Use of A FFP in Emergent situations

[SMILLER]

Anyone  have a recent reference for the use of A FFP (instead of depletion of AB FFP stock) in certian emergency massive transfusion situations?  I have seen a few studies but nothing recent, and cannot find a comment from AABB or the FDA or whomever regarding best practices regarding this.

 

Scott

[Auntie-D]

http://www.mayomedicallaboratories.com/media/articles/hot-topic/2014/2014-03-15-group-a-thawed-plasma-fulltext.pdf

 

There are a few articles in the references

[SMILLER]

Thanks.  I read that one. 

 

I just question how these sites that have published these studie get away with what AABB clearly would consider an "ABO incompatibility".  That is why I wondered if there is any guidance from some accrediting agency regarding this.

 

Any other facilities out there using A FFP for emergencies to save AB?

 

Scott

[Teristella]

We have transitioned to using group A FFP and liquid plasma for our trauma patients who are emergency released blood, and for all MTPs (we still use AB if we have an abundance of it thawed or if we are only able to get AB liquids to restock). My supervisor worked with the trauma program medical director and the CMO and we developed new SOPs for this. We have discussed putting together a short paper, as we've been collecting data on all emergency release patients. Since September we've had about 40 trauma patients receive group A plasma, and we've only had three B/AB patients in that group. On each of these patients we ran some extra post-transfusion labs (renal panel and LDH, DAT), nothing really notable so far. We've also been doing an abbreviated titer on the liquid plasma units we receive and setting aside anything with a titer of 64 or greater (only about 10%) for use on A or O patients only, if possible (which is most patients anyway!). FFP is not titered.

 

So far we've had no problems and it's been much less stressful than trying to restock AB after multiple traumas. In fact we had a day last month where we had 7 bleeding traumas in one shift, we would have been in a pickle if we'd used AB for them, so it was a huge help.

Edited December 3, 2014 by Teristella

[Auntie-D]

It's only an incompatibility for group B/AB patients and the units are HT neg anyway so the antibody load should be low. It is risk/benefit issue - the incompatibility is an issue with red cells due to illiciting an immune response, but plasma with only sensitise the red cells creating a DHTR. You can't deny a product when a patient is bleeding out because they might have a delayed HTR - most of the reaction will be occuring on the floor of the ER...

[CMCDCHI]

It's only an incompatibility for group B/AB patients and the units are HT neg anyway so the antibody load should be low. It is risk/benefit issue - the incompatibility is an issue with red cells due to illiciting an immune response, but plasma with only sensitise the red cells creating a DHTR. You can't deny a product when a patient is bleeding out because they might have a delayed HTR - most of the reaction will be occuring on the floor of the ER...

Help me out- what is HT neg?

[Malcolm Needs ☆]

Negative for high titre ABO antibodies.

[AMcCord]

Check with your blood supplier - they may have more references. Our blood supplier (ARC) presented about this in a regional educational session and they had the  following references. They presented data from the University of Massachusetts, Mayo Clinic and UNMC (which was a small data set at the time of presentation). We haven't made the switch, but have talked about it. Since we use type A platelets for most patients, it wouldn't be a big jump to use type A plasma for trauma patients. 

Using Type A Plasma for Trauma Cases

References/Resources

 

1. Cooling L. Going from A to B: the safety of incompatible group A plasma for emergency release in trauma and massive transfusion patients. Transfusion 2014; 54:1695-1697.

 

2. Holcomb J et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg 2008; 248:447– 458.

 

3. Maegele M et al. Red blood cell to plasma ratios transfused during massive transfusion are associated with mortality in severe multiply injury: a retrospective analysis from the Trauma Registry of the Deutsche Gesellschaft fur Unfallchirurgie. Vox Sanguinis 2008; 95:112–119.

 

4. Bhangu, et al. Meta-analysis of plasma to red blood cell ratios and mortality in massive blood transfusions for trauma. Injury, Int. J. Care Injured 2013; 44:1693–1699

 

5. Ho A et al. Prevalence of survivor bias in observational studies on fresh frozen plasma:erythrocyte ratios in trauma requiring massive transfusion. Anesthesiology 2012; 116:716-728

 

6. De Biasi A et al. Blood product use in trauma resuscitation: plasma deficit versus plasma ratio as predictors of mortality in trauma. Transfusion 2011;51:1925-1932.

 

7. Stubbs JR. Emergent use of group A thawed plasma to trauma patients. Mayo Medical Laboratories Hot Topic video. March 13, 2014. link: http://www.mayomedicallaboratories.com/articles/hottopic/

2014/03-15-group-a-thawed-plasma/index.html

 

8. Berseus O et al. Risks of hemolysis due to anti-A and anti-B caused by the transfusion of blood or blood components containing ABOincompatible plasma. Transfusion 2013; 53:114S-123S.

 

9. Daniel-Johnson J et al. Probiotic-associated high-titer anti-B in a group A platelet donor as a cause of severe hemolytic transfusion reactions. Transfusion 2009; 49:1845-1849

Edited November 28, 2014 by AMcCord

[DPruden]

I would love to start using A plasma in trauma/emergency situations, but I'm trying to come up with a justification to contradict the statement in the Circular of Information that states "Plasma must be ABO compatible with the recipient's red cells."  And since the FDA considers the Circular an extension of the blood product label, I'm a little wary of implementing. I would also be curious if any of the faciliites using A plasma are in areas with high Asian populations.

[David Saikin]

Just tell the FDA that this is an AABB and Red Cross recommendation due to a shortage in AB plasma while there is the transition to all male donors.  I'm certain that this will be acceptable.  I don't think you need to apply for a variance.

[Eman]

Just to clarify, we do not titer our A plasma. It was considered but we decided not to. Been using A FFP emergently for years (that's our facility linked earlier) without problems. It definitely helps preserve your AB inventory. And we did not apply for a variance.

 

I think we may have done some studies and found very low anti-B titers anyway so didn't need to continue. I suspect our rationale includes the generally low anti-B titers we saw, the lower prevalence of group B and AB in the population as well as the generally low number of B antigens on group B and AB red cells.

 

All that said, we are titering our group O platelets for anti-A, and if its over 200 the platelet is tagged "transfuse to group O only."

 

And we're working on a new whole blood for trauma protocol, it'll be group O only and we'll test the anti-A and anti-B titers. I don't recall what our cutoff there will be.

Edited December 17, 2014 by Eman