Fresh Frozen Plasma Dosing for INR 2.3
For an INR of 2.3, fresh frozen plasma (FFP) transfusion is not recommended as it will not effectively correct this mildly elevated INR and exposes the patient to unnecessary risks. 1, 2
Effectiveness of FFP for Mildly Elevated INR
- FFP transfusion for mild abnormalities of coagulation (INR <2.0) fails to normalize PT/INR in 99% of patients and only achieves partial normalization in a minority of cases 1
- Studies show that the change in INR per unit of FFP can be predicted by the pre-transfusion INR, with minimal effect seen in patients with INR less than 1.7 2
- FFP is not effective in correcting mild to moderate coagulation defects, and large volumes would be required to cause significant INR improvement 3
Recommended Approach for INR 2.3
For Non-Bleeding Patients:
- Withhold FFP transfusion as it provides minimal benefit for INR correction at this level 1, 2
- Consider treating the underlying cause of the coagulopathy rather than transfusing FFP 2
- Monitor INR serially as minimally prolonged INRs often decrease with treatment of the underlying disease alone 2
For Bleeding Patients or Those Requiring Urgent Procedures:
- For life-threatening bleeding or urgent surgical procedures, prothrombin complex concentrate (PCC) is the first-line treatment rather than FFP 4
- The recommended protocol includes 4-factor PCC and 5 mg intravenous vitamin K 4
- FFP should only be given if PCC is not available, at a dose of 10-15 mL/kg IV 4, 5
Risks vs. Benefits
- FFP transfusion carries significant risks including transfusion-related acute lung injury (TRALI), allergic reactions, and transmission of infectious agents 5
- The minimal benefit of FFP for an INR of 2.3 does not justify these risks in non-bleeding patients 1, 2
- Recent evidence suggests that the INR has poor predictive value for bleeding risk in patients not on vitamin K antagonist therapy 4
Special Considerations
- For patients on warfarin with an INR of 2.3 who are not bleeding, no reversal is needed as this is within or near the therapeutic range for many indications 4
- For patients with mechanical heart valves, an INR of 2.3 may actually be within the target range (2.0-3.0 for aortic position, 2.5-3.5 for mitral position) 4
- In patients with liver disease, FFP transfusion has even less effect on INR correction and should be avoided unless there is active bleeding 4, 3
Monitoring After Intervention
- If reversal agents are administered for urgent situations, repeat INR testing should be performed 15-60 minutes after administration 4
- Serial INR monitoring every 6-8 hours for the next 24-48 hours is recommended if reversal was performed 4
Remember that the INR was developed specifically to monitor vitamin K antagonist therapy and has poor correlation with bleeding risk in other clinical contexts 4.