In a dengue patient with a spontaneous subdural hematoma, is fresh frozen plasma indicated and what coagulation abnormalities would warrant its use?

FFP in Spontaneous Subdural Hematoma in Dengue Patients

Fresh frozen plasma is NOT routinely indicated for spontaneous subdural hematoma in dengue patients unless there is documented coagulopathy with INR >1.5 or specific coagulation factor deficiencies, and even then, platelet transfusion and surgical evacuation take priority over FFP. 1

Primary Management Approach

Platelet transfusion is the critical intervention for dengue-related intracranial hemorrhage, not FFP. 2 The pathophysiology of bleeding in dengue is primarily thrombocytopenia-driven, not coagulation factor deficiency. 2, 3

When FFP May Be Considered

FFP should only be administered if ALL of the following criteria are met:

• Active bleeding is present (expanding hematoma or clinical deterioration) 1, 4
• Documented coagulopathy with INR ≥1.5, PT >1.5 times normal, or aPTT >2 times normal 1, 5
• Patient is being prepared for urgent neurosurgical evacuation 1, 4

Specific Dosing if FFP is Indicated

If the above criteria are met, administer 10-15 ml/kg (approximately 700-1050 ml for a 70 kg patient, or 3-4 units) as rapidly as clinically tolerated. 5, 6 Doses below 10 ml/kg are unlikely to achieve the 30% factor concentration threshold needed for hemostasis. 5

Critical Coagulation Parameters to Check

Before considering FFP, obtain:

• Platelet count (primary concern in dengue; transfuse if <50,000/mm³ with active bleeding or <10,000/mm³ prophylactically) 2
• INR/PT and aPTT (FFP only justified if INR >1.5) 1
• Fibrinogen level (if <1.5 g/L, use cryoprecipitate instead of FFP) 1, 5
• Liver enzymes (AST/ALT) (elevated levels are risk factors for bleeding in dengue) 2

Common Pitfalls to Avoid

Do not use FFP to correct laboratory values alone without active bleeding. 1, 5 This is a critical error that exposes patients to unnecessary risks including TRALI, circulatory overload, and infectious transmission. 5

Do not use FFP as a treatment for thrombocytopenia in dengue. 3 While one study showed a transient platelet increase at 12 hours post-FFP infusion, this effect was not sustained at 24-48 hours and is not clinically meaningful. 3 The mechanism of thrombocytopenia in dengue is consumptive and immune-mediated, not factor deficiency. 2

Do not delay neurosurgical consultation while attempting medical reversal. 2 Dengue-related subdural hematomas often require urgent surgical evacuation regardless of coagulation status. 2, 7

Evidence-Based Management Algorithm

1. Confirm diagnosis: Dengue serology (IgG/IgM, NS1 antigen) plus neuroimaging showing subdural hematoma 2, 7

2. Assess bleeding severity: Serial CT scans to evaluate hematoma progression 2, 8

3. Check coagulation profile: Platelet count, INR, PT, aPTT, fibrinogen 2

4. Primary interventions:

   • Platelet transfusion if count <50,000/mm³ with active bleeding 2
   • Urgent neurosurgical evaluation for evacuation 2, 7
   • FFP only if INR >1.5 at dose of 10-15 ml/kg 1, 5

5. Monitor: Repeat imaging and coagulation studies every 3-6 hours initially 8

Special Considerations for Dengue

Unlike anticoagulant-associated intracranial hemorrhage where FFP has clear indications 1, dengue-related hemorrhage is fundamentally different. The coagulation profile in dengue patients is often normal or only mildly deranged despite severe thrombocytopenia. 2, 7 One case report documented a dengue patient with spontaneous spinal subdural hematoma whose "hemogram, biochemistry, and coagulation profile was within normal limits." 7

Risk factors for bleeding in dengue include: thrombocytopenia, elevated AST/ALT, and positive IgG antibodies (indicating secondary infection). 2 These do not respond to FFP therapy.

Administration Details if FFP is Used

• ABO compatibility required: Use group AB if blood type unknown 5, 9
• Infusion rate: As rapidly as tolerated in acute bleeding 5
• Monitoring: Recheck INR 15-60 minutes post-infusion 1
• Storage: Once thawed, use within 30 minutes if removed from refrigeration 5, 9