Evidence Exchange Author: Dr. Khosravani
NEJM - the world's top medical journal is partnering with Dr. Glaucomflecken! His real name is Will Flanary - he's a ophthalmologist who during COVID made great videos to make people understand and laugh at aspects of medicine.

This is a fun view - released Jan 2026 - by NEJM (New England Journal of Medicine) about the arterial line study! Published October 29, 2025

N Engl J Med 2025;393:1875-1888

Here are the details:  Deferring Arterial Catheterization in Critically Ill Patients with Shock, below is directly from the NEJM website
"RESULTS: A total of 1010 patients underwent randomization; 504 patients assigned to the noninvasive-strategy group and 502 assigned to the invasive-strategy group were included in the analyses. A total of 74 patients (14.7%) in the noninvasive-strategy group and 493 (98.2%) in the invasive-strategy group underwent insertion of an arterial catheter. Death within 28 days occurred in 173 patients (34.3%) in the noninvasive-strategy group and 185 (36.9%) in the invasive-strategy group (adjusted risk difference, −3.2 percentage points; 95% confidence interval, −8.9 to 2.5; P=0.006 for noninferiority). Results of per-protocol analyses were similar in the two groups. A total of 66 patients (13.1%) in the noninvasive-strategy group and 45 (9.0%) in the invasive-strategy group had at least 1 day of pain or discomfort related to the ongoing presence of the blood-pressure–monitoring device. Hematoma or hemorrhage related to the arterial catheter occurred in 5 patients (1.0%) in the noninvasive-strategy group and 41 patients (8.2%) in the invasive-strategy group.

CONCLUSIONS: Among patients with shock, results for death from any cause at day 28 indicated that management without early arterial catheter insertion was noninferior to early catheter insertion."

Evidence Exchange Author: Dr. Khosravani
We observe different transfusion practices in the unit.

However, It is best to standardize our approach, because the transfusion/blood bank lab have to be stewarts of this precisious resouce - and the act of transfusion comes with risks to the patient - transfusion reaction, or more severe complications such as TACO and TRALI.
If you see / or have a request that is contrary to the below - please direct the provider to this information and the Choosing Wisely website.

• Here is a common one - Pt not actively bleeding? Pt not unstable?
  Don’t transfuse more than one red cell unit at a time when transfusion is required in stable, non-bleeding patients.

  • Transfuse 1 unit at a time!
    "Indications for red blood transfusion depend on clinical assessment and the cause of the anemia. In a stable, non-bleeding patient, often a single unit of blood is adequate to relieve patient symptoms or to raise the hemoglobin to an acceptable level. Transfusions are associated with increased morbidity and mortality in high-risk hospitalized inpatients. Transfusion decisions should be influenced by symptoms and hemoglobin concentration. Single unit red cell transfusions should be the standard for non-bleeding, hospitalized patients. Additional units should only be prescribed after re-assessment of the patient and their hemoglobin value." - Choosing Wisely Canada

• Don’t transfuse plasma to correct a mildly elevated (<1.8) international normalized ratio (INR) or activated partial thromboplastin time (aPTT) before a procedure.

  • A mildly elevated INR is not predictive of an increased risk of bleeding. Furthermore, transfusion of plasma has not been demonstrated to significantly change the INR value when the INR was only minimally elevated (<1.8).

  • FFP itself has a INR, of somewhere between 1-1.6, or 1-1.4 so you cannot use FFP to "reverse INR"

  • Remember if it's for reversing Warfarin - PCC is a better alternative + Must remember to give Vitamin K 10mg IV x 1

  • FFP also comes with a lot of volume - so alternatives are for lower volume are:  Cirrhosis patient?

    • "For bleeding in cirrhosis patients not on anticoagulants, both fibrinogen concentrate and prothrombin complex concentrate (PCC) are low-volume alternatives to fresh frozen plasma, but neither is routinely recommended as first-line therapy, and the choice depends on the specific clinical scenario and coagulation deficits identified." - from OpenEvidence