Does a patient with cirrhosis and an elevated international normalized ratio undergoing splenectomy require plasma transfusion?

Plasma Transfusion for Cirrhotic Patient with INR 3.2 Undergoing Splenectomy

No, plasma transfusion is NOT recommended for this patient with cirrhosis and INR 3.2 undergoing splenectomy, as prophylactic FFP correction of elevated INR does not reduce procedure-related bleeding and carries significant risks including increased portal pressure, volume overload, and transfusion-related complications. 1

Primary Guideline Recommendations

The European Association for the Study of the Liver (EASL) provides a strong recommendation (Level of Evidence 1) against correcting prolonged INR with FFP to decrease procedure-related bleeding in cirrhotic patients undergoing invasive procedures. 1 This recommendation is based on high-quality evidence demonstrating that:

• FFP transfusion frequently fails to normalize prothrombin time in cirrhotic patients 1
• Ex vivo studies show FFP only minimally improves thrombin generation capacity in liver disease, and actually worsened hemostatic capacity in one-third of patients 2
• No studies demonstrate efficacy of prophylactic FFP in preventing bleeding during procedures in cirrhotic patients 2

Why INR is Misleading in Cirrhosis

INR is a poor predictor of bleeding risk in liver disease because it only measures select procoagulant factors (I, II, V, VII, X) and ignores anticoagulant proteins (protein C, protein S). 1, 2 Key limitations include:

• INR was specifically designed for monitoring warfarin therapy, not assessing bleeding risk in cirrhosis 3
• Cirrhotic patients have a "rebalanced" hemostatic system with concurrent deficits in both pro- and anticoagulant factors 1, 3
• A systematic review of 13,276 cirrhotic patients found no significant association between pre-procedural INR and periprocedural bleeding events (pooled OR 1.52; 95% CI 0.99-2.33; P=0.06) 4
• INR does not correlate with thromboelastography parameters in cirrhotic patients (r=0.01-0.23 across Child-Pugh classes) 5

Significant Risks of FFP in Cirrhotic Patients

FFP transfusion carries potentially life-threatening complications that are particularly problematic in cirrhotic patients: 2

• Increased portal pressure from volume expansion, paradoxically increasing bleeding risk 2, 3
• Transfusion-related acute lung injury (TRALI) - the leading cause of transfusion-related mortality 2, 3
• Transfusion-associated circulatory overload (TACO) with 5-15% mortality rate 2, 3
• Allergic/anaphylactic reactions (1:591 to 1:2,184 plasma units) 3
• Infection transmission and hemolytic reactions 2

Additionally, FFP contains both procoagulant and anticoagulant proteins in balanced proportions, so transfusion frequently fails to normalize INR and provides minimal hemostatic benefit. 2

Specific Considerations for Splenectomy

Splenectomy is a high-risk surgical procedure, but the evidence against prophylactic FFP remains strong even for major surgery in cirrhotic patients. 1 The key factors that predict bleeding are:

• Technical surgical factors and local hemostasis capability 1
• Severity of portal hypertension 1
• Platelet count (more relevant than INR) 1

For platelet management in this high-risk procedure: 1

• Platelet transfusion or TPO-R agonists are NOT recommended when platelet count is >50 × 10⁹/L 1
• When platelet count is 20-50 × 10⁹/L, transfusion should not be routine but may be considered case-by-case 1
• Only when platelet count is <20 × 10⁹/L should platelet support be strongly considered 1

Alternative Approaches

Instead of prophylactic FFP, the following strategies are recommended: 1, 2

• Optimize surgical technique and ensure experienced surgical team 1
• Consider viscoelastic testing (TEG/ROTEM) to guide management rather than INR, which has been shown to reduce blood product use (17% vs 100%) without increasing bleeding complications 3, 5
• Correct specific deficiencies only if documented: fibrinogen <1.5 g/L warrants cryoprecipitate or fibrinogen concentrate, not FFP 2, 3
• Optimize hemoglobin levels by treating iron, folic acid, vitamin B6, and B12 deficiencies preoperatively 1

Critical Clinical Pitfalls to Avoid

Do not reflexively transfuse FFP based solely on elevated INR in cirrhotic patients. 2, 3 Common errors include:

• Using INR alone to guide transfusion decisions - it does not reflect true hemostatic balance 2, 3
• Attempting to "normalize" INR to arbitrary thresholds (e.g., <1.5) before surgery 1
• Using FFP for volume expansion - crystalloids or colloids are appropriate 2
• Ignoring that elevated INR in liver disease represents rebalanced hemostasis, not simply deficiency 1, 3

When FFP IS Indicated in Cirrhotic Patients

FFP has a role only in specific circumstances: 2

• Active major bleeding when administered in balanced ratios with RBCs (1:1 or 1:1.5 ratio) until coagulation results available 2
• Disseminated intravascular coagulation (DIC) with active bleeding or high bleeding risk 2
• Warfarin reversal in active bleeding when prothrombin complex concentrates unavailable 2

Prophylactic correction before elective surgery, even high-risk surgery like splenectomy, does not fall into these categories. 1, 2

Practical Management Algorithm

For this patient with cirrhosis, INR 3.2, undergoing splenectomy: 1

1. Do NOT administer prophylactic FFP 1
2. Check platelet count - if >50 × 10⁹/L, no platelet transfusion needed 1
3. Consider checking fibrinogen - if <1.5 g/L, give cryoprecipitate (not FFP) 2, 3
4. Ensure experienced surgical team with meticulous hemostatic technique 1
5. Have blood products available for intraoperative use if active bleeding occurs 2
6. Monitor closely postoperatively for bleeding complications 1

The decision to proceed with surgery should be based on the patient's overall clinical status, Child-Pugh class, presence of portal hypertension, and surgical indication - not on the INR value alone. 1, 6