Strategies to Enhance Plasma Availability
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- Alexis Snow
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2 Strategies to Enhance Plasma Availability Andrew Bernard, MD Professor of Surgery Medical Director, Acute Care Surgery and Trauma Chief, Section on Trauma and Acute Care Surgery Paul A. Kearney, MD Endowed Chair in Trauma Surgery UK Healthcare, University of Kentucky College of Medicine
3 Learning Objectives Attendees will: List the major benefits of early plasma in hemorrhagic shock. Outline the major barriers to making plasma available in a timely way. Describe system interventions that are relevant to their team.
4 Disclosure Statement I have no relevant conflicts to disclose.
5 Overview 1. Why plasma? 2. Why plasma early? 3. Plasma types 4. Optimizing plasma delivery 5. Options in plasma shortage 6. Future 7. Waste
6 Why plasma?
7 Why plasma? Acute coagulopathy of trauma is deadly. Brohi et al Curr Opin Crit Care 2007
8 Why plasma EARLY? Addressing the issue of survival bias. Lower Mortality Even Lower
9 Plasma Types 1. Fresh whole blood (FWB)-MILITARY (THEORETICAL CIVILIAN) 2. Stored whole blood (SWB)-FEASIBLE, HERE NOW 3. Fresh frozen plasma (FFP, related to FP24)-SLOW 4. Thawed plasma (thawed FFP)-IDEAL 5. Liquid plasma (LP, never frozen)-ideal 6. Dried plasma (DP, for reconstitution)-europe
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11 Optimizing Plasma Delivery 1. Create an MTP that works Pack it right (target 1:1:1 EARLY) Activate for the right reasons (ABC or similar) Activate early In the ED Cotton AB. JoT 2009.
12 Cotton AB. JoT 2009.
13 Cotton AB. JoT 2009.
14 JTACS July 2017
15 Optimizing Plasma Delivery 2. Make your plasma pool larger, using: Thawed plasma (up to 5 days) Liquid plasma (up to 28 days) Blood group A plasma (because AB is rare) Prevalent Solid historical basis (military) Safe?
16 JTACS 2017 Jul;83(1): patients 120 received incompatible transfusion Mortality Predictors (n=1536) Odds Ratio 95% CI p-value Incompatible Type A transfusion 0.98 (0.65,1.51) 0.99 # 4 hours 1.04 (1.03, 1.05) <0.01 ISS 1.03 (1.02,1.04) <0.01 Age 1.01 (1.01,1.02) <0.01
17 Safety of the use of group A plasma in trauma: the STAT study 354 B and AB patients 809 A patients Comparable (age, sex, TRISS, total blood products) No difference: in-hospital mortality early mortality hospital LOS for group B and AB patients (vs group A patients) Transfusion 2017 Aug;57(8):
18 Optimizing Plasma Delivery 3. Make plasma transport time shorter Put thawed plasma in/close to your ED Satellite BB (very expensive) Frig Runner/cooler Tube (slow) Put thawed plasma in the field
19 Pneumatic Tube Faster Fewer units? hemolysis Requires validation Tiwari et al. Clin Chem Lab Med. 2011
20 11 Centers: ED Frig: 1 Cooler: 1 BB in ED: 1 Runner: 8 Mean time to call: 9 minutes Mean time to bedside: 8 minutes Transfusion 2015 June ; 55(6):
21 Field Plasma Trials
22 Future Rapid thawing?-no GOOD METHOD Whole blood-closer THAN YOU THINK Dried plasma-in EUROPE In lieu of plasma-indication AND DOSING? PCC Fibrinogen concentrate
23 1) ISS > 15 and 2) abnormal thrombelastometry (ROTEM) Lancet Haematol 2017;4: e258 71
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25 In the initial management of patients with expected massive haemorrhage, we recommend one of the two following strategies: 1. Plasma, in a plasma RBC ratio of at least 1:2 as needed. (Grade 1B) 2. Fibrinogen concentrate and RBC according to Hb level. (Grade 1C)
26 America Europe
27 America Europe
28
29 Transfusion 2013
30
31 Center FFP Thaw Time #FFP Units Level IV Trauma Patients 2013 ABC 0 ABC 1 Patients Mortality 3 (0.4%) 6 (14.3%) RBC 5 2 FFP 0 0
32 Transfusion April ; 56(Suppl 2): S173 S181.
33 Avoiding Waste
34 2017 MTP COOLER USAGE, UK Pick up phase 1 cooler only Pick up > phase 5 cooler Pick up > phase 1 < phase 5 cooler 19% 4% 77% 29% 26% 33% 8% 11% 4% 63% 63% 63% 46% 40% 36% 38.0% 7% 7.0% 12% 15% 57% 55.0% 42% 45% JUNE JULY AUG SEP OCT NOV DEC YTD
35 2017 MTP Not Transfused Blood 20% 19% 18% 20% 18% 17.0% 15% 11% 8% 8% JAN-APR MAY JUNE JULY AUG SEP OCT NOV DEC YTD
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37 Summary + + Pack it right-1:1:1 Plasma into Community Centers? Keep it thawed PCC or FGN Concentrate? Move it close to the patient Activate Early
38
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