Emergency use of prethawed Group A plasma in trauma patients

Blood banking considerations in pediatric trauma

ABSTRACT

Transfusion of blood products to a hemorrhaging pediatric trauma patient requires seamless partnership and communication between trauma, emergency department, critical care, and transfusion team members. To avoid confusion and delays, understanding of blood banking principles and mutually agreed upon procedures and policies must be regularly updated as knowledge evolves. Because pediatric patients require specialized considerations distinct from those in adults, this brief review covers transfusion principles, policies, and procedures specific to the resuscitation of pediatric trauma patients.

Plasma Isoagglutinin Depletion for Blood Group Independent Plasma Transfusion

Background

Plasma transfusion is one of the basic treatments in patients with major blood loss. The anti-A and anti-B antibodies contained in the plasma demand ABO blood group compatibility. This is limiting the use of plasma in emergency situations and can cause a shortage in the supply of plasma of certain blood groups. We developed a method for anti-A and anti-B depletion by adsorbing plasma isoagglutinins using red blood cells.

Materials and Methods

Three units of fresh frozen plasma were thawed after quarantine storage, pooled, and an aliquot of red cell concentrate was added. After 2 h of incubation at room temperature antibody-red-cell complexes were removed by centrifugation, the isoagglutinin-depleted plasma was split into three units and deep frozen. Isoagglutinin titers, free hemoglobin, residual red cells, clotting factor activity, and sterility of plasma units were determined after isoagglutinin depletion and a double freeze-thawing procedure.

Results

Anti-B titers in group A plasma were reduced from values of 1:64 to 1:1 or lower, anti-A titers in group B plasma decreased from values of 1:128 to at least 1:16. Postprocedure clotting factor activities were preserved with 88.0 ± 7.3% (factor V), 106.9 ± 11.4% (factor VIII), and 84.0 ± 7.5% (factor XI) fulfilling the quality control requirements. No residual red cells were found, but free hemoglobin slightly increased to 53.7 ± 5.2 μmol/L. All units were sterile.

Discussion

We described a method for the production of anti-A- and anti-B-depleted plasma in a closed system that uses standard equipment. The resulting isoagglutinin-depleted plasma may allow for blood group independent plasma transfusion.

Risk of ABO-Incompatible Plasma From Non-ABO-Identical Components

The last several decades have seen significant changes in the approach to resuscitation of bleeding patients. These include the adoption of ABO-incompatible plasma transfusion in the form of group A plasma and/or low titer group O whole blood for trauma patients of unknown ABO group. Studies to date have examined the impact of these practices on patient outcomes and clinical markers of hemolysis in recipients of ABO-incompatible plasma compared to those for whom the plasma is ABO-compatible. Risk for increased mortality and/or overt hemolysis appear to be low among recipients of ABO-incompatible plasma; however, nearly all of studies are retrospective and most have focused only on adult trauma patients so results may not be generalizable to other bleeding patients. Work continues to evaluate the role of various titer thresholds in decreasing hemolytic risk and opportunities remain to improve our understanding of anti-A and anti-B antibody interactions with complement/endothelium and identify strategies to minimize risk.

Evaluation of safety of using incompatible plasma for therapeutic plasma exchange during shortage of AB plasma

BACKGROUND

Criteria for selection of FFP blood type has not been clearly established and use of group AB plasma is preferred by numerous transplantation protocols.

AIMS

This study assesses the safety and efficacy of alternative group A or B plasma in ABO incompatible solid organ transplantation.

MATERIALS & METHODS

Alternative use of group A or B plasma (incompatible plasma) was inevitable during the shortage of group AB plasma. Experience from select number of patients during the period of extreme group AB plasma shortage is described.

RESULTS

The result of alternative use of group A or B plasma was within expectation, showing effective reduction of isoagglutinin titers for pre-operative desensitization and efficacy for treatment of post-operative patients. No immediate hemolytic transfusion reaction was reported.

DISCUSSION

While validation in a larger cohort of patients is necessary, our limited experience have shown satisfactory clinical outcomes without adverse events.

CONCLUSIONS

Use of incompatible group A or B plasma is a viable option when group AB plasma is limited.

Kidney problems in disaster situations

Mass disasters, particularly earthquakes, cause many medical problems, including kidney problems, but an organized approach to cope with them was initiated only at the end of previous century, subsequent to the Armenian Spitak earthquake in 1988. Originally, interventions were focused on acute kidney injury (AKI) following crush injury and rhabdomyolysis in victims who had been trapped under the debris of collapsed buildings. However, similar problems were also registered in the context of other catastrophic events, especially man-made disasters like wars and torture. Other kidney-related problems, such as the preservation of treatment continuity in chronic kidney disease (CKD), especially in maintenance dialysis patients, deserved attention as well. Specific therapeutic principles apply to disaster-related kidney problems and these may differ from usual day-to-day clinical practice. Those approaches have been formulated in global and specific country-related guidelines and recommendations. It is clear that a well-conceived and organized management of kidney diseases in disasters benefits outcomes. Furthermore, it may be useful if the model and philosophy that were applied over the last three decades could be adapted by broadening the scope of disasters leading to intervention. Actions should be guided and coordinated by a panel of experts steering ad hoc interventions, rather than applying the "old" static model where a single coordinating center instructs and uses volunteers listed long before a potential event occurs.

Group A emergency-release plasma in trauma patients requiring massive transfusion

BACKGROUND

Both groups A and AB plasma have been approved for emergency-release transfusion in acutely bleeding trauma patients before blood grouping being performed. The safety profile associated with this practice has not been well characterized, particularly in patients requiring massive transfusion.

METHODS

This secondary analysis of the Pragmatic, Randomized, Optimal Platelet and Plasma Ratios trial examined whether exposure to group A emergency-release plasma (ERP) was noninferior to group AB ERP. We also examined patients whose blood groups were compatible with group A ERP versus patients whose blood groups were incompatible with group A ERP. Outcomes included 30-day mortality and complication rates including systemic inflammatory response syndrome, infection, renal injury, pulmonary dysfunction, and thromboembolism.

RESULTS

Of the 680 patients predicted to receive a massive transfusion, 584 (85.9%) received at least 1 U of ERP. Of the 584 patients analyzed, 462 (79.1%) received group AB and 122 (20.9%) received group A ERP. Using a hazard ratio (HR) of 1.35 as the noninferiority margin, transfusion with group A versus group AB ERP was not associated with increased thromboembolic rates (HR, 0.52; 95% confidence interval [CI], 0.31-0.90). Mortality (HR, 1.15; 95% CI, 0.91-1.45) and nonfatal complication rates (HR, 1.24; 95% CI, 0.87-1.77) were inconclusive. In the subgroup analysis, transfusion with incompatible ERP (group B or AB patients receiving group A ERP) was not associated with increased nonfatal complications (HR, 1.02; 95% CI, 0.80-1.30). There were no reported hemolytic transfusion reactions.

CONCLUSION

The use of ERP is common in patients requiring massive transfusion and facilitates the rapid balanced resuscitation of patients who have sustained blood loss. Group A ERP is an acceptable option for patients requiring massive transfusion, especially if group AB ERP is not readily available.

LEVEL OF EVIDENCE

Therapeutic/Care Management, level IV; Prognostic, level III.

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.

Risk analysis of transfusion of cryoprecipitate without consideration of ABO group

BACKGROUND

Transfusion medicine standards in Canada state that adult recipients can be transfused with cryoprecipitate of any ABO group, however, not all hospitals follow this guideline. There is a paucity of data on cryoprecipitate anti-A/B levels to reinforce standards.

STUDY DESIGN AND METHODS

Manual tube antibody titration was performed on 7 units of group O plasma and the corresponding cryosupernatant plasma and cryoprecipitate. IgG/IgM levels were determined by nephelometry. Additionally, 10 cryoprecipitate each from groups A, B, and O were similarly assessed. From the antibody titer distribution among these samples, the probability of making a pool of cryoprecipitate with a titer ≥1:100 was calculated using bootstrap analysis.

RESULTS

Anti-A/B titers in cryoprecipitate were equivalent to those in corresponding plasma; partitioning of anti-A/B activity into cryoprecipitate was not observed. Average IgM concentration was higher in cryoprecipitate than in plasma (P < .01). However, no correlation between IgM levels and anti-A/B titers was established. Among 30 cryoprecipitates from routine blood bank inventory, the median antibody titer and mode were 1:32 and 1:16, respectively. Of the samples tested, 4 of 30 and 9 of 30 had titers above 1:100 and 1:50, respectively. The probability of transfusing an adult dose of cryoprecipitate (pool of 10 cryoprecipitate) with a titer higher than 1:100 was calculated to be less than 1 in 3 million.

CONCLUSIONS

This study provides strong evidence to support current Canadian transfusion medicine standards on the safety of transfusion of cryoprecipitate without the need for blood group matching in adult recipients.

Transfusion of blood components containing ABO-incompatible plasma does not lead to higher mortality in civilian trauma patients

BACKGROUND

This study investigated the effect on mortality of transfusing ABO-incompatible plasma from all sources during trauma resuscitation.

METHODS

Demographic, transfusion, and survival data were retrospectively extracted on civilian trauma patients. Patients were divided by receipt of any quantity of ABO-incompatible plasma from any blood product (incompatible group) or receipt of solely ABO-compatible plasma (compatible group). The primary outcome was 30-day mortality, while other outcomes included 6- and 24-hour mortality. Mixed-effects logistic regression was used to model the effect of various predictor variables, including receipt of incompatible plasma, on mortality outcomes.

RESULTS

Nine hospitals contributed data on a total of 2618 trauma patients. There were 1282 patients in the incompatible group and 1336 patients in the compatible group. In both the unadjusted and adjusted models, the 6-hour, 24-hour, and 30-day mortality rates were not significantly different between these groups. The patients in the incompatible group were then divided into high volume (>342 mL) and low volume (≤342 mL) incompatible plasma recipients. In the adjusted model, the high-volume group had higher 24-hour mortality when the Trauma Injury Severity Score survival prediction was >50%. Mortality at 6 hours and 30 days was not higher in this model. The low-volume group did not have increased mortality at any of the time points in this adjusted model.

CONCLUSION

The transfusion of incompatible plasma in civilian trauma resuscitation does not lead to higher 30-day mortality. The finding of higher mortality in a select group of recipients in the secondary analysis warrants further study.

Trauma-Induced Coagulopathy and Massive Bleeding: Current Hemostatic Concepts and Treatment Strategies

Hemorrhage after trauma remains a significant cause of preventable death. Trauma-induced coagulopathy (TIC) at the time of hospital admission is associated with an impaired outcome. Rather than a universal phenotype, TIC represents a complex hemostatic disorder, and standard coagulation tests are not designed to adequately reflect the complexity of TIC. Viscoelastic testing (VET) has gained increasing interest for the characterization of TIC because it provides a more comprehensive depiction of the coagulation process. Thus, VET has been established as a point-of-care-available hemostatic monitoring tool in many trauma centers. Damage-control resuscitation and early administration of tranexamic acid provide the basis for treating TIC. To improve survival, ratio-driven massive transfusion protocols favoring early and high-dose plasma transfusion have been implemented in many trauma centers around the world. Although plasma contains all coagulation factors and inhibitors, only high-volume plasma transfusion allows for adequate substitution of lacking coagulation proteins. However, high-volume plasma transfusion has been associated with several relevant risks. In some European trauma facilities, a more individualized hemostatic therapy concept has been implemented. The hemostatic profile of the bleeding patient is evaluated by VET. Subsequently, goal-directed hemostatic therapy is primarily based on coagulation factor concentrates such as fibrinogen concentrate or prothrombin complex concentrate. However, a clear difference in survival benefit between these two treatment strategies has not yet been shown. This concise review aims to summarize current evidence for different diagnostic and therapeutic strategies in patients with TIC.

The impact of blood product ratio and procoagulant therapy on the development of thromboembolic events in severely injured hemorrhaging trauma patients

INTRODUCTION

Transfusion therapy in hemorrhaging trauma patients is associated with the development of thromboembolic events. It is unknown whether current resuscitation strategies, including large volumes of plasma and early administration of procoagulant therapy, increases this risk.

METHODS

A systematic search was conducted in MEDLINE, PubMed, and Embase. Studies were screened by two independent reviewers and included if they reported on thromboembolic events in patients with severe trauma (injury severity score ≥16) who received transfusion of at least 1 unit of red blood cells. The ratio by which blood products were transfused, as well as use of procoagulant or antifibrinolytic medication, was recorded.

RESULTS

A total of 40 studies with 11.074 bleeding trauma patients were included, in which 1.145 thromboembolic events were reported, yielding an incidence of 10% thromboembolic events. In studies performing routine screening for thromboembolic complications, the incidence ranged from 12% to 23%. The risk of thromboembolic events was increased after administration of tranexamic acid (TXA; odds ratio [OR], 2.6; 95% confidence interval [CI], 1.7-4.1; p < 0.001) and fibrinogen concentrate (OR, 2.1; 95% CI, 1.0-4.2; p = 0.04). Blood product ratio, the use of prothrombin complex concentrate or recombinant factor VIIa were not associated with thromboembolic events.

CONCLUSION

This systematic review identified an incidence of thromboembolic events of 10% in severely injured bleeding trauma patients. The use of TXA and fibrinogen concentrate was associated with the development of thromboembolic complications.

Characterization of Ebola convalescent plasma donor immune response and psoralen treated plasma in the United States

BACKGROUND

In 2014, passive immunization by transfusion of Ebola convalescent plasma (ECP) was considered for treating patients with acute Ebola virus disease (EVD). Early Ebola virus (EBOV) seroconversion confers a survival advantage in natural infection, hence transfusion of ECP plasma with high levels of neutralizing EBOV antibodies is a potential passive immune therapy. Techniques to reduce the risk of other transfusion-transmitted infections (TTIs) are warranted as recent ECP survivors are ineligible as routine blood donors. As part of an ongoing clinical trial to evaluate the safety and effectiveness of ECP, the impact of amotosalen/UVA pathogen reduction technology (PRT) on EBOV antibody characteristics was examined.

STUDY DESIGN AND METHODS

Serum and plasma samples were collected from EVD-recovered subjects at multiple timepoints and evaluated by ELISA for antibodies to recombinant EBOV glycoprotein (GP) and irradiated whole EBOV antigen, as well as for EBOV microneutralization, classic plaque reduction neutralization test (PRNT) and EBOV pseudovirion neutralization assay (PsVNA) activity.

RESULTS

Six subjects donated 40 individual ECP units. Substantial antibody titers and neutralizing activity results were demonstrated but were generally lower for the ACD plasma samples compared to the serum samples. Anti-EBOV titers by all assays remained essentially unchanged after PRT.

CONCLUSION

Treatment of ECP with PRT to reduce the risk of TTI did not significantly reduce EBOV IgG antibody titers or neutralizing activity. Although ECP was used in the treatment of repatriated patients, no PRT units from this study were transfused to EVD patients. This inventory of PRT-treated ECP is currently available for future clinical evaluation.

Reducing AB plasma utilisation through the AB plasma appropriateness index

OBJECTIVES

We hypothesised that there was inappropriate group AB plasma used in our hospital, identifiable by a novel key quality indicator (KQI) and mitigable through massive transfusion protocol (MTP) modification.

BACKGROUND

Group AB plasma is a scarce resource strained by increasing usage worldwide when used as universal donor plasma in non-group AB patients. To reduce inappropriate use and to promote benchmarking to the best practice, we developed the AB plasma appropriateness index (ABAI). ABAI is the ratio of AB plasma transfused to group AB or unknown blood group patients to all AB plasma utilised, where values closer to 1 are better.

METHODS

Data collected included AB plasma disposition by blood group, indications for transfusion, total blood utilisation, patient clinical characteristics and outcomes. ABAI during a 12-month period was retrospectively assessed, which led to implementation of pre-thawed group A plasma instead of group AB plasma for trauma patients starting in July 2017.

RESULTS

The ABAI retrospectively showed inappropriate use in non-group AB patients in our hospital, the majority used to avoid expiry after thaw. When comparing 1-year pre- and post-implementation periods, ABAI improved from 0·464 to 0·900 (P < 0·0001). After exclusion of therapeutic plasma exchange, ABAI still improved (0·486-0·720, P < 0·0001). No differences in the length of stay or mortality associated in 32 patients receiving group A plasma for emergency release were observed.

CONCLUSION

The ABAI is a novel KQI to indicate inappropriate AB plasma usage for quality improvement. This led to thawed A plasma use for MTPs, reducing inappropriate AB plasma usage.

Damage Control Resuscitation

Damage control resuscitation (DCR) is a strategy for resuscitating patients from hemorrhagic shock to rapidly restore homeostasis. Efforts are focused on blood product transfusion with whole blood or component therapy closely approximating whole blood, limited use of crystalloid to avoid dilutional coagulopathy, hypotensive resuscitation until bleeding control is achieved, empiric use of tranexamic acid, prevention of acidosis and hypothermia, and rapid definitive surgical control of bleeding. Patients receiving uncrossmatched Type O blood in the emergency department and later receiving cumulative transfusions of 10 or more red blood cell units in the initial 24-hour post-injury (massive transfusion) are widely recognized as being at increased risk of morbidity and mortality due to exsanguination. Ideally, these patients should be rapidly identified, however anticipating transfusion needs is challenging. Useful indicators of massive transfusion reviewed in this guideline include: systolic blood pressure <110 mmHg, heart rate > 105 bpm, hematocrit <32%, pH < 7.25, injury pattern (above-the-knee traumatic amputation especially if pelvic injury is present, multi-amputation, clinically obvious penetrating injury to chest or abdomen), >2 regions positive on Focused Assessment with Sonography for Trauma (FAST) scan, lactate concentration on admission >2.5, admission international normalized ratio ≥1.2-1.4, near infrared spectroscopy-derived StO2 < 75% (in practice, rarely available), BD > 6 meq/L. Unique aspects of out-of-hospital DCR (point of injury, en-route, and remote DCR) and in-hospital (Medical Treatment Facilities: Role 2b/Forward surgical teams - role 3/ combat support hospitals) are reviewed in this guideline, along with pediatric considerations.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

BACKGROUND

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.

RESULTS

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Acute Hemolytic Transfusion Reaction in Group B Recipient Associated with Group A Apheresis Platelet Donor: Case Report and Literature Review

Acute hemolytic transfusion reaction is a known but rare potential adverse event related to platelet transfusion. Most reported cases of platelet-related hemolytic transfusion reaction have resulted from transfusion of platelets from group O donor to group A recipient. We identified only one prior case report in the literature of hemolytic transfusion reactions resulting from transfusion of apheresis platelets from group A donor to group B recipient. In that case report, two platelet units were obtained from a single donation and transfused into two separate patients. Both patients exhibited acute hemolytic reactions. The donor is reported to have high anti-B titers, as well as report of probiotic use. We report a case of acute hemolytic reaction in group B recipient following transfusion of apheresis platelets from group A donor with high-titer anti-B but unknown status of probiotic use. This case demonstrates that while low, there still exists potential risk for hemolysis from out-of-group A plasma transfusion.

Preventing Mistransfusions: An Evaluation of Institutional Knowledge and a Response

BACKGROUND

Blood product mistransfusions occur when a process error causes transfusion of incompatible blood products. These events are known sources of negative patient outcomes. One such event demonstrated an institutional knowledge gap and an opportunity to reduce this source of transfusion errors. The focus of this study was to evaluate the application of point of care cognitive aids to bridge potentially lethal knowledge gaps in blood product to patient compatibility.

METHODS

A patient-donor ABO antigen compatibility grid for red blood cells (RBC) and fresh frozen plasma (FFP) was developed for creation of a cognitive aid and a blood product safety quiz. Participants included 117 registered nurses and postgraduate medical interns who were given 2 minutes to complete the quiz for establishing institutional controls. A separate group of 111 registered nurses and interns were given the same timed quiz twice, without and then with a blood product compatibility cognitive aid. An analysis of covariance was used to evaluate without cognitive aid versus with cognitive aid quiz results while taking the specialty (nurse versus interns) and baseline score into consideration. The blood bank adopted the grid as a forcing function to be completed before release of blood products.

RESULTS

The correct RBC answer percentage increased from 84.7% to 98.3% without and with cognitive aid (average improvement 13.6%, standard deviation [SD] = 18.3%, 95% confidence interval, 10.1%-17.1%, P < .0001, ); the correct FFP answer percentage increased from 54.2% to 99.6% without and with cognitive aid (average improvement 45.4%, SD = 20.1%, 95% confidence interval, 41.7%-49.2%, P < .0001). Participants with lower baseline RBC and FFP score showed better improvement in the correct answer percentage for RBC and FFP (P < .001), respectively.

CONCLUSIONS

The use of a cognitive aid for determining blood product ABO compatibility may improve performance during a time-limited test for matching correct patient and blood product ABO type. The use of the cognitive aid as a "forcing function" before the release of blood from the blood bank and before transfusion at the bedside may reduce transfusion mismatch associated with gaps in ABO compatibility knowledge.

Resuscitation for Hypovolemic Shock

Hemorrhage is the leading cause of preventable deaths in trauma patients. After presenting a brief history of hemorrhagic shock resuscitation, this article discusses damage control resuscitation and its adjuncts. Massively bleeding patients in hypovolemic shock should be treated with damage control resuscitation principles including limited crystalloid, whole blood or balance blood component transfusion to permissive hypotension, preventing hypothermia, and stopping bleeding as quickly as possible.

Transfusion Practice in Trauma Resuscitation

Recognition of the acute coagulopathy of trauma and the limits of reconstituting whole blood with conventional blood components has led to a radical change in the way trauma patients with severe injuries are resuscitated. Massive transfusion protocols (MTP) have evolved toward the administration of conventional blood components in fixed ratios. Administration of a 1:1:1 unit ratio of fresh frozen plasma to whole-blood-derived platelets to packed red blood cells is now the most common strategy and the stated goal of directors of >80% of the level I trauma centers in the United States. Various physiologic scoring systems exist to guide early activation of an MTP. After activation of an MTP, more goal-directed therapy follows as soon as laboratory results are available. Hemostatic resuscitation using defined blood component ratios modified by early laboratory results can lead to more efficient blood product usage and improved patient outcomes.

Incompatible type A plasma transfusion in patients requiring massive transfusion protocol: Outcomes of an Eastern Association for the Surgery of Trauma multicenter study

With a relative shortage of type AB plasma, many centers have converted to type A plasma for resuscitation of patients whose blood type is unknown. The goal of this study is to determine outcomes for trauma patients who received incompatible plasma transfusions as part of a massive transfusion protocol (MTP).

METHODS

As part of an Eastern Association for the Surgery of Trauma multi-institutional trial, registry and blood bank data were collected from eight trauma centers for trauma patients (age, ≥ 15 years) receiving emergency release plasma transfusions as part of MTPs from January 2012 to August 2016. Incompatible type A plasma was defined as transfusion to patient blood type B or type AB.

RESULTS

Of the 1,536 patients identified, 92% received compatible plasma transfusions and 8% received incompatible type A plasma. Patient characteristics were similar except for greater penetrating injuries (48% vs 36%; p = 0.01) in the incompatible group. In the incompatible group, patients were transfused more plasma units at 4 hours (median, 9 vs. 5; p < 0.001) and overall for stay (11 vs. 9; p = 0.03). No hemolytic transfusion reactions were reported. Two transfusion-related acute lung injury events were reported in the compatible group. Between incompatible and compatible groups, there was no difference in the rates of acute respiratory distress syndrome (6% vs. 8%; p = 0.589), thromboembolic events (9% vs. 7%; p = 0.464), sepsis (6% vs. 8%; p = 0.589), or acute renal failure (8% vs. 8%, p = 0.860). Mortality at 6 (17% vs. 15%, p = 0.775) and 24 hours (25% vs. 23%, p = 0.544) and at 28 days or discharge (38% vs. 35%, p = 0.486) were similar between groups. Multivariate regression demonstrated that Injury Severity Score, older age and more red blood cell transfusion at 4 hours were independently associated with death at 28 days or discharge; Injury Severity Score and more red blood cell transfusion at 4 hours were predictors for morbidity. Incompatible transfusion was not an independent determinant of mortality or morbidity.

CONCLUSION

Transfusion of type A plasma to patients with blood groups B and AB as part of a MTP does not appear to be associated with significant increases in morbidity or mortality.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Damage Control Resuscitation for Catastrophic Bleeding

The timely recognition of shock secondary to hemorrhage from severe facial trauma or as a complication of complex oral and maxillofacial surgery presents formidable challenges. Specific hemostatic disorders are induced by hemorrhage and several extreme homeostatic imbalances may appear during or after resuscitation. Damage control resuscitation has evolved from massive transfusion to a more complex therapeutic paradigm that includes hemodynamic resuscitation, hemostatic resuscitation, and homeostatic resuscitation. Definitive control of bleeding is the principal objective of any comprehensive resuscitation scheme for hemorrhagic shock.

Safety of the use of group A plasma in trauma: the STAT study

BACKGROUND

Use of universally ABO-compatible group AB plasma for trauma resuscitation can be challenging due to supply limitations. Many centers are now using group A plasma during the initial resuscitation of traumatically injured patients. This study was undertaken to evaluate the impact of this practice on mortality and hospital length of stay (LOS).

STUDY DESIGN AND METHODS

Seventeen trauma centers using group A plasma in trauma patients of unknown ABO group participated in this study. Eligible patients were group A, B, and AB trauma patients who received at least 1 unit of group A plasma. Data collected included patient sex, age, mechanism of injury, Trauma Injury Severity Score (TRISS) probability of survival, and number of blood products transfused. The main outcome of this study was in-hospital mortality differences between group B and AB patients compared to group A patients. Data on early mortality (≤24 hr) and hospital LOS were also collected.

RESULTS

There were 354 B and AB patients and 809 A patients. The two study groups were comparable in terms of age, sex, TRISS probability of survival, and total number of blood products transfused. The use of group A plasma during the initial resuscitation of traumatically injured patients of unknown ABO group was not associated with increased in-hospital mortality, early mortality, or hospital LOS for group B and AB patients compared to group A patients.

CONCLUSION

These results support the practice of issuing thawed group A plasma for the initial resuscitation of trauma patients of unknown ABO group.

Optimal Fluid Therapy for Traumatic Hemorrhagic Shock

The resuscitation of traumatic hemorrhagic shock has undergone a paradigm shift in the last 20 years with the advent of damage control resuscitation (DCR). Major principles of DCR include minimization of crystalloid, permissive hypotension, transfusion of a balanced ratio of blood products, and goal-directed correction of coagulopathy. In particular, plasma has replaced crystalloid as the primary means for volume expansion for traumatic hemorrhagic shock. Predicting which patient will require DCR by prompt and accurate activation of a massive transfusion protocol, however, remains a challenge.

Platelet function in reconstituted whole blood variants: An observational study over 5 days of storage time

BACKGROUND

Platelet concentrates (PCs) are usually stored at room temperature under constant gentle agitation. Risk of bacterial contamination limits maximum storage time to 5 days. The objective of the study was to investigate platelet function with regard to storage time in different reconstituted whole blood (RWB) variants.

METHODS

Donated apheresis PCs were stored at 22°C over 5 days. To obtain RWB, apheresis PCs were mixed with plasma-free packed red blood cells (RBCs) and either prethawed fresh frozen plasma (PT) or solvent-detergent plasma (SD) [1:1:1 ratio], or with leukocyte- and platelet-depleted whole blood (LD-WB) as control. Platelet function in RWB variants was assessed by impedance aggregometry (Multiplate) on Days 0, 1, 3, and 5 following platelet donation.

RESULTS

Platelet aggregometry did not reach the lower limits determined from healthy volunteers in any of the RWB variants. Platelet aggregability measured by ASPI test, ADP test, and COL test declined over storage time in all RWB variants. No differences were observed in the TRAP test. At most measurement time points, LD-RWB provided significantly higher platelet aggregability compared with SD-RWB and PT-RWB (p < 0.01). SD-RWB demonstrated higher platelet aggregability on Day 0 in the ASPI test, ADP test, and TRAP test compared with PT-RWB.

CONCLUSION

Apheresis PCs stored for 5 days at 22°C demonstrated reduced platelet aggregability, as measured by multiple electrode aggregometry when mixed with RBCs and plasma. As platelet aggregation in LD-RWB was superior compared with SD-RWB and PT-RWB variants, it might be possible that additives in RBCs or plasma are responsible for the observed depressed platelet function. Critical evaluation of current massive transfusion recommendations proposing early platelet transfusion is indicated.

Care bundles for management of obstetrical hemorrhage

Peripartum hemorrhage is one of the most preventable causes of maternal mortality worldwide. Much effort has been directed toward creating programs that address deficits in maternity care responsible for preventable hemorrhage-related morbidity and mortality. To have a significant impact on outcomes, such programs must address both providers and processes involved in the delivery of maternity care. At the core of a successful program, are standardized care bundles integrating medical and surgical techniques for managing hemorrhage with principles of transfusion medicine and critical care. In this article, we review the components of the safety bundle for obstetric hemorrhage developed by ACOG District II Safe Motherhood Initiative.

A possible new paradigm? A survey-based assessment of the use of thawed group A plasma for trauma resuscitation in the United States

BACKGROUND

Although evidence supporting this practice is limited, some centers use thawed group A plasma for the initial resuscitation of trauma patients.

STUDY DESIGN AND METHODS

To better understand the current use of plasma in trauma resuscitation, a survey was developed, validated, and distributed via e-mail to 121 American trauma centers.

RESULTS

A total of 61 responses were received. Most were from Level 1 trauma centers (56/61, 92%) in urban settings (47/61, 77%). Virtually all centers reported maintaining A thawed plasma inventory (59/61, 97%). Among the 56 Level 1 trauma center respondents, most keep thawed A immediately available (49/56, 88%) and many use group A plasma for trauma recipients of unknown ABO group (34/49, 69%). Half of the surveyed centers implemented this practice within the past year. The majority do not limit the amount of A plasma that can be administered to a patients of unknown ABO group (21/34, 62%), and most do not titer for anti-B (27/34, 79%).

CONCLUSION

The majority of Level 1 trauma centers maintain thawed plasma inventories and use group A plasma for trauma recipients of unknown ABO group. Most centers do not limit the amount of group A plasma used in this situation or titer the anti-B.

Making thawed universal donor plasma available rapidly for massively bleeding trauma patients: experience from the Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial

BACKGROUND

The Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial was a randomized clinical trial comparing survival after transfusion of two different blood component ratios for emergency resuscitation of traumatic massive hemorrhage. Transfusion services supporting the study were expected to provide thawed plasma, platelets, and red blood cells within 10 minutes of request.

STUDY DESIGN AND METHODS

At the 12 Level 1 trauma centers participating in PROPPR, blood components transfused and delivery times were tabulated, with a focus on universal donor (UD) plasma management. The adequacy of site plans was assessed by comparing the bedside blood availability times to study goals and the new American College of Surgeons guidelines.

RESULTS

Eleven of 12 sites were able to consistently deliver 6 units of thawed UD plasma to their trauma-receiving unit within 10 minutes and 12 units in 20 minutes. Three sites used blood group A plasma instead of AB for massive transfusion without complications. Approximately 4700 units of plasma were given to the 680 patients enrolled in the trial. No site experienced shortages of AB plasma that limited enrollment. Two of 12 sites reported wastage of thawed AB plasma approaching 25% of AB plasma prepared.

CONCLUSION

Delivering UD plasma to massively hemorrhaging patients was accomplished consistently and rapidly and without excessive wastage in high-volume trauma centers. The American College of Surgeons Trauma Quality Improvement Program guidelines for massive transfusion protocol UD plasma availability are practicable in large academic trauma centers. Use of group A plasma in trauma resuscitation needs further study.

How we provide thawed plasma for trauma patients

Almost 50% of trauma-related fatalities within the first 24 hours of injury are related to hemorrhage. Improved survival in severely injured patients has been demonstrated when massive transfusion protocols are rapidly invoked as part of a therapeutic approach known as damage control resuscitation (DCR). DCR incorporates the early use of plasma to prevent or correct trauma-induced coagulopathy. DCR often requires the transfusion of plasma before determination of the recipient's ABO group. Historically, group AB plasma has been considered the "universal donor" plasma product. At our facility, the number of AB plasma products produced on an annual basis was found to be inadequate to support the trauma service's DCR program. A joint decision was made by the transfusion medicine and trauma services to provide group A thawed plasma (TP) for in-hospital and prehospital DCR protocols. A description of the implementation of group A TP into the DCR program is provided as well as outcome data pertaining to the use of TP in trauma patients.

Damage control resuscitation

The early recognition and management of hemorrhage shock are among the most difficult tasks challenging the clinician during primary assessment of the acutely bleeding patient. Often with little time, within a chaotic setting, and without sufficient clinical data, a decision must be reached to begin transfusion of blood components in massive amounts. The practice of massive transfusion has advanced considerably and is now a more complete and, arguably, more effective process. This new therapeutic paradigm, referred to as damage control resuscitation (DCR), differs considerably in many important respects from previous management strategies for catastrophic blood loss. We review several important elements of DCR including immediate correction of specific coagulopathies induced by hemorrhage and management of several extreme homeostatic imbalances that may appear in the aftermath of resuscitation. We also emphasize that the foremost objective in managing exsanguinating hemorrhage is always expedient and definitive control of the source of bleeding.

Implementation and execution of civilian remote damage control resuscitation programs

Remote damage control resuscitation is a recently defined term used to describe techniques and strategies to provide hemostatic resuscitation to injured patients in the prehospital setting. In the civilian setting, unlike the typical military setting, patients who require treatment for hemorrhage come in all ages with all types of comorbidities and have bleeding that may be non-trauma related. Thus, in the austere setting, addressing the needs of the patient is no less challenging than in the military environment, albeit the caregivers are typically not putting their lives at risk to provide such care. Two organizations have pioneered remote damage control resuscitation in the civilian environment: Mayo Clinic and Royal Caribbean Cruises Ltd. The limitations in rural Minnesota and shipboard are daunting. Patients who have hemorrhage requiring transfusion are often hundreds of miles from hospitals able to provide damage control resuscitation. This article details the development and implementation of novel programs specifically designed to address the varied needs of patients in such circumstances. The Mayo Clinic program essentially takes a standard-of-care treatment algorithm, by which the patient would be treated in the emergency department or trauma bay, and projects that forward into the rural environment with specially trained prehospital personnel and special resources. Royal Caribbean Cruises Ltd has adapted a traditional military field practice of transfusing warm fresh whole blood, adding significant safety measures not yet reported on the battlefield (see within this Supplement the article entitled "Emergency Whole Blood Use in the Field: A Simplified Protocol for Collection and Transfusion"). The details of development, implementation, and preliminary results of these two civilian programs are described herein.

Multicenter comparison of emergency release group A versus AB plasma in blunt-injured trauma patients

INTRODUCTION

Group AB plasma, the traditional universal donor plasma product, is a limited resource. We compared outcomes of Group A plasma transfusion in comparison to AB.

METHODS

Analysis of blunt-injured patients who received emergency release plasma from was performed. Multivariable logistic regression was utilized to identify associations with morbidity and mortality.

RESULTS

There were 191 patients; 115 Group A and 76 Group AB. No differences were seen in age, sex, plasma transfusions, uncrossmatched red blood cells (RBCs), and Glasgow Coma Scale (GCS). Patients who received Group A plasma had significantly lower Injury Severity Score, chest Abbreviated Injury Scale (AIS), and scene transfer rate but not head AIS, or abdomen AIS. In addition, significant differences were noted in terms of blood products transfused within 24 hours in those receiving Group A over AB. Development of acute respiratory distress syndrome (ARDS), but not mortality, was higher within the AB cohort. No hemolytic or transfusion associated-ARDS reactions were noted in either group. ARDS; RBC transfusion volumes and head AIS were independently associated with mortality.

CONCLUSION

Utilization of Group A plasma for emergency blood resuscitation is a safe option which may alleviate potential shortages of AB plasma.

Plasma first in the field for postinjury hemorrhagic shock

Hemorrhage is the most preventable cause of death in civilian and military trauma, and despite tremendous advances in patient transport in the field, survival within the first hour has changed little over the past 40 years. The pathogenesis of trauma-induced coagulopathy is multifactorial, but most authorities believe there is an early depletion of clotting factors. While fresh frozen plasma delivered early in the emergency department has been shown to be beneficial, the rapid onset of trauma-induced coagulopathy suggests advancing this concept to the scene may improve patient outcome. The purpose of this report was to describe the rationale and design of a randomized trial to test the hypothesis that prehospital "plasma-first" resuscitation will benefit the critically injured patient. The rationale includes the possibility that plasma-first resuscitation may be advantageous beyond direct effects on clotting capacity. The study design is based on a ground ambulance system that allows rapid prehospital thawing of frozen plasma.

How we manage AB plasma inventory in the blood center and transfusion service

The growing use of group AB plasma in the United States in recent years poses unique challenges to blood centers and transfusion services. Blood centers must collect sufficient plasma components from a limited pool of group AB donors while taking steps to improve transfusion safety that further restricts the available supply. Transfusion services, on the other hand, must use the finite resource in the most conscientious and medically appropriate manner. Recently, many investigations have challenged long-held beliefs about transfusion practice and appropriate indications for blood components across a variety of specialties. Balancing supply and demand of group AB plasma requires collaboration between blood suppliers and transfusion services, and opportunities for improvement exist on both sides of the equation.

Resuscitation of trauma-induced coagulopathy

For 30 years, the Advanced Trauma Life Support course of the American College of Surgeons taught that coagulopathy was a late consequence of resuscitation of injury. The recognition of trauma-induced coagulopathy overturns that medical myth and creates a rationale for procoagulant resuscitation. Analysis of the composition of currently available blood components allows prediction of the upper limits of achievable coagulation activity, keeping in mind that oxygen transport must be maintained simultaneously. RBCs, plasma, and platelets given in a 1:1:1 unit ratio results in a hematocrit of 29%, plasma concentration of 62%, and platelet count of 90,000 in the administered resuscitation fluid. Additional amounts of any 1 component dilute the other 2 and any other fluids given dilute all 3. In vivo recovery of stored RBCs is ∼90% and that of platelets ∼60% at the mean age at which such products are given to trauma patients. This means that useful concentrations of the administered products are a hematocrit of 26%, a plasma coagulation factor activity of 62% equivalent to an international normalized ratio of ∼1.2, and a platelet count of 54,000. This means there is essentially no good way to give blood products for resuscitation of trauma-induced coagulopathy other than 1:1:1. Because 50% of trauma patients admitted alive to an academic-level 1 trauma center who will die of uncontrolled hemorrhage will be dead in 2 hours, the trauma system must be prepared to deliver plasma- and platelet-based resuscitation at all times.