What is the best course of action for a hemodynamically stable patient with a significantly elevated Prothrombin Time (PT)/International Normalized Ratio (INR) of 20/2, who was initially advised to receive Fresh Frozen Plasma (FFP) transfusion but instead received 1 unit of Packed Red Blood Cells (PRBC) and has a normal hemoglobin level?

Immediate Management of Critical Coagulopathy with Inappropriate Transfusion

This patient requires immediate FFP transfusion at 10-15 ml/kg (approximately 4 units for a 70 kg adult) to reverse the life-threatening coagulopathy, as the PRBC transfusion was completely inappropriate and does not address the critical INR of 20. 1, 2

Understanding the Clinical Error

The transfusion of 1 unit PRBC was a significant medical error that must be immediately corrected:

• FFP is indicated for active bleeding or planned invasive procedures when INR >2.0 1, 3
• This patient has an INR of 20, which is 10 times the threshold for FFP transfusion 1, 2
• PRBC transfusion is indicated for anemia or blood loss, not for coagulopathy correction 1
• With hemoglobin of 13 g/dL, there was no indication whatsoever for PRBC 1

Immediate Action Required

Administer FFP immediately using the following protocol:

• Dose: 10-15 ml/kg body weight (approximately 700-1050 ml or 3-4 units for a 70 kg patient) 1, 2
• Ensure ABO compatibility - use same blood group as patient, or AB if unknown 1, 2
• Infuse as rapidly as clinically tolerated in this critical coagulopathy 2
• Recheck INR after transfusion to determine need for additional doses 2

Critical Considerations for This Case

Why FFP is Essential Here

• INR of 20 represents severe coagulation factor deficiency requiring immediate correction 1, 4
• Even though the patient is currently hemodynamically stable, spontaneous life-threatening bleeding can occur at any moment with such severe coagulopathy 1
• FFP contains all coagulation factors needed to reverse this critical state 1, 2

Expected Response to FFP

• Complete normalization of INR is unlikely even with adequate FFP dosing 1, 5
• Studies show FFP normalizes PT-INR in only a minority of patients, but partial correction is still clinically beneficial 5, 6
• Doses below 10 ml/kg are unlikely to achieve the 30% factor concentration threshold needed for hemostasis 2
• You may need additional doses based on repeat INR after initial transfusion 2

Additional Management Steps

Concurrent Interventions

• Administer vitamin K 10 mg IV if warfarin-induced coagulopathy is suspected (though effect takes hours) 1
• Consider prothrombin complex concentrate (PCC) if available, as it may be more effective than FFP alone for rapid reversal 1
• Hold all anticoagulant medications immediately 1

Monitoring Requirements

• Recheck INR within 1-2 hours after FFP transfusion 2
• Monitor for signs of bleeding: neurological changes (intracranial hemorrhage), abdominal pain (intraperitoneal bleeding), muscle pain (hematomas) 1
• Watch for transfusion complications: TRALI, circulatory overload, allergic reactions 1

Common Pitfalls to Avoid

• Do not wait for bleeding to occur before treating this critical INR 1, 3
• Do not use inadequate FFP doses (<10 ml/kg) - this is the most common error 2, 3
• Do not assume the PRBC will help - it addresses the wrong problem entirely 1
• Do not delay FFP while waiting for thawing - alert blood bank immediately for rapid preparation 2

Special Considerations

If Patient Has Cirrhosis

• FFP may still be indicated despite balanced hemostasis in cirrhosis, given the extreme INR elevation 1
• However, FFP can increase portal pressure and potentially worsen bleeding risk in portal hypertension 1
• Consider fibrinogen concentrate or cryoprecipitate as alternatives if fibrinogen is low 1

Documentation and Follow-up

• Document the transfusion error and corrective actions taken 2
• Investigate the cause of the critical INR (warfarin overdose, liver failure, vitamin K deficiency) 1
• Establish a plan to prevent recurrence of coagulopathy 1