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Eliminating international normalized ratio threshold for transfusion in pediatric patients with acute liver failure
Angela Lee1, Julianne Mendoza2, Aleah L Brubaker1
1Division of Abdominal Transplantation, Department of Surgery, Stanford University, Stanford, California.
Insights
Using clinical judgment for transfusions in pediatric acute liver failure (ALF) patients is as safe as using an international normalized ratio (INR)-based threshold. This approach did not increase complications in ALF patients undergoing liver transplantation.
Area of Science:
- Pediatric Hepatology
- Transfusion Medicine
- Liver Transplantation
Background:
- Transfusion protocols for pediatric acute liver failure (ALF) are not well-established.
- Evaluating transfusion strategies is crucial for optimizing outcomes in pediatric liver transplant recipients.
Purpose of the Study:
- To assess the effectiveness and safety of an international normalized ratio (INR)-based transfusion threshold compared to clinical judgment in pediatric ALF patients.
Main Methods:
- Retrospective review of 44 pediatric ALF patients from 2009-2018.
- Comparison of two groups: INR threshold (INR > 3.0) vs. clinical judgment.
- Analysis of preoperative INRs, transfusions, reoperations, renal/graft function, and survival.
Main Results:
- The INR threshold group had lower preoperative INRs but received more fresh frozen plasma (FFP) and cryoprecipitate.
- No significant differences were observed in pre-transplant bleeding, operative transfusions, or 1-year patient and graft survival between the groups.
- Liver failure severity was comparable between the groups.
Conclusions:
- An international normalized ratio (INR)-based transfusion threshold did not demonstrate superiority over clinical judgment in pediatric ALF patients.
- Clinical judgment-based transfusion strategies are a safe alternative, avoiding increased perioperative complications.
Introduction:
Transfusion protocols are not well-studied for pediatric patients with acute liver failure (ALF). This study evaluates the utility of an international normalized ratio (INR)-based transfusion threshold for these patients.
Methods:
Forty-four ALF pediatric patients from 2009 to 2018 were reviewed and divided into two groups: (a) a threshold group including patients between 2009 and 2015 who were transfused for an INR above 3.0, per institutional policy (n = 30), and (b) a post-threshold group including patients after 2015 through 2018 who were transfused based on clinical judgment (n = 14). Preoperative INRs, preoperative transfusions, intraoperative transfusions, early reoperation, renal function, graft function and deaths were compared.
Results:
Liver failure severity was similar between threshold and post-threshold groups. Threshold patients had a lower average INR prior to transplantation, 2.8 (range 1.8-3.8) vs 4.4 (range 2.1-9.0), respectively (P = .01). Twenty-six threshold patients (87%) received preoperative FFP compared with seven post-threshold patients (50%, P = .0088). Two threshold patients (7%) received preoperative cryoprecipitate compared with five post-threshold patients (36%, P = .014). The incidence of pre-transplant bleeding, operative transfusions, and 1-year patient and graft survival did not differ significantly.
Conclusion:
Clinical judgment vs an INR-based threshold for transfusions did not increase perioperative complications in children with ALF.
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