Liquid plasma: A solution to optimizing early and balanced plasma resuscitation in massive transfusion

Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies

Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The "physiological classification of HS" dictates the timely management and suits the 'titrated hypotensive resuscitation' tactics and the 'damage control surgery' strategy. In any hypotensive but not yet critical shock, the body's response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/- lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/- upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps.

Achieving optimal massive transfusion ratios: The trauma white board, whole blood, and liquid plasma. Real world low-tech solutions for a high stakes issue

BACKGROUND

It is well established that achieving optimal ratios of packed red blood cells (PRBC) to fresh frozen plasma (FFP) to platelet ratios during massive transfusion leads to improved outcomes but is difficult to accomplish.

METHODS

Between September 2018 and May 2019 our level 2 trauma center implemented 3 new processes to optimize transfusion ratios during massive transfusion protocol (MTP). Two units of low titer group O whole blood (LTOWB) were added as the first step to our MTP. Second, a dry erase board whiteboard was attached to each fluid warmer for real time recording of transfusions. Last, liquid plasma was incorporated into our MTP. We performed a retrospective review evaluating PRBC:FFP ratios for patients who had the massive transfusion protocol initiated and received 4 or more units of blood.

RESULTS

A total of 50 patients had the massive transfusion protocol initiated and received 4 or more units of PRBCs and/or LTOWB within 4 h of arrival. There were 21 patients evaluated prior to protocol changes and 29 patients after the changes. In the study group mean age, sex, pulse, systolic blood pressure (SBP), and injury severity scale (ISS) on admission were not different. In the pre-protocol (preP) group 90% of patients were blunt trauma and in the post-protocol group (postP) 72% were blunt trauma, p = 0. 22. For the preP group the mean units of PRBCs was 7.6 units and FFP 4.7 units. PostP the mean units of PRBCs was 11.4 units and FFP 10.0 units. PRBC/FFP ratios were 1.7 preP and 1.2 postP, p = 0.0072.

CONCLUSION

The institution of whole blood, use of the trauma white board, and the addition of liquid plasma to our transfusion services have allowed us to approach a 1:1 transfusion ratio during the course of our massive transfusions.

Step by step transfusion timeline and its challenges in trauma: A retrospective study in a level one trauma center

BACKGROUND

Hemorrhagic shock is the leading cause of preventable early death in trauma patients. Transfusion management is guided by international guidelines promoting early and aggressive transfusion strategies. This study aimed to describe transfusion timelines in a trauma center and to identify key points to performing early and efficient transfusions.

METHODS

This is a monocentric retrospective study of 108 severe trauma patients, transfused within the first 48 h and hospitalized in an intensive care unit between January 2017 and May 2019.

RESULTS

One hundred and eight patients were transfused with 1250 labile blood products. Half of these labile blood products were transfused within 3 h of admission and consumed by 26 patients requiring massive transfusion (≥4 red blood cells [RBC] within 1 h). Among these, the median delay from patient's admission to labile blood products prescription was -11 min (-34 to -1); from admission to delivery of labile blood products was 1 min (-20 to 16); and from admission to first transfusion was 20 min (7-37) for RBC, 26 min (13-38) for plasma, and 72 min (51-103) for platelet concentrates. The anticipated prescription of labile blood products and the use of massive transfusion packs and lyophilized plasma units were associated with earlier achievement of high transfusion ratios.

CONCLUSION

This study provides detailed data on the transfusion timelines and composition, from prescription to initial transfusion. Transfusion anticipation, use of preconditioned transfusion packs including platelets, and lyophilized plasma allow rapid and high-ratio transfusion practices in severe trauma patients.

Impact of time to surgery on mortality in hypotensive patients with noncompressible torso hemorrhage: An AAST multicenter, prospective study

BACKGROUND

Death from noncompressible torso hemorrhage (NCTH) may be preventable with improved prehospital care and shorter in-hospital times to hemorrhage control. We hypothesized that shorter times to surgical intervention for hemorrhage control would decrease mortality in hypotensive patients with NCTH.

METHODS

This was an AAST-sponsored multicenter, prospective analysis of hypotensive patients aged 15+ years who presented with NCTH from May 2018 to December 2020. Hypotension was defined as an initial systolic blood pressure (SBP) ≤ 90 mm Hg. Primary outcomes of interest were time to surgical intervention and in-hospital mortality.

RESULTS

There were 242 hypotensive patients, of which 48 died (19.8%). Nonsurvivors had higher mean age (47.3 vs. 38.8; p = 0.02), higher mean New Injury Severity Score (38 vs. 29; p < 0.001), lower admit systolic blood pressure (68 vs. 79 mm Hg; p < 0.01), higher incidence of vascular injury (41.7% vs. 21.1%; p = 0.02), and shorter median (interquartile range, 25-75) time from injury to operating room start (74 minutes [48-98 minutes] vs. 88 minutes [61-128 minutes]; p = 0.03) than did survivors. Multivariable Cox regression showed shorter time from emergency department arrival to operating room start was not associated with improved survival (p = 0.04).

CONCLUSION

Patients who died arrived to a trauma center in a similar time frame as did survivors but presented in greater physiological distress and had significantly shorter times to surgical hemorrhage intervention than did survivors. This suggests that even expediting a critically ill patient through the current trauma system is not sufficient time to save lives from NCTH. Civilian prehospital advance resuscitative care starting from the patient first contact needs special consideration.

LEVEL OF EVIDENCE

Prognostic/Epidemiologic, Level III.

Targeting repair of the vascular endothelium and glycocalyx after traumatic injury with plasma and platelet resuscitation

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Endothelial glycocalyx shedding is a key instigator of the endotheliopathy of trauma.

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Plasma and platelet transfusions preserve vascular integrity in pre-clinical models.

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However, platelets may be less effective than plasma in preserving the glycocalyx.

Severely injured patients with hemorrhagic shock can develop endothelial dysfunction, systemic inflammation, and coagulation disturbances collectively known as the endotheliopathy of trauma (EOT). Shedding of the endothelial glycocalyx occurs early after injury, contributes to breakdown of the vascular barrier, and plays a critical role in the pathogenesis of multiple organ dysfunction, leading to poor outcomes in trauma patients. In this review we discuss (i) the pathophysiology of endothelial glycocalyx and vascular barrier breakdown following hemorrhagic shock and trauma, and (ii) the role of plasma and platelet transfusion in maintaining the glycocalyx and vascular endothelial integrity.

Hemostatic Activity of Canine Never-Frozen Liquid Plasma Collected for Transfusion

This study measured the changes of hemostatic activity in liquid plasma (LP) over 7 days of storage. Five canine plasma units, divided into two aliquots were evaluated: one stored refrigerated at 2–6°C as never-frozen LP and one frozen at −18°C as fresh frozen plasma (FFP). Clotting times, coagulation activities of factor (F) V, VIII, X, XI, antithrombin (AT), and von Willebrand (vWF), fibrinogen and D-dimers (DD) content were assessed before storage (baseline value), and after 12, 24, 48 h and 7 days (D7) in LP stored refrigerated, and on day 7 in FFP. At baseline median values of all factor activity were greater than 80%, and for clotting times, AT, fibrinogen and DD content, were within the canine reference range. Some hemostatic parameters changed significantly over 7 days and at the end of storage in LP. However, median activities of FV, FVIII, FX and FXI, coagulation time, AT, fibrinogen and DD content remained within reference ranges at all time points. The only exception was for vWF which median activity was lower than reference range for all storage time points. Activity of FVIII was significant lower in LP at D7 when compared to activity in FFP, with values of 62 vs. 118%, respectively. DD content showed a median value higher than reference range in FFP at D7. Despite some statistically significant changes at the end of 7-day storage period, never-frozen LP maintained median factor activities >80% for most factors. The clinical impact of the drop over time of vWF activity is unknown.

A comparison between liquid group A plasma and thawed group A plasma for massive transfusion activation in trauma patients

BACKGROUND AND OBJECTIVES

The use of group A thawed 24-h plasma when resuscitating haemorrhagic shock patients has become more common; however, limited data exist on the clinical use of liquid plasma (LP). Our aim is to determine whether LP is of clinical benefit to patients requiring massive transfusion.

MATERIALS AND METHODS

The objective of this retrospective study was to detect any difference in 24-h survival between patients receiving liquid or thawed plasma (TP) during their massive transfusion activation. Other objectives were to report any difference in hospital length of stay (LOS), intensive care unit (ICU) LOS and in-hospital survival. Data collected included gender, age, mechanism of injury, Injury Severity Score, Revised Trauma Score and Trauma Injury Severity Score.

RESULTS

A total of 178 patients received 1283 units of LP, median 4 and range (1-56), whereas 270 patients received 2031 units of TP, median 5 and range (1-87). The two study groups were comparable in terms of gender, age, mechanism of injury, whole blood, red blood cells, platelets and cryoprecipitate transfused. The use of LP during the massive transfusion activation in traumatically injured patients was not associated with increased 24-h survival compared to when using TP, p = 0.553.

CONCLUSION

Our study did not show a difference in 24-h or 30-day survival between the use of LP compared to TP in trauma patients. LP should be considered an alternative to TP in trauma patients requiring immediate plasma resuscitation.

Ex vivo hemostatic and immuno-inflammatory profiles of freeze-dried plasma

BACKGROUND

Hemorrhage is a leading cause of preventable death in civilian and military trauma. Freeze-dried plasma is promising for hemostatic resuscitation in remote prehospital settings, given its potential benefits in reducing blood loss and mortality, long storage at ambient temperatures, high portability, and rapid reconstitution for transfusion in austere environments. Here we assess the ex vivo characteristics of a novel Terumo's freeze-dried plasma product (TFDP).

STUDY DESIGN AND METHODS

Rotational thromboelastometry (ROTEM) tests (INTEM, EXTEM, and FIBTEM) were conducted on plasma samples at 37°C with a ROTEM delta-machine using standard reagents and procedures. The following samples were analyzed: pooled plasma to produce TFDP, TFDP reconstituted, and stored immediately at -80°C, reconstituted TFDP stored at 4°C for 24 h and room temperature (RT) for 4 h before freezing at -80°C. Analysis of plasma concentrations of selected cytokines, chemokines, and vascular molecules was performed using a multiplex immunoassay system. One-way ANOVA with post hoc tests assessed differences in hemostatic and inflammatory properties.

RESULTS

No significant differences in ROTEM variables (coagulation time [CT], clot formation time, α-angle, maximum clot firmness, and lysis index 30) between the TFDP-producing plasma and reconstituted TFDP samples were observed. Compared to control plasma, reconstituted TFDP stored at 4°C for 24 h or RT for 4 h showed a longer INTEM CT. Levels of immuno-inflammatory mediators were similar between frozen plasma and TFDP.

CONCLUSIONS

TFDP is equivalent to frozen plasma with respect to global hemostatic and immuno-inflammatory mediator profiles. Further investigations of TFDP in trauma-induced coagulopathy models and bleeding patients are warranted.

Never-frozen liquid plasma transfusion in civilian trauma: a nationwide propensity-matched analysis

BACKGROUND

Never-frozen liquid plasma (LQP) was found to reduce component waste, decrease health care expenses, and have a superior hemostatic profile compared with fresh frozen plasma (FFP). Although transfusing LQP in hemorrhaging patients has become more common, its clinical effectiveness remains to be explored. This study aims to examine outcomes of trauma patients transfused with LQP compared with thawed FFP.

METHODS

Adult (≥18 years) trauma patients receiving early (≤4 hours) plasma transfusions were identified in the Trauma Quality Improvement Program 2017. Patients were stratified into those receiving LQP versus FFP. Propensity-score matching in a 1:2 ratio was performed. Primary outcome measures were mortality and time to first plasma unit transfusion. Secondary outcome measures were major complications and hospital length of stay.

RESULTS

A total of 107 adult trauma patients receiving LQP were matched to 214 patients receiving FFP. Mean age was 48 ± 19 years, 73% were male, and median Injury Severity Score was 27 [23-41]. A total of 42% of patients were in shock, 22% had penetrating injuries, and 31% required surgical intervention for hemorrhage control. Patients received a median of 4 [2-6] units of PRBC, 2 [1,3] units of LQP or FFP, and 1 [0-1] unit of platelets. The median time to the first LQP unit transfused was significantly shorter compared with the first FFP unit transfused (54 [28-79] minutes vs. 98 [59-133] minutes; p < 0.001). Rates of 24-hour mortality (2.8% vs. 3.7%; p = 0.664) and in-hospital mortality (16.8% vs. 20.1%; p = 0.481) were not different between the LQP and FFP groups. Similarly, there was no difference in major complications (15.9% vs. 21.5%; p = 0.233) and hospital length of stay (12 [6-21] vs. 12 [6-23] days; p = 0.826).

CONCLUSION

Never-frozen liquid plasma is safe and effective in resuscitating trauma patients. Never-frozen liquid plasma has the potential to expand our transfusion armamentarium given its longer storage time and immediate availability.

LEVEL OF EVIDENCE

Therapeutic, Level IV.