Prophylactic correction of the international normalized ratio in neurosurgery: a brief review of a brief literature

A review

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Prophylactic fresh-frozen plasma (FFP) transfusion is often undertaken in hemodynamically stable patients with a minimally elevated international normalized ratio (INR) prior to invasive procedures, despite little evidence in support of this practice. The authors review the current literature in an attempt to clarify best clinical practice with regard to this issue. Although the activated partial thromboplastin time and prothrombin time–INR are useful laboratory tests to measure specific clotting factors in the coagulation cascade, in the absence of active bleeding or a preexisting coagulopathy, their utility as predictors of overall bleeding risk is limited. Several studies have shown an imperfect correlation between mild elevations in the INR and subsequent bleeding tendency. Furthermore, FFP transfusion is not always sufficient to achieve normal INR values in patients who have mild elevations (< 2) to begin with. Finally, there are risks associated with FFP transfusion, including potential transfusion-associated [disease] exposures as well as the time delay imposed by laboratory testing and transfusion administration prior to initiation of procedures. The authors propose that the current concept of a “normal” INR value warrants redefinition to make it a more meaningful clinical tool. Based on their review of the literature, the authors suggest that in a hemodynamically stable patient population there is a range of mildly prolonged INR values for which FFP transfusion is not beneficial, and is potentially harmful.

Abbreviations used in this paper: aPTT = activated partial thromboplastin time; FFP = fresh-frozen plasma; GCS = Glasgow Coma Scale; HMWK = high-molecular-weight kininogen; ICP = intracranial pressure; INR = international normalized ratio; ISI = international sensitivity index; PCC = prothrombin complex concentrate; PK = prekallikrein; PT = prothrombin time; RBC = red blood cell; rFVIIa = recombinant activated factor VII; TBI = traumatic brain injury.
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Contributor Notes

Address correspondence to: Cory Adamson, M.D., Duke University Medical Center, Box 2624, Durham, North Carolina 27715. email: cory.adamson@duke.edu.Please include this information when citing this paper: published online September 3, 2010; DOI: 10.3171/2010.7.091857.

© AANS, except where prohibited by US copyright law.

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