Recommendations

Australian and New Zealand Society of Blood Transfusion

The Australian and New Zealand Society of Blood Transfusion comprises over 400 members from diverse scientific, medical and nursing backgrounds working within the area of blood transfusion and related fields. NB. These recommendations do not apply to emergency situations, severe acute bleeding and acute phase of major trauma resuscitation.

5.

Do not transfuse standard doses of fresh frozen plasma to correct a mildly elevated (<1.8) international normalized ratio prior to a procedure.

There is no evidence to support the prophylactic administration of fresh frozen plasma (FFP) to correct a mildly elevated international normalized ratio (INR) prior to procedure. The evidence supports the use of Vitamin K and suggests the use of FFP correlated with an increased risk of intra-operative bleeding and/or increased risk of transfusion reactions.

Supporting evidence

Abdel-Wahab et al, ‘Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities’, Transfusion. 2006 Aug;46(8):1279-1285. https://pubmed.ncbi.nlm.nih.gov/16934060/

Carson, J.L., Ness, P.M., Pagano, M.B., Philipp, C.S., Bracey, A.W., Brooks, M.M., Nosher J.L., Hogshire, L., Noveck, H. Triulzi, D.J. ‘Plasma trial: Pilot randomized clinical trial to determine safety and efficacy of plasma transfusions’. Transfusion. 2021;61:2025–2034. https://onlinelibrary.wiley.com/doi/full/10.1111/trf.16508.

Darwood, M.Y., Hashmi, Z.A. and Dasika, U.K. ‘Is ultra-slow intravenous Vitamin K administration superior to Fresh Frozen Plasma for acute reversal of elevated INR?. Chest. 2005; 128(4_MeetingAbstracts):300S.DOI: 10.1378/chest.128.4_MeetingAbstracts.300S.

Jia, Q., Brown, M.J., Clifford, L., Wilson, G.A., Truty, M.J., Stubbs, J.R., Schroeder, D.R., Hanson, A.C., Gajic, O. and Kor, D.J. ‘Prophylactic plasma transfusion for surgical patients with abnormal preoperative coagulation tests: a single-institution propensity-adjusted cohort study. Lancet Haematology. 2016; 3(3):e139-48. DOI: 10.1016/S2352-3026(15)00283-5.

Patient Blood Management Guidelines: Module 2 Perioperative (Recommendation 21; Practice Points 17 and 18; Section 3.7 and 3.8.1), National Blood Authority Australia, 2012. https://www.blood.gov.au/pbm-module-2

Shaikh, H., Shaikh, S., Lee, D. and Mewawalla, P. ‘Fresh frozen plasma: under-dosed and over-transfused’. Vox Saguinis. 2018; 113(7): 296. DOI: https://doi-org.smhslibresources.health.wa.gov.au/10.1111/vox.12658.

Soundar, E.P., Besandre, R., Hartman, S.K., Teruya, J. and Hui, S.R. ‘Plasma is ineffective in correcting mildly-elevated PT-INR in critically ill children: a retrospective observational study’. Journal of Intensive care. 2014; 2(1):64. DOI: 10.1186/s40560-014-0064-1.

Raval, J.S., Waters, J.H., Triulzi, D.J. and Yazer, M.H. ‘Complications following an unnecessary peri-operative plasma transfusion and literature review’. Asian Journal of Transfusion Science. 2014; 8(2): 139-141. DOI: 10.4103/0973-6247.137458.

Warner, M.A., Woodrum, D.A., Hanson, A.C., Schroeder, D.R., Wilson G.A. et al. ‘Prophylactic plasma transfusion before interventional radiology procedures is not associated with reduced bleeding complications’. Mayo Clinic Proceedings. 2016; 91(8): 1045-55. DOI: https://pubmed.ncbi.nlm.nih.gov/27492911/.

Yang et al, ‘Is fresh frozen plasma clinically effective? An update of a systematic review of randomized controlled trials’. Transfusion. 2012 Aug;52: 1673 – 86 https://pubmed.ncbi.nlm.nih.gov/22257164/.

How this list was made

As part of the Evolve program, the RACP Policy and Advocacy team has worked with the Australian and New Zealand Society of Blood Transfusion (ANZSBT) to develop and finalise this Evolve Top-5 list of low-value care that pertains to the specialty.

Per usual processes, the list of low value practices was first identified by the ANZSBT Council and condensed to the top-5 recommendations, through a membership survey, extensive research and rounds of redrafting under the guidance of the ANZSBT Council. The list was subjected to an extensive review and consultation process that involved RACP-affiliated specialty societies and other key colleges via the Choosing Wisely program. Feedback from the consultation has been integrated into the top-5 recommendations by the ANZSBT and approved by its Council in December 2021.

Version 1 published January 2022.