title: Dose-associated pulmonary complication rates after fresh frozen plasma administration for warfarin reversal.
abstract: ESSENTIALS: Fresh frozen plasma (FFP) may be associated with a dose-based risk of pulmonary complications. Patients received FFP for warfarin reversal at a large academic hospital over a 3-year period. Almost 20% developed pulmonary complications, and the risk was highest after > 3 units of FFP. The risk of pulmonary complications remained significant in multivariable analysis.
  
  
  BACKGROUND
  Fresh frozen plasma (FFP) is often administered to reverse warfarin anticoagulation. Administration has been associated with pulmonary complications, but it is unclear whether this risk is dose-related. Aims We sought to characterize the incidence and dose relationship of pulmonary complications, including transfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury (TRALI), after FFP administration for warfarin reversal.
  
  
  METHODS
  We performed a structured retrospective review of patients who received FFP for warfarin reversal in the emergency department (ED) of an academic tertiary-care hospital over a 3-year period. Logistic regression was used to explore the relationship between FFP dose and risk of pulmonary events.
  
  
  RESULTS
  Two hundred and fifty-one patients met the inclusion criteria. Overall, 49 patients (20%) developed pulmonary complications, including 30 (12%) with TACO, two (1%) with TRALI, and 17 (7%) with pulmonary edema not meeting the criteria for TACO. Pulmonary complications were significantly more frequent in those who received > 3 units of FFP (34.0% versus 15.6%, 95% confidence interval for risk difference 7.9%-8.9%). After stratification by subtype of complication, only the risk of TACO was statistically significant (28.3% versus 7.6%, 95% confidence interval for risk difference 8.2%-16.6%). In multivariable analysis controlling for age, sex, initial systolic blood pressure, and intravenous fluids given in the ED, > 3 units of FFP remained a significant risk factor for pulmonary complications (odds ratio 2.49, 95% confidence interval 1.21-5.13).
  
  
  CONCLUSIONS
  Almost 20% of patients who received FFP for warfarin reversal developed pulmonary complications, primarily TACO, and this risk increased with > 3 units of FFP. Clinicians should be aware of and prepared to manage these complications.
authors.affiliation: Mayo Clinic, Rochester, MN, USA.
authors.forename: A L
authors.initials: AL
authors.lastname: Marshall
authors.affiliation: University of Southern California, Los Angeles, CA, USA.
authors.forename: M
authors.initials: M
authors.lastname: Levine
authors.affiliation: Massachusetts General Hospital, Boston, MA, USA.
authors.forename: M L
authors.initials: ML
authors.lastname: Howell
authors.affiliation: Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Y
authors.initials: Y
authors.lastname: Chang
authors.affiliation: Massachusetts General Hospital, Boston, MA, USA.
authors.forename: E
authors.initials: E
authors.lastname: Riklin
authors.affiliation: Massachusetts General Hospital, Boston, MA, USA.
authors.forename: B A
authors.initials: BA
authors.lastname: Parry
authors.affiliation: Massachusetts General Hospital, Boston, MA, USA.
authors.forename: R T
authors.initials: RT
authors.lastname: Callahan
authors.affiliation: Massachusetts General Hospital, Boston, MA, USA.
authors.forename: I
authors.initials: I
authors.lastname: Okechukwu
authors.affiliation: Massachusetts General Hospital, Boston, MA, USA.
authors.forename: A M
authors.initials: AM
authors.lastname: Ayres
authors.affiliation: Massachusetts General Hospital, Boston, MA, USA.
authors.forename: B V
authors.initials: BV
authors.lastname: Nahed
authors.affiliation: Massachusetts General Hospital, Boston, MA, USA.
authors.forename: J N
authors.initials: JN
authors.lastname: Goldstein
mesh_terms: D055371:Acute Lung Injury / Q000175:diagnosis / Q000453:epidemiology*; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects*; D001777:Blood Coagulation / Q000187:drug effects*; D016913:Blood Component Transfusion / Q000009:adverse effects*; D001900:Boston / Q000453:epidemiology; D004636:Emergency Service, Hospital; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced / Q000517:prevention & control*; D006801:Humans; D015994:Incidence; D019934:International Normalized Ratio; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010949:Plasma; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D062606:Tertiary Care Centers; D013997:Time Factors; D014859:Warfarin / Q000009:adverse effects*
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: blood component transfusion; fresh frozen plasma; pulmonary edema; warfarin