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      Correcting Coagulopathy With Fresh Frozen Plasma in the Surgical Intensive Care Unit: How Much Do We Need to Transfuse?

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          Abstract

          Introduction

          Thromboelastography (TEG) is an assay that assesses the coagulation status. Patients with prolonged reaction time (R) require fresh frozen plasma (FFP); however, the volume required to correct the R time is unknown. We sought to quantify the volume required to correct the R time and calculate the response ratio in our surgical intensive care unit (SICU) to allow for targeted resuscitation

          Methods

          Surgical intensive care unit patients between Aug 2017 and July 2019 with a prolonged initial R time and at least two TEG tests performed within 24 hours were included. The response ratio was defined as the change in the R time divided by the number of FFP units. High responders (response ratio >5 minutes/unit) were compared to low responders (response ratio ≤5 minutes/unit).

          Results

          Forty-six patients were included. While the mean response ratio was 5 minutes/unit, there was significant variation among patients. There were 28.0 (60.9%) low responders and 18.0 (39.1%) high responders. Low responders were more likely male (64.0% vs. 33.0%, P = .04), had a higher Acute Physiology and Chronic Health Evaluation (APACHE) IV score (42.0 vs. 27.0, P = .03), and a higher mortality rate (54.0% vs. 22.0%, P = .04).

          Conclusions

          On average, one unit of FFP corrects the R time by 5 minutes; however, there was significant variation between high and low responders. Male patients with higher APACHE IV score are expected to be low responders with a higher mortality rate. These findings can guide FFP transfusion and provide additional prognostication.

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          Most cited references21

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          Acute Physiology and Chronic Health Evaluation (APACHE) IV: hospital mortality assessment for today's critically ill patients.

          Jack E Zimmerman, Andrew A Kramer, Douglas S. McNair … (2006)
          To improve the accuracy of the Acute Physiology and Chronic Health Evaluation (APACHE) method for predicting hospital mortality among critically ill adults and to evaluate changes in the accuracy of earlier APACHE models. : Observational cohort study. A total of 104 intensive care units (ICUs) in 45 U.S. hospitals. A total of 131,618 consecutive ICU admissions during 2002 and 2003, of which 110,558 met inclusion criteria and had complete data. None. We developed APACHE IV using ICU day 1 information and a multivariate logistic regression procedure to estimate the probability of hospital death for randomly selected patients who comprised 60% of the database. Predictor variables were similar to those in APACHE III, but new variables were added and different statistical modeling used. We assessed the accuracy of APACHE IV predictions by comparing observed and predicted hospital mortality for the excluded patients (validation set). We tested discrimination and used multiple tests of calibration in aggregate and for patient subgroups. APACHE IV had good discrimination (area under the receiver operating characteristic curve = 0.88) and calibration (Hosmer-Lemeshow C statistic = 16.9, p = .08). For 90% of 116 ICU admission diagnoses, the ratio of observed to predicted mortality was not significantly different from 1.0. We also used the validation data set to compare the accuracy of APACHE IV predictions to those using APACHE III versions developed 7 and 14 yrs previously. There was little change in discrimination, but aggregate mortality was systematically overestimated as model age increased. When examined across disease, predictive accuracy was maintained for some diagnoses but for others seemed to reflect changes in practice or therapy. APACHE IV predictions of hospital mortality have good discrimination and calibration and should be useful for benchmarking performance in U.S. ICUs. The accuracy of predictive models is dynamic and should be periodically retested. When accuracy deteriorates they should be revised and updated.
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            Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations.

            David S Kauvar, Rolf Lefering, Charles Wade (2006)
            The world-wide impact of traumatic injury and associated hemorrhage on human health and well-being cannot be overstated. Twelve percent of the global disease burden is the result of violence or accidental injury. Hemorrhage is responsible for 30 to 40% of trauma mortality, and of these deaths, 33 to 56% occur during the prehospital period. Among those who reach care, early mortality is caused by continued hemorrhage, coagulopathy, and incomplete resuscitation. The techniques of early care, including blood transfusion, may underlie late mortality and long-term morbidity. While the volume of blood lost cannot be measured, physiologic and chemical measures and the number of units of blood given are readily recorded and analyzed. Improvements in early hemorrhage control and resuscitation and the prevention and aggressive treatment of coagulopathy appear to have the greatest potential to improve outcomes in severely injured trauma patients.
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              The independent association of massive blood loss with mortality in cardiac surgery.

              Jacek Karski, W Scott Beattie, Stephen Yau … (2004)
              Although the association between massive perioperative blood loss (MBL) and adverse outcomes is well recognized, it is unclear whether MBL is an independent risk factor or, instead, simply a marker for other adverse events or severity of illness. The objective of this cohort study was to quantify the independent association of MBL in cardiac surgery with all-cause in-hospital mortality. Data were prospectively collected on consecutive patients who underwent cardiac surgery with cardiopulmonary bypass at a quaternary-care academic center from 1999 to 2003. The number of red blood cell (RBC) units transfused within 1 day of surgery was used as a surrogate measure of perioperative blood loss. Receiver-operating characteristic curve analyses were employed to identify the most appropriate cutoff for defining MBL. The independent association of MBL with mortality was determined with multivariable logistic regression analyses. Bootstrapping and sensitivity analyses were used to confirm the validity of the results. MBL was defined as receiving at least 5 units of RBCs within 1 day of surgery. Of 9215 patients analyzed, 1.8 percent (n = 169) died and 9.7 percent (n = 890) had MBL. After adjusting for multiple potential confounders (including perioperative adverse events), MBL was associated with an 8.1-fold (95% confidence interval, 3.9-17.0) increase in the odds of death. This risk estimate was stable across different modeling conditions as well as in bootstrap sampling. MBL after cardiac surgery has a strong, independent association with in-hospital mortality.
              Article 0 comments Cited 66 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Title: The American Surgeon
                Abbreviated Title: The American Surgeon
                Publisher: SAGE Publications
                ISSN (Print): 0003-1348
                ISSN (Electronic): 1555-9823
                Publication date (Electronic): May 31 2021
                Page: 000313482110234
                Affiliations
                [1 ]Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
                Article
                DOI: 10.1177/00031348211023412
                SO-VID: b1ed72e2-ce0b-46b3-b90c-64e6ddd2c4ac
                Copyright © © 2021
                License:

                http://journals.sagepub.com/page/policies/text-and-data-mining-license

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