What is the appropriate transfusion for a patient with Disseminated Intravascular Coagulation (DIC) or a supratherapeutic International Normalized Ratio (INR) due to warfarin (coumarin) use?

From the Guidelines

For a patient with DIC or a supratherapeutic INR greater than 3.5 from warfarin use, plasma transfusion, specifically with fresh frozen plasma (FFP), would be the most appropriate initial treatment, alongside vitamin K administration, to rapidly reverse coagulopathy and correct the INR. However, considering the most recent evidence from 1, prothrombin complex concentrate (PCC) is emerging as a preferred option over FFP for warfarin reversal due to its ability to provide more rapid and complete factor replacement with potentially fewer risks of transfusion-associated complications. The dosage of PCC can be calculated based on body weight and INR level, with a recommended stepwise dosage, and it should be administered simultaneously with vitamin K. For patients with severely depleted fibrinogen levels, particularly in DIC, cryoprecipitate may be added to the treatment regimen. Platelet transfusion would only be indicated if there is concurrent thrombocytopenia with active bleeding, as suggested by guidance from 1. Whole blood transfusion is not typically recommended for these conditions due to the availability of more targeted component therapies. It's also important to consider the potential risks associated with PCC, including an increased risk of venous and arterial thrombosis, and the need for thromboprophylaxis after its use. Vitamin K administration, in a dose of 5-10 mg, is recommended alongside PCC or plasma to provide sustained correction of the coagulopathy, as noted in 1. In summary, the approach to managing DIC or supratherapeutic INR due to warfarin involves:

• Plasma transfusion or PCC for rapid reversal of coagulopathy
• Vitamin K administration for sustained correction
• Cryoprecipitate for severely depleted fibrinogen levels
• Platelet transfusion for concurrent thrombocytopenia with active bleeding
• Consideration of thromboprophylaxis after PCC use.

From the Research

Appropriate Transfusion Options

For a patient with Disseminated Intravascular Coagulation (DIC) or a supratherapeutic International Normalized Ratio (INR) greater than 3.5 from warfarin use, the following transfusion options may be considered:

• Plasma transfusion: This may be useful in bleeding patients with DIC and prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT) 2.
• Platelet transfusion: This should be considered in patients with DIC and bleeding or at high risk of bleeding, and a platelet count of <50 x 10(9)/l 2.
• Cryoprecipitate transfusion: This may be used to treat severe hypofibrinogenaemia (<1 g/l) that persists despite fresh frozen plasma (FFP) replacement 2.

Inappropriate Transfusion Options

• Whole blood transfusion: There is no evidence to support the use of whole blood transfusion in patients with DIC or supratherapeutic INR 2, 3.
• Prophylactic plasma transfusion: This should be discouraged in patients with an elevated INR in the intensive care unit, as it is either avoidable by the use of vitamin K or inappropriate in the case of liver disease or an anti-Xa DOAC 4.

Important Considerations

• The cornerstone of the treatment of DIC is treatment of the underlying condition 2, 3.
• Transfusion of platelets or plasma should not primarily be based on laboratory results and should in general be reserved for patients who present with bleeding 2.
• The use of anticoagulants, such as heparin, should be considered in patients with DIC and thrombosis 2, 3.