What is the most appropriate product to administer to a bleeding patient with thrombocytopenia (low platelet count), elevated international normalized ratio (INR), and normal fibrinogen level?

From the Guidelines

For a bleeding patient with thrombocytopenia, elevated INR, and normal fibrinogen level, the most appropriate products to administer are platelet transfusion and fresh frozen plasma (FFP). The patient's current platelet count is 105,000/µL, which is below the recommended threshold of 150,000/µL for a bleeding patient, but according to the most recent guidelines 1, platelet transfusion is recommended to maintain a platelet count above 50 × 10^9/L in patients with active bleeding. The elevated INR of 2.2 indicates a coagulation factor deficiency, which can be addressed with FFP administration at 10-15 mL/kg, as suggested by the guidelines 1. The normal fibrinogen level of 250 mg/dL suggests that cryoprecipitate or fibrinogen concentrate is not needed, as the guidelines recommend these products only for patients with severe hypofibrinogenemia (< 1.5 g/L) 1. Key points to consider when administering these products include:

• Monitoring the patient's vital signs and laboratory results closely to adjust the dose and type of blood products as needed
• Investigating and treating the underlying cause of the coagulopathy
• Considering the use of vitamin K (10 mg IV) if the elevated INR is due to vitamin K deficiency or warfarin effect
• Being mindful of the potential for volume overload and considering alternative products, such as prothrombin complex concentrate, if necessary 1.

From the Research

Patient Assessment

The patient is currently receiving the tenth unit of packed red blood cells due to bleeding, with vital signs indicating a blood pressure of 115/85 mm Hg, heart rate of 110 bpm, respiratory rate of 24/min, and a temperature of 35.8°C. Laboratory results show a hemoglobin level of 10.1 g/dL, platelets at 105,000/µL, international normalized ratio (INR) at 2.2, fibrinogen at 250 mg/dL, and calcium at 8.3 mg/dL.

Coagulopathy and Transfusion Options

Given the patient's thrombocytopenia (low platelet count), elevated INR, and normal fibrinogen level, the most appropriate product to administer would be one that addresses these specific coagulopathy issues.

• The patient's elevated INR suggests a coagulopathy that could be addressed by fresh frozen plasma (FFP) or other plasma products, as indicated by 2 and 3.
• However, studies such as 4 suggest that FFP may not significantly correct mild coagulopathy, and its use should be carefully considered based on the patient's specific needs and risks.
• Platelets are also a consideration given the patient's thrombocytopenia, as discussed in 5 and 6, which highlight the risks and benefits of platelet transfusions in critically ill patients.
• Cryoprecipitate could be considered for its ability to increase fibrinogen and von Willebrand's factor levels, but given the patient's normal fibrinogen level, this may not be the most immediate concern, as noted in 3.

Decision

Based on the evidence, the most appropriate product to administer to this bleeding patient with thrombocytopenia, elevated INR, and normal fibrinogen level would be platelets, as they directly address the low platelet count, which is a significant risk factor for bleeding. Fresh frozen plasma could also be considered to address the elevated INR, but the decision should be made based on a careful assessment of the patient's overall condition and the potential risks and benefits of each transfusion product, as discussed in 6.