ABSTRACT
Background: There is universal concern about the inappropriate use of fresh frozen plasma (FFP). Earlier investigations have indicated that FFP may be associated with high rates of inappropriate transfusion, with some studies indicating rates of up to 50% non-compliance with established guidelines. The current British Committee for Standards in Haematology (BCSH) guidelines on the use of FFP aim to reinforce the message regarding avoidance of its inappropriate use. Aims: Audit the use of appropiate FFP in the context of the COVID pandemia. Methods: Retrospective analysis of requests for plasma transfusion in adults, in our institution, between January/2020 and January/2022, This audit was undertaken to determine current use of FFP and to see if any improvements in the use of this component in relation to recommended guidance. May be we use more FFP due to covid situation. The data was obtained by consulting the Integrated System of Blood Banks. Results: During the study period, 98 units of FFP were used for 'acute' episodes including management of acute COVID complications. Only 67% of these transfusion episodes were deemed appropriate, based on the BSH criteria. This also means that 13 units of FFP may have been wasted. FFP is used by both medical and surgical specialties with general surgery, general medicine and neurosurgery being the main users. During the study period, 98 units of FFP were used for 'acute' episodes including management of acute COVID complications. Only 67% of these transfusion episodes were deemed appropriate, based on the BSH criteria. This also means that 13 units of FFP may have been wasted. FFP is used by both medical and surgical specialties with general surgery, general medicine and neurosurgery being the main users. 159 requests for plasma were registered in the analyzed period. In most cases (98), the reason was hemorrhage due to multiple factor deficiencies, including liver disease, trauma, lung disease or a massive transfusion. Prophylactic/therapeutic replacement of congenital factor XI deficiency, associated with bleeding episodes, was indicated in 2 situations. In 1 case, the indication was treatment of HUS and 2 cases of HELLP syndrome. In 7 cases, there was an overlapping of indications. In 7 cases, plasma was administered in unforeseen situations, such as for the correction of laboratory abnormalities without clinical manifestations (4 cases) or for prophylaxis of invasive techniques without abnormal coagulation tests (2 cases). Summary/Conclusion: The proportion of inappropriate requests is similar between surgical and non-surgical specialties and also when broken down into individual departments, the number of inappropriate requests consistently outnumbers appropriate requests across all departments. FFP continues to be frequently used in the absence of bleeding and / or evidence of abnormal coagulation, thus highlights the need for concerted efforts in the education of clinicians who prescribe FFP. In the analysis of the indications for plasma prescription, it is concluded that in 17 % cases the indication was not complete adequately or justifable. 7% of cases given FFP had no record of post-transfusion coagulation data. Following this work, dissemination coupled with education was undertaken. The use of FFP for Warfarin reversal has correctly indicated (> 95%). it may suggest that an education programmes directed at specific aspects of practice do influence clinical behaviour over needs to be addressed.
ABSTRACT
Basingstoke and North Hampshire hospital is part of the Southern Haemophilia Network (SHN) and is the Comprehensive Care Centre for the network. It spans a wide area and also receives regional referrals for further investigations of suspected platelet disorders. Platelet aggregation is a second-line test to investigate patients with possible bleeding disorders. It is usually performed after clotting factors are established to be normal and there is still concern about an underlying bleeding disorder. The aim of this study was to assess whether platelet aggregation studies led to a formal diagnosis of a platelet disorder. Further outcomes were to assess how many bleeding assessment tool (BAT) scores were documented and whether these corresponded with diagnostic rates. Patient records were retrospectively analysed over 13 months (from 20 June to 21 July). Seventy-two patients were identified who underwent platelet aggregation studies. These included regional and local referrals. Patients identified had their electronic records analysed for the appropriate information. Of note, platelet aggregation studies were stopped at the beginning of the COVID pandemic and only restarted in summer 2020. Therefore, these numbers may not be fully representative of a normal year due to a waiting list which developed during the suspension of this test. The 72 patients were made up of 78% females ( n = 56) and 22% males ( n = 16). Out of the 72 patients reviewed, 63% ( n = 45) were regional referrals and 37% were local referrals ( n = 27). The average age of this group was 31.89 years. Median age was 31 years (range 74). The youngest patient was 2 years old and the oldest was 76. BSH guidelines recommend using the BAT as a standardised tool for assessing bleeding history. However, it is not sensitive in determining which patients require further testing including platelet aggregometry. Only one patient had a documented BAT score out of the 72 referrals (1.39%). Platelet aggregometry did not go on and lead to a diagnosis in this patient. All the samples for platelet aggregometry were taken on site in keeping with national guidance. Three of the four cases of thrombocytopenia, (75%) had a blood film reviewed locally. Platelet aggregometry led to a diagnosis in 17% of patients ( n = 12) with a higher number of diagnoses in males than females. Forty-four per cent ( n = 7) of males seen were diagnosed with a platelet disorder compared to 9% ( n = 5) of females. Other diagnoses included connective tissue disease at 8% ( n = 6), drug induced/acquired defect 5% ( n = 4), thrombocytopenia 5% ( n = 4) and other bleeding disorders (such as VWF or Factor XI deficiency) at 4% ( n = 3). Out of the 12 diagnoses of bleeding disorders, 100% ( n = 12) were registered with the national database. In total 67% ( n = 48) of patients were discharged followed their platelet aggregations studies. In this study, platelet aggregometry had a low rate of diagnostic yield. There was a higher rate of diagnosis in the male population which likely reflects the that women are more heavily investigated due to menorrhagia . Despite the low diagnostic rates, platelet aggregation studies lead to a high number of discharges and reassurance to a number of patients that there is no underlying bleeding disorder. Therefore, they continue to have important role in the diagnosis and exclusion of underlying bleeding disorders.