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Mabel Adams

AB plasma shortage

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Our blood supplier has just sent a letter that we can expect a worsening supply of AB plasma as the new AABB standard to prevent TRALI goes into effect April 1.  They recommend various tactics to reduce use of AB plasma including the use of PCC in warfarin reversal of bleeding patients.  Does anyone have a good flowchart, algorithm or other chart of how drs should approach these patients besides filling them with FFP?  They should use vitamin K if there's time, PCC rather than emergency release plasma if there is not enough time (and the cost can be justified) and FFP in some cases. For invasive procedures sometimes they don't even need to correct the INR.  I am looking for a simple way for ED docs to do the right thing in various situations.

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I do recall that Sunny (Walter) Dzik did some work on FFP and the reversal of warfarin some time ago and showed that it took some time for the FFP to work (if you like, a bit like 2-3-DPG in red cells having to be top-up again before they are useful oxygen carrying cells again - although, of course, in the case of FFP, it certainly isn't 2-3-DPG depletion, but he didn't say what it was - indeed, if it is known).

If I can find it, I will post it (but don't hold your collective breaths)!

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I do have a couple of articles on use of Vitamin K instead of FFP (which I have to tell you; is a thorn in my side where I work right now). They think the higher the INR, the more FFP they have to Order (but it is not a simple 1:1 ratio; so we waste FFP on these patients). If I can figure out how to add an attachment on this site (right now, I feel like I can barely post on the site); then I will send them out.

Also.....I did not attend the last AABB but listened to a synopsis of one of the talks from an ARC Medical Director. Another recommendation being made (and if I recall correctly, this study was performed by Mayo Clinic and is already being done by them; as well as others).....was to use some Group A FFP in trauma situations before switching to group AB (or hopefully by then, you would have a type on the patient). The reasons (as I recall them) that they did not see significant problems were;

1. Most patients are group O or A anyway....so it would "statistically" be compatible with most patients

2. When you think about it, we cannot always give group specific specific platelets (though if you work somewhere

that certain patient populations are using a lot of platelets, I have been taught to monitor the amount of

incompatible platelets given....may have to pack them at some point).

3. There were no hemolytic reactions in their study (though there were other complications; but not necessarily to

the FFP because remember, we are talking about critical patients). Group AB plasma use was decreased by 96.6%.

4. Their conclusion from the study: Use of Group A for emergency release plasma resulted in ABO-incompatible

transfusions; however, this had little effect on clinical outcomes.

At the talk I heard, they did not give a "magic #" of how many group A to give before you switched them to AB (if you did not yet have a blood type).

I also have papers on this study...but again, will have to see if I can put them somewhere on the website.....

Coincidentally, I have a meeting tomorrow with ER Physicians and Trauma Surgeons at my Institution to discuss our Uncrossmatched/ Massive Protocol. I briefly mentioned this at a previous ER meeting...but plan to present it again tomorrow when "all parties" are present. I am going to recommend that the first 2 units we give to these bleeding patients coming through the ER (w/o a type) is group A FFP. It just made a lot of sense to me.

Brenda Hutson, CLS(ASCP)SBB

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Ok, "if" successful, I have posted 2 sections of articles in the Library. 1 (with 2 articles) related to appropriate use of FFP and Vit K. The other (with 5 articles) related to use of "potentially" incompatible (sp. group A) FFP/Plasma in emergency situations (due to decreased availability of AB FFP).

Brenda Hutson

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We will be making the switch to using A plasma as emergency release I think.  I went to a RAP session on it at the last AABB meeting and there was an article recently (in Transfusion?).  The ARC is recommending this approach in their letter about the coming shortage.  I have pulled data from our computer and an even higher than expected proportion of our population is either A or O so I feel better about that.  If we are going to start keeping thawed plasma it would have to be A.

 

Thanks for the other info.  I will check out the library.

 

PS to attach something to a post, just click on "more reply options" then scroll down.

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Sorry, Cliff had to delete the articles I had posted in the Library because of the copyright (didn't know you couldn't share articles in that if someone wrote them and presented/shared them.....seems like they are open for public viewing; after all, the reason I had access to them is that they were first sent to me). Guess I don't understand those laws then.....

If any of you would like a copy of articles regarding giving Group A Plasma (instead of AB) in emergencies; and/or giving Plasma vs. Vit K.....send me your e-mail address and I will share the information I have.

Thanks,

Brenda Hutson

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Or could you post the references so that 4 years from now when you are on an extended vacation some poor soul won't have to wait by his/her email box pining for the articles from you?  :)  I suspect I have seen at least one of them.

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We are a level 1 trauma center for pediatrics. What are others doing for this population? Using an age cut-off or weight or using AB plasma as emergency release?

For adults, we are using A plasma as recommmended by ARC.

Thanks for any input.

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I have a question, is there some evidence proved that at the first 20min to transfuse plasma will get a higher survival rate in trauma patients  than other fluid and protein?

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We, too, got 'the letter' from our blood provider ... and yes, it contained the information about the use of incompatible plasma (e.g. Group A).

 

In a nutshell, we have elected to use Group A Plasma (or whatever is immediately available) instead of Group AB Plasma for the 'unknowns'.   Also, we raised the question of the use of products like Kcentra instead of plasma.  The MDs are hashing that out 'as we speak'.

 

And like others, we are issuing non-type specific Apheresis Platelets routinely (mostly Group A).

 

I think it's only fair to reserve the AB Plasma for the 4% of the population that actually needs AB plasma.

 

And, we too, are wondering just how much incompatible plasma can be tolerated.  If anyone out there knows the answer to that question, please share!

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Is anyone going to titrate the anti-B in the A plasma to avoid using the rare high-titer units?  This seems possible if you are storing thawed plasma but not very practical if you are thawing on demand.

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I have a question, is there some evidence proved that at the first 20min to transfuse plasma will get a higher survival rate in trauma patients  than other fluid and protein?

Shily, I read an article giving conclusions of a study conducted by the US Army field medics in the Transfusion Medicine journal about four or five years ago that supported this finding. As a result I think that there was a change to supporting trauma patients with a one-to-one ratio of packed red cells and ABO compatible plasma. I do not remember the title of the article; perhaps some of our colleagues remember this article.

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Just today I was sent a presentation put on by Mayo Clinic regarding use of A plasma for emergency release.  Copy this link to take you to it.

 

http://www.mayomedicallaboratories.com/articles/hot-topic/2014/03-15-group-a-thawed-plasma/?utm_source=email-rapidnewsletter&utm_medium=email&utm_content=2014-03-thawed-plasma&utm_campaign=hot-topics

 

It also covers some of the info on urgent use of plasma early in a resuscitation.  They send it on their helicopters and give it before the RBCs I think he said.

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