Volume 46, August 2006
Blackwell Publishing IncMalden, USATRFTransfusion0041-11322006 American Association of Blood BanksAugust 200646812791285Original ArticleEFFECT OF FFP ON PTABDEL-WAHAB ET AL.
ABBREVIATIONS: ICU = intensive care unit; INR = international
normalized ratio; PT = prothrombin time; PTT = partial
From the Department of Internal Medicine, Massachusetts
General Hospital, Boston, Massachusetts; the Department of
Biostatistics, Harvard School of Public Health; and the Blood
Transfusion Service, Department of Pathology, Massachusetts
General Hospital, Boston, Massachusetts.
Address reprint requests to: Walter H. Dzik, MD, Gray/Jackson
Building, Room 224, Massachusetts General Hospital, 55 Fruit
Street, Boston, MA 02114; e-mail: firstname.lastname@example.org.
Received for publication November 16, 2005; revision
received January 9, 2006, and accepted January 10, 2006.
T R A N S F U S I O N P R A C T I C E
Effect of fresh-frozen plasma transfusion on prothrombin time
and bleeding in patients with mild coagulation abnormalities
Omar I. Abdel-Wahab, Brian Healy, and Walter H. Dzik
BACKGROUND: Fresh-frozen plasma (FFP) is frequently
transfused to patients with mild prolongation of
coagulation values under the assumption that FFP will
correct the coagulopathy. There is little evidence to
support this practice, however. To determine the effect
of FFP on coagulation variables and correlation with
bleeding in patients with mildly prolonged coagulation
values, a prospective audit of all FFP transfusions at the
Massachusetts General Hospital between September 2,
2004, and September 30, 2005, was performed.
STUDY DESIGN AND METHODS: All patients
transfused with FFP for a pretransfusion prothrombin time
(PT) between 13.1 and 17 seconds (international
normalized ratio [INR], 1.1-1.85) and with a follow-up PT-
INR within 8 hours of transfusion were included. Of 1091
units of FFP transfused, follow-up coagulation values
within 8 hours were available for 121 patients (324 units).
RESULTS: Transfusion of FFP resulted in normalization
of PT-INR values in 0.8 percent of patients (95%
confidence interval [CI], 0.0020-0.045) and decreased the
PT-INR value halfway to normalization in 15.0 percent of
patients (95% CI, 0.097-0.225). Median decrease in PT
was 0.20 seconds (median decrease in INR, 0.07).
Pretransfusion PT-INR, partial thromboplastin time,
platelet count, and creatinine values had no correlation
with red blood cell loss.
CONCLUSION: It is concluded that transfusion of FFP for
mild abnormalities of coagulation values results in partial
normalization of PT in a minority of patients and fails to
correct the PT in 99 percent of patients.
resh-frozen plasma (FFP) is frequently transfused
to patients with mild-to-moderate elevations in
prothrombin time (PT) under the twin assump-
tions that these test results imply a coagulopathy
and that FFP transfusion will correct the coagulopathy.
The assumption that coagulation test variables predict the
risk of bleeding has been challenged.1-3 Numerous studies
evaluating bleeding following central venous line place-
ment,4,5 liver biopsy,6 thoracentesis,7 paracentesis,7 and
lumbar puncture8 have all revealed no correlation
between the risk of bleeding and mild abnormalities in
preprocedure PT, partial thromboplastin time (PTT), or
platelet (PLT) values. Despite this, use of FFP before inva-
sive procedures for mildly prolonged PT values is a wide-
spread practice.9,10 The persistence of this transfusion
practice may relate to the assumption that FFP corrects
the abnormal coagulation results.
In contrast to the substantial evidence indicating the
poor predictive value of preoperative coagulation screen-
ing assays, there have been few studies examining the
effect of FFP transfusion on the PT value after transfusion.
In 1966 Spector and coworkers11 published the first study
of the effect of large volumes of FFP (3-9 units) transfused
to 13 patients with liver disease and elevated PT values
(17-26 sec).11 The PT failed to normalize in any of these
patients and elevation of coagulation factors were short-
EFFECT OF FFP ON PT
Volume 46, August 2006
1.85) who did not receive FFP were not studied. Therefore,
no comparison can be made regarding the extent of blood
loss with and without FFP for patients with mild eleva-
tions in PT.
The data presented here reveal a trivial effect of FFP
transfusion on the PT in patients with mild elevations of
pretransfusion PT. These results call to question the prac-
tice of FFP transfusion given to patients with mild to
moderate prolongation of the PT and suggest that there is
no relationship between mild elevations in the PT and
extent of estimated blood loss. Given the absence of evi-
dence of benefit coupled with the known risks of transfu-
sion of FFP, FFP transfusion to nonbleeding patients in
response to a mild to moderately prolonged PT value
cannot be supported. Of note, the incidence of transfu-
sion reactions observed in this study was consistent with
the known incidence of transfusion complications
The role of FFP transfusion to bleeding patients with
a PT of 13.1 to 17 seconds (INR, 1.1-1.85) is not entirely
clear but results from this study question both goals and
assumptions surrounding the PT as a guide to therapy.
The true value of FFP transfusion administered to patients
with surgical bleeding or transfused before procedures
will be best answered in future prospective controlled tri-
als where patients with abnormal coagulation values are
randomized to receive FFP versus placebo.
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