The impact of plasma preparations and their storage time on short-term posttransfusion mortality: A population-based study using the Scandinavian Donation and Transfusion database

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.

A Comparison of Growth Factors and Cytokines in Fresh Frozen Plasma and Never Frozen Plasma

BACKGROUND

Fresh frozen plasma (FFP) contains proinflammatory mediators released from cellular debris during frozen storage. In addition, recent studies have shown that transfusion of never-frozen plasma (NFP), instead of FFP, may be superior in trauma patients. We hypothesized that FFP would have higher levels of inflammatory mediators when compared to NFP.

MATERIALS AND METHODS

FFP (n = 8) and NFP (n = 8) samples were obtained from an urban, level 1 trauma center blood bank. The cytokines in these samples were compared using a Milliplex (Milliplex Sigma) human cytokine magnetic bead panel multiplex assay for 41 different biomarkers.

RESULTS

Growth factors that were higher in NFP included platelet-derived growth factor-AA (PDGF-AA; 8.09 versus 108.00 pg/mL, P < 0.001) and PDGF-AB (0.00 versus 215.20, P= 0.004). Soluble CD40-ligand (sCD40L), a platelet activator and pro-coagulant, was higher in NFP (31.81 versus 80.45 pg/mL, P< 0.001). RANTES, a leukocyte chemotactic cytokine was higher in NFP (26.19 versus 1418.00 pg/mL, P< 0.001). Interleukin-4 (5.70 versus 0.00 pg/mL, P= 0.03) and IL-8 (2.20 versus 0.52 pg/ml, P= 0.03) levels were higher in were higher in FFP.

CONCLUSIONS

Frozen storage of plasma may result in decrease of several growth factors and/or pro-coagulants found in NFP. In addition, the freezing and thawing process may induce release of pro-inflammatory chemokines. Further studies are needed to determine if these cytokines result in improved outcomes with NFP over FFP in transfusion of trauma patients.

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

BACKGROUND

Early and balanced resuscitation for traumatic hemorrhagic shock is associated with decreased mortality, making timely plasma administration imperative. However, fresh frozen plasma (FFP) thaw time can delay administration, and the shelf life of thawed FFP limits supply and may incur wastage. Liquid plasma (LP) offers an attractive alternative given immediate transfusion potential and extended shelf life. As such, we hypothesized that the use of LP in the massive transfusion protocol (MTP) would improve optimal plasma/red blood cell (RBC) ratios, initial plasma transfusion times, and clinical outcomes in the severely injured patient.

METHODS

Using Trauma Quality Improvement Program data from our level 1 trauma center, we evaluated MTP activations from 2016 to 2018. Type A LP use was instated April 2017. Before this, thawed FFP was solely used. Plasma/RBC ratios and initial plasma transfusion times were compared in MTP patients before and after LP implementation. Patient and injury characteristics were accounted for using linear regression analysis. Secondary outcomes of mortality, 28-day recovery, and complications were evaluated using Cox proportional hazards regression.

RESULTS

A total of 95 patients were included (pre-LP, 39; post-LP, 56). Time to initial plasma transfusion and plasma/RBC ratios at 4 and 24 hours were improved post-LP implementation with a coinciding reduction in RBC units transfused (p < 0.05). In a 28-day Cox proportional hazards regression LP implementation was associated with favorable recovery (hazard ratio, 3.16; 95% confidence interval, 1.60-6.24; p < 0.001) and reduction in acute kidney injury (hazard ratio, 0.092; 95% confidence interval, 0.011-0.77; p = 0.027). No post-LP patients with blood group type B or AB (n = 9) demonstrated evidence of hemolysis within 24 hours of type A LP transfusion.

CONCLUSION

Initial resuscitation with LP optimizes early plasma administration and improves adherence to transfusion ratio guidelines. Furthermore, LP offers a solution to inherent delays with FFP and is associated with improved clinical outcomes, particularly 28-day recovery and odds of acute kidney injury. Liquid plasma should be considered as an alternative to FFP in MTPs.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

Essentials of emergency transfusion-The complement to stop the bleed

Over the past decade, the shift toward damage control surgery for bleeding trauma patients has come with an increased emphasis on optimal resuscitation. Two lifesaving priorities predominate: to quickly stop the bleed and effectively resuscitate the hemorrhagic shock. Blood is separated into components for efficient storage and distribution; however, bleeding patients require all components in a balanced ratio. A variety of blood products are available to surgeons, and these products have evolved over time. This review article describes the current standards for resuscitation of bleeding patients, including characteristics of all available products. The relevant details of blood donation and collection, blood banking, blood components, and future therapies are discussed, with the goal of guiding surgeons in their emergency transfusion practice.

Protocol for a national blood transfusion data warehouse from donor to recipient

INTRODUCTION

Blood transfusion has health-related, economical and safety implications. In order to optimise the transfusion chain, comprehensive research data are needed. The Dutch Transfusion Data warehouse (DTD) project aims to establish a data warehouse where data from donors and transfusion recipients are linked. This paper describes the design of the data warehouse, challenges and illustrative applications.

STUDY DESIGN AND METHODS

Quantitative data on blood donors (eg, age, blood group, antibodies) and products (type of product, processing, storage time) are obtained from the national blood bank. These are linked to data on the transfusion recipients (eg, transfusions administered, patient diagnosis, surgical procedures, laboratory parameters), which are extracted from hospital electronic health records.

APPLICATIONS

Expected scientific contributions are illustrated for 4 applications: determine risk factors, predict blood use, benchmark blood use and optimise process efficiency. For each application, examples of research questions are given and analyses planned.

CONCLUSIONS

The DTD project aims to build a national, continuously updated transfusion data warehouse. These data have a wide range of applications, on the donor/production side, recipient studies on blood usage and benchmarking and donor-recipient studies, which ultimately can contribute to the efficiency and safety of blood transfusion.

Focus on fresh frozen plasma - facilitating optimal management of bleeding through collaboration between clinicians and transfusion specialists on component specifications

BACKGROUND

A symposium on plasma for direct clinical use was held in September 2015 by the European directorate for the quality of medicines and healthcare (EDQM) in order to consider changes to the Council of Europe guide to the preparation, use and quality assurance of blood components monographs on plasma components.

METHODS

The programme reviewed use of plasma in various settings, novel components, adverse reactions, manufacturing and quality monitoring issues.

RESULTS

The main requirement identified was that plasma should be made available to support early transfusion in the trauma/massive haemorrhage setting. Further guidance on component manufacturing and reviewing of quality monitoring requirements will also be addressed.

CONCLUSION

A working group has been established to review component monographs and other advice in the guide relating to plasma components, with the aim of providing optimal components to support clinical management of patients requiring plasma.

What is new in the blood bank for trauma resuscitation

PURPOSE OF REVIEW

The aim of the present review was to describe recent changes in blood banking thinking, practice, and products that affect trauma care.

RECENT FINDINGS

Prompt balanced hemostatic resuscitation of major hemorrhage from trauma improves outcome and reduces blood use. New blood processes and products can help deliver appropriate doses of procoagulant plasma and platelets quicker and more safely. New processes include holding larger inventories of thawed plasma with risk of wastage and rapid plasma thawers. New products in the blood bank include group A or group A low-titer B thawed plasma and AB or A liquid (never-frozen) plasma for resuscitation, prepooled cultured whole blood-derived platelets in plasma, and prepooled cryoprecipitate in varying pool sizes. Single-donor apheresis or pooled whole blood-derived platelets in additive solution, designed to reduce plasma-related transfusion reactions, are also increasingly available but are not an appropriate blood component for hemorrhage control resuscitation because they reduce the total amount of administered plasma coagulation factors by 10%.

SUMMARY

Early initiation of balanced massive transfusion protocols leading to hemostatic resuscitation is lifesaving. Changing blood product availability and composition will lead to higher complexity of massive transfusion. It is critical that anesthesiologists understand the composition of the available new blood products to use them correctly.

Thawed and liquid plasma--what do we know?

There is increasing interest in the use of liquid or frozen plasma thawed and stored for extended periods (>24 h) to reduce wastage and to improve rapid availability of plasma in massive transfusion protocols advocating the early use of plasma in trauma by some centres. There is now a body of studies that have assessed individual coagulation factors during storage of thawed plasma. These show that factor VIII (FVIII) is the worst affected factor and that its activity is mainly lost during the first 24 h following thawing. However, for most factors studied, there is a continual decline during further storage. The few studies that have assessed thrombin generation in thawed plasma have shown variable results. Extended storage of plasma is associated with an increase in levels of DEHP in the component and could theoretically increase the risk of bacterial contamination, although the latter does not appear to have been an issue in countries that have adopted the use of thawed plasma. There are no clinical studies relating to the efficacy of extended-thawed plasma, and therefore, the potential reduction in its efficacy must be balanced with the clinical need for the component.

Never-frozen liquid plasma blocks endothelial permeability as effectively as thawed fresh frozen plasma

BACKGROUND

Thawed fresh frozen plasma (TP) is a preferred plasma product for resuscitation but can only be used for up to 5 days after thawing. Never-frozen, liquid plasma (LQP) is approved for up to 26 days when stored at 1°C to 6°C. We have previously shown that TP repairs tumor necrosis factor α (TNF-α)-induced permeability in human endothelial cells (ECs). We hypothesized that stored LQP repairs permeability as effectively as TP.

METHODS

Three single-donor LQP units were pooled. Aliquots were frozen, and samples were thawed on Day 0 (TP0) then refrigerated for 5 days (TP5). The remaining LQP was kept refrigerated for 28 days, and aliquots were analyzed every 7 days. The EC monolayer was stimulated with TNF-α (10 ng/mL), inducing permeability, followed by a treatment with TP0, TP5, or LQP aged 0, 7, 14, 21, and 28 days. Permeability was measured by leakage of fluorescein isothiocyanate-dextran through the EC monolayer. Hemostatic profiles of samples were evaluated by thrombogram and thromboelastogram. Statistical analysis was performed using two-way analysis of variance, with p < 0.05 deemed significant.

RESULTS

TNF-α increased permeability of the EC monolayer twofold compared with medium control. There was a significant decrease in permeability at 0, 7, 14, 21, and 28 days when LQP was used to treat TNF-α-induced EC monolayers (p < 0.001). LQP was as effective as TP0 and TP5 at reducing permeability. Stored LQP retained the capacity to generate thrombin and form a clot.

CONCLUSION

LQP corrected TNF-α-induced EC permeability and preserved hemostatic potential after 28 days of storage, similar to TP stored for 5 days. The significant logistical benefit (fivefold) of prolonged LQP storage improves the immediate availability of plasma as a primary resuscitative fluid for bleeding patients.