Appropriate Use of Plasma

Plasma use is often inappropriate. Studies show that many units are given for minor laboratory abnormalities without bleeding, in doses too small to correct the abnormality, and for conditions where a specific agent works better. Each unit carries risks of allergy, lung injury and overload, and uses stock that bleeding patients may need.

Principle. Plasma treats bleeding caused by multiple coagulation factor deficiency. It should not be given to correct a number, to expand volume, or when a specific agent exists.

Why the international normalised ratio misleads. A minor rise (about 1.1 to 1.7) corresponds to factor levels that are usually sufficient for haemostasis, and plasma barely changes it. Prolonged prothrombin time does not reliably predict bleeding at procedures.

Special groups. Liver disease, neonates, pregnancy, anticoagulated patients, and patients with heart or kidney failure.

Appropriate uses.

• Bleeding with a prolonged prothrombin time or activated partial thromboplastin time over 1.5 times normal and no better option (dilutional coagulopathy, massive haemorrhage, disseminated intravascular coagulation).

• Massive haemorrhage in balanced resuscitation.

• Thrombotic thrombocytopenic purpura.

• Warfarin related major bleeding when prothrombin complex concentrate is not available, always with vitamin K.

• Single factor deficiency without concentrate.

• Congenital deficiencies of factor V, factor XI and others as the haematologist directs.

Inappropriate uses.

• Volume expansion, hypoalbuminaemia, nutritional support and burns resuscitation.

• A minor isolated prolongation of prothrombin time or activated partial thromboplastin time without bleeding or a planned high risk procedure.

• Prophylaxis before low risk procedures (central line insertion, lumbar puncture, paracentesis, thoracentesis, endoscopy with banding) in liver disease or in general.

• Reversal of direct oral anticoagulants, where specific reversal agents or prothrombin complex concentrate are used.

• Routine prophylaxis in preterm neonates.

• Sepsis with abnormal coagulation and no bleeding.

• Prophylaxis in cardiac surgery without bleeding.

Vitamin K first. Vitamin K deficiency (poor intake, cholestasis, antibiotics, warfarin) is corrected with vitamin K intravenously, usually 5 to 10 mg slowly in adults with bleeding or severe prolongation, and 1 to 10 mg depending on weight in children and neonates. The effect begins in 6 to 12 hours, so plasma bridges only when bleeding is life-threatening.

Red flags. Bleeding with a normal coagulation screen (consider platelet function, surgical bleeding, low fibrinogen, factor XIII or von Willebrand factor), and bleeding on a direct oral anticoagulant.

Decision steps.

1. Is the patient bleeding or about to undergo a high risk procedure?

2. Is there a laboratory or viscoelastic abnormality that fits multiple factor deficiency?

3. Is there a specific alternative (vitamin K, prothrombin complex concentrate, fibrinogen, tranexamic acid, specific factor)?

4. If plasma is indicated, give 10 to 15 mL/kg, check response and repeat only for a defined reason.

Warfarin and vitamin K antagonist reversal. Prothrombin complex concentrate with vitamin K 5 to 10 mg intravenously is first choice in major bleeding. Plasma 10 to 15 mL/kg is used only when concentrate is unavailable, with attention to volume.

Liver disease. Bleeding in cirrhosis is often from portal hypertension and does not need plasma. Treat the source, use viscoelastic tests, restrict volume and avoid over-transfusion, which raises portal pressure.

Procedures. For an invasive procedure with true multiple factor deficiency, give plasma shortly before the procedure and not hours earlier. For most low risk procedures, no plasma is needed.

Special groups.

• Neonates: 10 to 20 mL/kg only for bleeding or procedures with demonstrated deficiency, and vitamin K 1 mg intramuscularly at birth as prophylaxis.

• Pregnancy: fibrinogen replacement is usually the priority in obstetric haemorrhage.

• Heart and kidney failure: small volume, slow rate.

Monitoring. Clinical bleeding, prothrombin time, activated partial thromboplastin time and fibrinogen 15 to 60 minutes after a dose, with oxygen saturation and fluid balance during infusion.

Complications. Transfusion associated circulatory overload, transfusion related acute lung injury, allergic reactions and, rarely, infection.

Referral and escalation. Haematology for recurrent coagulopathy, liver disease with major bleeding, and suspected factor deficiencies. Transfusion service for audit of use.

Disposition. Record the indication and the target. Plan vitamin K, treatment of the cause and review of ongoing anticoagulants.