From the Guidelines
Fresh frozen plasma (FFP) should be administered to neonates with an INR greater than or equal to 1.4, particularly when there is active bleeding or before an invasive procedure, as recommended by the most recent guideline 1. The typical dose is 10-15 mL/kg, which can be repeated as needed based on clinical response and follow-up INR values. Key considerations for FFP administration in neonates include:
- Active bleeding or planned invasive procedure
- INR greater than or equal to 1.4
- Vitamin K deficiency, which may be corrected with vitamin K (1 mg IV or IM) before considering FFP
- Clinical context, including overall condition, cause of coagulopathy, and bleeding risk FFP contains all coagulation factors and can temporarily correct coagulopathy in neonates with vitamin K deficiency, liver dysfunction, or disseminated intravascular coagulation. However, FFP should not be used prophylactically for mild elevations in INR without bleeding risk, as it carries risks including fluid overload, transfusion reactions, and transmission of infections, as noted in the guideline 1. The decision to transfuse should always be individualized based on the clinical context, including the neonate's overall condition, cause of coagulopathy, and bleeding risk. In contrast to earlier studies, such as the 2012 American College of Chest Physicians guideline 1, the more recent 2016 Neurocritical Care Society and Society of Critical Care Medicine guideline 1 provides stronger evidence for the use of FFP in neonates with elevated INR.
From the Research
Fresh Frozen Plasma Administration in Neonates
- The use of Fresh Frozen Plasma (FFP) in neonatology should be primarily for neonates with active bleeding and associated coagulopathy 2, 3.
- There is limited and poor-quality evidence supporting neonatal FFP transfusion, and considerable FFP usage continues to be outside of this recommendation 2, 3.
Elevated INR in Neonates
- The studies provided do not specify an exact INR number for administering FFP to neonates 2, 4, 5, 3, 6.
- However, it is mentioned that FFP should be used in neonates with active bleeding and associated coagulopathy, which may be indicated by an elevated INR 2, 3.
Comparison with Other Studies
- Studies on adult patients with warfarin-associated intracranial hemorrhage suggest that recombinant factor VIIa may be effective in rapidly correcting coagulopathy and reducing the need for FFP 4, 5, 6.
- However, these findings may not be directly applicable to neonates, and more research is needed to determine the best practices for FFP administration in this population.