Plasma for AB positive patients

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BLADEMDA

BLADEMDA

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A trauma rolls into your O.R. bay. He is 25 years with a gunshot to the abdomen and likely liver. He will need Prbcs, FFP, cryo, etc.

Trauma surgeon asks for 6 units Prbc in the room along with FFP. Blood bank sends up matched, type specific blood AB+ for the patient.

The blood bank informs you there is a shortage of AB+ FFP. They only have 2 units on hand. What do you tell them? Is there a good substitute for type specific FFP in this AB+ patient?
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“Dr. Chaffin, I started working at a new blood bank recently, and I think they are breaking the rules! A patient came into the emergency room after an auto accident, and the FFP given to him was blood group A! Isn’t AB the ‘universal plasma,’ not A? The patient happened to be group O, so type A FFP turned out to be just fine, but I am worried! Are we doing the wrong thing?”
This exchange illustrates one of the things I love most about blood bankers: They pay attention, and are always on the lookout for unsafe practices. In this case, though, the use of group A plasma transfusions in emergency transfusions is absolutely okay. Despite how wrong it might feel, use of group A FFP in emergency settings is a growing trend – and a good one, for several reasons.

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Breaking the Rules; Group A Plasma in Emergencies - Blood Bank Guy
 
In The Real World
The use of group A as an automatic choice in emergency settings is growing rapidly, and I am seeing it more and more in hospitals with whom I work. I always caution anyone considering this strategy, though, that I personally believe it is essential to draw a blood sample from the patient as quickly as possible so the transfusion service can switch to ABO-specific products expediently. In the interim, group A FFP, while not truly “universal,” can be used in place of AB FFP without significant risk.

I must remind you, however, that the above does not mean that group A plasma is the right choice for all routine plasma transfusions! I have seen transfusion services try to apply this to non-emergency situations, and that is not a wise strategy! This is a practice shown safe in a specific, emergency situation. Routine plasma transfusions should still follow the ABO compatibility rules (repeated here for emphasis!):

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ABO Rules for FFP
 
My understanding is that this is common practice in the emergency medicine world already
 
Transfusion reactions are very uncommon in true massive hemorrhage, probably for a reason like immune suppression and severe dilution if native blood elements
 
On a related note, let's say the patient needed an emergent crani, and they had just taken ASA/Plavix/Ticlid etc... Would you give platelets? PATCH trial seems to say that giving them = doing harm, but they're not looking at surgical patients. Makes you wonder though
 
BLADEMDA said:
That's great. I'm a bit older than you so I like to keep up to date. I'm seeing more CRYO these days for TRAUMA as well.
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I give cryo once I hit about 6 units

Plavix should get platelets imo. Asa is a little iffy but I think not depending on when.
 
Expert Commentary:
ICH is a devastating disease, and often one which we often must watch powerlessly, despite the acuity of presentation. One of the first goals in ICH management is to prevent further bleeding. Platelets for aspirin reversal seemed promising, since it has been documented that patients on aspirin have more hematoma expansion and worse outcomes, as well as clear anecdotal evidence from surgeons that platelet infusion in aspirin users makes an overt difference intra-op. So why should PATCH have been negative?

Given the complexity of factors leading to hematoma expansion and subsequent hospitalization, it is hard to drive outcomes with any one intervention. However, even the rate of hematoma expansion was unchanged. Even though the irreversible binding of Aspirin usually takes many days to wash out, serum half-life is about 15-20 minutes (with active metabolites lingering a few hours). One thing to remember is that transfused platelets themselves can have time-limited efficacy due to immune-related consumption and inactivation. While even a temporarily effective transfusion can help stop brief bleeding such as in the OR or during acute stabilization, it is unlikely to prevent the stuttering hematomal expansion of ICH.

Platelets, unlike other blood products, must be stored at room temperature. Therefore, platelet transfusions are associated with high risks of transfusion reactions. It is theorized that some platelets may become activated prior to transfusion and can therefore also be associated with a risk of pathological clotting. These factors could blunt any potential benefit of treatment.

Intracerebral hemorrhage is a rarer and more heterogenous illness than stroke or MI. This trial is as high of quality as we are likely to obtain on the topic. When applying the results of the PATCH trial, it is important to remember that no patients with platelet counts below 100k were enrolled, so transfusions to meet that goal may still be performed. Also, it is still acceptable to transfuse for procedures or surgery. The study did not explore any sort of functional assays, namely Platelet Function Assay (PFA) or Platelet Aspirin Assay (PAA).



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Stephen Trevick, MD

Neurocritical Care Fellow, NUEM


The PATCH Trial
 
In this situation, what about B+ FFP? If A+ is preferred, is it due to better immune tolerance or availability ( A 35% vs B 9%)?
 
narcotics999 said:
In this situation, what about B+ FFP? If A+ is preferred, is it due to better immune tolerance or availability ( A 35% vs B 9%)?
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It’s because the majority of the population will be compatible with A+ , so if you don’t know someone’s blood type, if you had to hedge your bets, A + plasma will almost always be fine. it turns out that in reality antiB antibodies , when present, don’t frequently seem to cause a significant immune reaction. Also like I already mentioned, massive hemorrhage cases rarely develop transfusion reactions anyway, for some reason
 
FWIW and a bit OT:

I’m at a relatively small hospital compared to some of you guys, but we’re a very VERY busy level 2 trauma center. See everything.

If we ask for emergency release blood bank auto sends 4 RBC/4 FFP in first cooler. Once I ask for a second it’s 4/4 plus platelet. Third cooler is 4/4/1 plus cryo from there on out.

Easy management overall, and I don’t have to micromanage our nurses on what to get in the room. I can certainly get more of one specific product if I know of a specific factor to correct, but it works. Makes life easy.
 
Shimmy8 said:
FWIW and a bit OT:

I’m at a relatively small hospital compared to some of you guys, but we’re a very VERY busy level 2 trauma center. See everything.

If we ask for emergency release blood bank auto sends 4 RBC/4 FFP in first cooler. Once I ask for a second it’s 4/4 plus platelet. Third cooler is 4/4/1 plus cryo from there on out.

Easy management overall, and I don’t have to micromanage our nurses on what to get in the room. I can certainly get more of one specific product if I know of a specific factor to correct, but it works. Makes life easy.
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Sounds like your Blood Bank doctor actually reads the literature and parts attention to what people likely were asking for before the official policy change. That's far better than every (even military) hospital I've ever worked. I knew one Navy Blood Bank director that was super proactive regarding optimum transfusion ratios and needs (she'd even come to the unit or OR to see what else you might need, and how to speed things up), but even she was fighting an uphill battle with the rest of the Blood Bank

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This is why I love to skim the anesthesia forum: I don’t fully understand 99.8% of the topics covered but when you guys post this stuff, I may be able to provide some insight and learn something from you all too.

One trauma hospital I worked at (blood banker/mlt) we gave type A FFP for all trauma/MTP until we got a valid type and screen and second ABORh if the patient had no history. we’d switch to type specific afterwards. In fact, we always had 4 A plasmas thawed at all times since they expire 5 days after thawing. Since AB blood in patients is nowhere near as common as type A/O (~4% AB pos/neg vs 86% A/O pos/neg of population), that’s why most blood banks will issue A plasma first in trauma/massive transfusions if the director signed off on it. I wish I could help more but haven’t had any trauma/massive transfusions with the rare blood types (thank god). I know I’ll be s hitting bricks if/when it happens.

I actually had an MTP the other day as the lone blood banker on my 3rd day at a new hospital. Supervisor helped for a few minutes but then went back to their office to do administrative things (obviously an MTP is no biggie right?). Anyways, they took ended up transfusing ~11-15 units of blood before requesting any plasma or platelets (3 plasma and 4 platelets while in the OR). Why would they wait so long to transfuse plasma and platelets? I believe they had a ruptured AAA but I’m not sure. I know it’s hard without anymore info but it just seemed odd they would load them with so much blood and then plasma and platelets. I made sure I was way ahead of the game and even took platelets from other patients to have on standby. Before I left that evening (stayed 1 hour past schedule with no lunch/breaks), I had 9 rbcs, 2 plasma and 2 platelets on standby for them in case something happened over night. It felt good coming in the next day and they were still alive but didn’t seem too good (lactate was fluctuating between 4 and 6). Their coags once transferred to the icu were slightly above normal with a fibrinogen <150. I know they transfused more plasma/platelets/cryo and his fibrinogen was at 650 later that day.

Thanks for reading! Hope I didn’t derail the thread. Looking forward to hearing some responses

Ps psychbender - love the PJ motto
 
BLADEMDA said:
A trauma rolls into your O.R. bay. He is 25 years with a gunshot to the abdomen and likely liver. He will need Prbcs, FFP, cryo, etc.

Trauma surgeon asks for 6 units Prbc in the room along with FFP. Blood bank sends up matched, type specific blood AB+ for the patient.

The blood bank informs you there is a shortage of AB+ FFP. They only have 2 units on hand. What do you tell them? Is there a good substitute for type specific FFP in this AB+ patient?
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i tell them - don’t sweat it, i havent used ffp for 2 years anyway, because rotem invariably shows all i need to give is prbcs and cryo i till i’ve done well over one blood volune
 
I see a lot of cryo here but no riastap mentioned? 7 units of cryo are needed for 1gm of fibrinogen right?
 
you tell him to send low titer A+ plasma has been shown to be relatively tolerated and is used as a substitute for AB+ plasma because AB + is rare in US (4% of population). Another option in Europe is to use lyophilized plasma which has a long long shelf life.
 
What about AB negative vs A Positive? Shouldn’t the Rh factor cause less of an reaction?
 
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