Although frozen plasma (FP) transfusion is ubiquitous in clinical practice there is growing evidence that calls into question its administration outside a few selected clinical disorders. Indications for FP have been further reduced by the introduction of prothrombin complex concentrates (PCCs), which are now recommended for reversal of coagulopathies due to vitamin K antagonists (VKA).
Audits consistently demonstrate that FP is administered to patients who do not have a specific indication for its use; in some cases “inappropriate” FP use exceeds “appropriate” FP use. This audit sought to determine if the introduction of PCCs has changed patterns of practice and the appropriateness of FP use.
After ethics review we performed a quality assurance retrospective chart audit at a single tertiary care hospital of consecutive patients receiving FP over a 3 month period. Baseline characteristics were obtained for each of these patients via chart review. Each episode of FP use over a 24 hour period was adjudicated independently by two Hematology fellows and determined to be appropriate, inconsistent (with guidelines) yet appropriate, or inappropriate in accordance to Canadian and AABB guidelines. Episodes where a consensus could not be reached were adjudicated independently by a consultant hematologist. Specific criteria for “appropriateness” were developed based on the chart review; for example, transfusion of more than 5 units of packed red blood cells in a 2:1 ratio or greater with FP was considered inconsistent yet appropriate. Bleeding was defined as a decrease in hemoglobin of 2 g/dL over 24 hours, a transfusion of 2 units of red blood cells without a rise in hemoglobin, or bleeding in an enclosed space. Reversal of oral VKAs with FP was always deemed inappropriate. FP usage during the study period was also compared to 3-month periods from previous years.
Over the study period, 111 episodes and 466 units of frozen plasma use were recorded. Comparisons to the three month period between January to March of previous years are shown in Figure 1. Interobserver agreement was good between the two Hematology fellows (weighted kappa=0.736) and very good with the fellows to the consensus adjudication (weighted kappa=0.824 and 0.810). After exclusion of FP use for plasmapheresis (always considered appropriate), 33/89 (37.1%), 16/89 (18.0%), and 40/89 (44.9%) episodes were deemed to be appropriate, inconsistent yet appropriate, or inappropriate, respectively. The most common reasons for inappropriate use were the absence of bleeding with an increased INR or VKA reversal. Results are presented in further detail in Table 1. FP transfusion occurred in the ICU 74.8% of the time.
Our study is the first to audit FP transfusions in the post-PCC era. FP usage remains inappropriately high. FP transfusion to patients who are not bleeding or having procedures despite INR prolongation and the use of FP to reverse VKA are the main reasons for inappropriate FP usage. The majority of FP usage occurred in the ICU. Targeted interventions to reduce FP usage in the future should include both educational and administrative programs, with a focus on the ICU. Clearer evidence on the role of FP in massive transfusions may also reduce FP usage.
Crowther: Pfizer: Consultancy, Honoraria, Research Funding; Octapharma: Consultancy, Membership on an entity’s Board of Directors or advisory committees; Merck: Consultancy; Leo Pharma: Consultancy, Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding, Speakers Bureau; CSL Behring: Speakers Bureau; Boehringer Ingelheim: Consultancy, Honoraria, Membership on an entity’s Board of Directors or advisory committees; Baxter: Membership on an entity’s Board of Directors or advisory committees, Speakers Bureau; Asahi Kasai: Membership on an entity’s Board of Directors or advisory committees; Sanofi-Aventis: Consultancy, Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Viropharma: Membership on an entity’s Board of Directors or advisory committees.