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Massive Transfusion and Incompatible Plasma

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If you are in a Massive Transfusion situation and the patient is bleeding so profusely that you run out of available (aka thawed or liquid) ABO compatible plasma - the only available plasma is Group O.  You have a specimen and the patient is Group A.  What would you do? 

 

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If at all possible, they would have to consult with our pathologist.  Then beyond that, the physician in charge of the case would have to provide documentation that it is an emergent situation and that they are aware that they are transfusing incompatible product.

Having said that, it seems like it would be a really bad idea.  Giving A plasma to an unknown is one thing, but O plasma?

Scott

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I think it depends on what is going on.  Look at the history of liver transplants.  When they started, pts were getting upwards of 400u rbc. The first 20 and last 20 were abo compatible.  in between it was whatever was available.  I've seen massive transfusions where the patient was mistyped, receiving 20+u incompatible rbcs.  Everything was fine for a few days - until the dilution factor was overcome by the pt's own immune system coming back on line.  Patient doesn't survive that.  Maybe, if you have to go with significant ABO incompatible plasma (O) you could switch the pt to O rbcs to reduce hemolytic activity.  Have to remember the  ABO abs are going to be diluted by the volumes of other solutions which are usually being infused at the same time.  If the need is for coag factors, pharmacy should be able to provide recombinant products.  It's a tough nut.

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22 hours ago, applejw said:

If you are in a Massive Transfusion situation and the patient is bleeding so profusely that you run out of available (aka thawed or liquid) ABO compatible plasma - the only available plasma is Group O.  You have a specimen and the patient is Group A.  What would you do? 

 

There was a prominent trauma surgeon who said, "Patients die from the blood they don't get, not the blood they do get".

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15 hours ago, Dansket said:

There was a prominent trauma surgeon who said, "Patients die from the blood they don't get, not the blood they do get".

There is some truth in that, and especially from his perspective.  However I have found that surgeons are not the best when it comes to understanding Transfusion Medicine.

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Considering the push to using Low Titre O Whole Blood for MTP and trauma's, i'd say the benefit outweighs the risk.  I have personally seen two incidents where a panicked Blood Banker accidentally issued O FFP in emergency release situations.  In both cases, the patients turned out to be incompatible blood types (one A one B). Guess what, there was no adverse effect whatsoever in either case.  No sign of hemolysis or transfusion reaction weeks later. 

 

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2 hours ago, jayinsat said:

Considering the push to using Low Titre O Whole Blood for MTP and trauma's, i'd say the benefit outweighs the risk.  I have personally seen two incidents where a panicked Blood Banker accidentally issued O FFP in emergency release situations.  In both cases, the patients turned out to be incompatible blood types (one A one B). Guess what, there was no adverse effect whatsoever in either case.  No sign of hemolysis or transfusion reaction weeks later. 

 

And in this vein - look at all the ABO incompatible plts we are forced to give (esp when you can only get group O)

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Posted (edited)

consult with pathologist and keep in mind

If you absolutely have to give incompatible plasma the  ideal is to give it while patient is actively bleeding. If possible give RBCs that will be compatible with patient and the plasma so in your case O and as the bleeding is beginning to come under control start giving ABO compatible plasma to "top them off".  The idea is that as long as patient is actively bleeding give them the incompatible product which is then being bled out onto the floor or wherever. Once bleeding is under control give the good stuff to help dilute the incompatible out and leave them with the most compatible antigen/antibody combinations possible.

 

 

 

Edited by jalomahe

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The size of the patient can be a factor in how much incompatible plasma you can safely give, but in an MTP you are poring the blood products in, and often it is poring right back out.

The comment on giving platelets is well founded.

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Thank you all for your invaluable input - does anyone know of literature referencing a mL/Kg formula looking at safety in transfusing incompatible plasma? 

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On ‎6‎/‎4‎/‎2019 at 7:38 AM, applejw said:

Thank you all for your invaluable input - does anyone know of literature referencing a mL/Kg formula looking at safety in transfusing incompatible plasma? 

I recently asked the Medical Director of our blood supplier what a "large volume" meant when transfusing incompatible plasma.  They replied 2- 4 units.

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Remember that the impact can be affected by A and B substance present in patients and donors.  Of course, that also means more immune complexes formed.

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