are a variety of other compensatory mechanisms. These patients do not routinely need transfusions of FFP prior to procedures, despite most centers being replete with similar protocols.

“Thrombelastography-Guided Blood Product Use Before Invasive Procedures in Cirrhosis With Severe Coagulopathy: A Randomized, Controlled Trial”
http://www.ncbi.nlm.nih.gov/pubmed/26340411