A Comparative Study Between International Normalized
Ratio (INR) Guided Versus Clinical Discretion Guided
Blood Component Replacement Therapy in Patients
Undergoing Major Surgery
Volume 3 - Issue 3
Rajeev Nair1 and Satish Kumar Mishra2*
- 2MD Anaesthesiology HOD Department of Anaesthesiology and critical care Command hospital Airforce Bangalore, India
- 2MD, Dm Cardiac Anesthesia, Department of Anaesthesiology and critical care Command hospital Airforce Bangalore, India
Received: May 29, 2020; Published: June 15, 2020
Corresponding author: Satish Kumar Mishra, MD, Dm Cardiac Anesthesia, Department of Anaesthesiology and critical care Command
hospital Airforce Bangalore, India
DOI: 10.32474/GJAPM.2020.03.000164
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Abstract
Bleeding is a frequent complication during surgery. The intraoperative administration of blood products, including packed red
blood cells, platelets, and fresh frozen plasma (FFP), is often lifesaving. Complications of blood transfusions contribute considerably
to perioperative costs and blood product resources are limited. The aim of the present study was to evaluate and compare the usage
of INR guided vis a vis clinician discretion based component replacement therapy which will optimize the use of FFP and may even
result in less blood loss during surgery. Materials and Method: This study was conducted in surgical patients in a large tertiary care
centre. Ethical clearance was taken from the local ethics committee at the proposal stage itself. Patients consent was taken after
providing all necessary information prior to surgery. This study was conducted on 200 patients. The groups were randomised to
two groups of Gp 1- study(S) -100 patients (point of care-based transfusion management) Gp 2- control (C)- 100 patients (physician
discretion-based management). After premedication with intravenous morphine (0.05- 0.1 mg/kg body weight), Glycopyrrolate
and ondansetron, General anaesthesia was induced with thiopentone sodium. Endotracheal intubation achieved after vecuronium.
Anesthesia was maintained using low flow nitrous oxide: oxygen mixture (fresh gas flow of 1ltr each) and isoflurane (1 MAC) via a
closed circuit circle absorber system and mechanical ventilation with 5 – 10 ml/kg. Standard monitoring will include HR, ECG (two
lead), blood pressure (NIBP/ IABP), SpO2, naso pharyngeal temperature. Patient warming was done with warm air blower (with
a target temp above 36 ̊C). In the control group physician discretion was used to guide Blood platelet or FFP transfusion based on
the institutional protocol. These are blood if Hb <8 gm%, platelets if <50,000 or between 50,000-80,000 with ongoing blood loss
and FFP if bleeding >20% or >2 units blood given and repeated if physician desires. However, these are guidelines and physician
discretion based on clinical judgment is freely allowed. In the test group if bleeding is estimated to be more than 205 CBC and POC
INR is done. If Hb < 8 gm% blood is transfused, if platelets <50,000 then 1 Single Donor Platelets or 6 Random Donor Platelets are
transfused. 2 units of FFP are transfused if POC INR >1.8. Test was repeated after 30 mins and 2 more units of FFP was given if INR
>1.5. Result: there was no difference in age distribution sex weight of patients between the two group, however the need for blood
component therapy was in higher in patients who were treated based on clinical discretion compared to INR guided treatment. The
mean duration of post-operative ventilation required for the patient to be extubated with stable haemodynamic parameters in the
test group was 48.55 hrs compared to 78.4 hrs for the control group. The maximum duration of post-operative ventilation in test
group was 212 hrs, compared to 281 hrs for the control group. While the minimum duration was comparable being 18 hrs for test
group and 19 hrs for control group. One-Sample Kolmogorov-Smirnov Test was done in each group to ensure normal distribution
due to wide distribution of data. From our study we concluded that when in guided blood component therapy was done the need
for blood products was much lesser and the need for post-operative mechanical ventilation was much lesser in INR guided group
compared to clinical discretion based therapy.
Keywords: INR: International Normalized Ratio; FFP: Fresh frozen plasma; POC: Point of care
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