Plasma FFP Evidence based usage - PowerPoint PPT Presentation

1 / 34
About This Presentation
Title:

Plasma FFP Evidence based usage

Description:

11/08-Platelet strategy: may screen for HLA antibodies in apheresis platelets (or AB plasma) ... Therapeutic apheresis for TTP. Plasma mistransfusion ... – PowerPoint PPT presentation

Number of Views:106
Avg rating:3.0/5.0
Slides: 35
Provided by: jgor1
Category:

less

Transcript and Presenter's Notes

Title: Plasma FFP Evidence based usage


1
Plasma (FFP) Evidence based usage
  • Jed B. Gorlin MD, MBA
  • Memorial Blood Centers
  • AABB-Jeddah Saudi Arabia 4/09

2
Goals and Objectives
  • Review AABB TRALI guideline and update
  • Review evidence based medicine ordering
    guidelines
  • Discuss studies of plasma usage
  • Discuss use and abuse of plasma

3
Transfusion Recipient Fatalities 03-08-FDA

4
TRALI
  • Popovsky and Moore, 1985, 36 cases
  • Respiratory distress
  • Hypoxemia
  • Hypotension
  • Within 16 hrs (usually within 12 hrs after
    transfusion of plasma containing blood components
  • Mechanical ventilation 72
  • Rapid resolution within 96 hrs 81
  • Mortality 6

5
Consensus Statement
TRALI is a clinical diagnosis
From Kleinman S et al. Toward an understanding
of transfusion-related acute lung injury
statement of a consensus panel.  Transfusion.
2004441774-89.
6
Pathogenesis
  • Priming and activation Neutrophils
  • Passive transfusion of donor Antibodies of HLA
    Class I II/Granulocyte Antibodies 90 of the
    cases
  • Anti-granulocyte antibodies in the recipient
    (10)
  • Lipid breakdown products in the blood product
  • Complement activation, release neutrophil enzymes
  • Damage endothelial lining
  • Pulmonary edema (exudate)

7
Gajic O, Moore SB. Mayo Clin Proc. 200580766
8
Transfusion Related Acute Lung Injury (TRALI)
Who Is at Risk?
  • Male Female 11
  • No age predilection
  • No disease or diagnosis predilection
  • No medication pattern

CP1155325-49
9
Laboratory Testing
  • Donor testing
  • HLA class I II and HNA antibodies
  • Broad screening test and then antibody ID
  • Recipient testing
  • HLA class I II typing
  • neutrophil typing, if possible
  • If antibody is found, perform cross--match
    (recipient cells and donor serum)
  • Recipient antigen testing or crossmatch is
    necessary to implicate a donor

10
UK-SHOT TRALI
  • UK hemovigilance reporting-Serious hazards of
    transfusion (SHOT) on-line reporting 1999-2005
  • Risk-high plasma (FFP, Platelets) 175,000
  • Low cryo, RBC 1500,000-gt1,000,000
  • All cases investigated including both male and
    female donors. Only female donors with antibodies
    against patient antigens were implicated.
  • UK SHOT conclusion Femme Fatale!

11
UK-NBS National Blood Service
  • Avoid additional questions label M, F
  • Implemented male only plasma 2004 but no
    inventory replacement-note some US imported
  • Marked reduction in incidence of plasma
    associated TRALI noted from 2005-7.
  • Recent reports up, but deaths still down
  • (Platelets in UK are most derived from whole
    blood using the buffy coat method. They are
    pooled but then resuspended in male plasma)

12
AABB TRALI guidance-Nov 06
  • Blood Centers must provide reduced risk (for
    TRALI) products
  • 11/07-Must have implemented strategy to reduce
    TRALI from plasma
  • 11/08-Platelet strategy
  • Not specific about what strategy
  • Hospitals Use evidenced-based medicine
    transfusion guidelines Reduce the Use
  • Improve reporting of severe adverse events (SAE)

13
Relative risk of components
  • HIGH
  • FFP from whole blood or apheresis
  • FP-24
  • Plasma, Cryoprecipitate reduced
  • Apheresis platelets
  • Whole blood
  • LOWER
  • Red Blood Cells from whole blood or apheresis
  • Platelets prepared from whole blood
  • Cryoprecipitate

14
Testing for WBC antibodies
15
Approach to whole blood plasma
  • Plasma-Whole blood-
  • Divert female plasma from A, B, O donors to
    recovered plasma, selectively use male plasma for
    FFP (or 24hour FP)-done June 2007
  • Ability to do this is predicated upon RBCPlasma
    usage gt 31 (Note some RBC are collected as 2
    unit collections and need to have reserves for
    inventory management)

16
AABB TRALI guidance
  • 11/07-Must have implemented strategy to reduce
    TRALI from plasma
  • Most centers using male whole blood plasma
  • 11/08-Platelet strategy may screen for HLA
    antibodies in apheresis platelets (or AB plasma)
  • Ordering practitioners should be using evidenced
    based guidelines Reduce the Use
  • Improve reporting of Severe Adverse Events
  • Revised guideline requires some intervention, not
    full implementation by target date

17
Transfusion Guidelines
  • The purpose of quality assurance is to maximize
    patient care and minimize risk.
  • The most risk-free transfusion is the one never
    given. Hence, eliminating unnecessary
    transfusions yields many benefits
  • Minimize risks from transfusion
  • Economic savings
  • Saves blood products for those recipients who
    most need them.

18
Review of FFP use
  • Prevent bleeding in patients with abnormal
    coagulation results who need urgent surgery or
    procedure
  • Treat bleeding in patients with abnormal
    coagulation test results
  • Thrombotic thrombocytopenic purpura
  • Not indicated fluid resuscitation, nutrition

19
AABB FFP guidance
  • An evidenced based plasma transfusion guidance is
    being prepared
  • Studies including both retrospective and
    prospective are being reviewed for their level of
    evidence and outcomes
  • Various indications, prophylactic, interventional
    are being evaluated

20
FFP for intervention
  • Segal Transfusion (2005) 451413
  • No evidence that abnormal coagulation tests
    predicted bleeding with invasive procedures
  • Dzik The James Blundell Award Lecture 2006
    transfusion and the treatment of haemorrhage
    past, present and future
  • Transfus Med. 2007 Oct17(5)367-74.

21
Lack of correlation between blood loss and coag
values
22
Prospective Review
  • Many transfusions occur in ER or OR where
    clinical information may not be readily available
    to transfusion service.
  • Rapidly bleeding patient may not have a low hct,
    or a low hct is documented using point of care
    (POC) testing, not apparent to blood bank

23
Adult Plasma Guidelines
  • Given to correct multiple deficiencies of plasma
    coagulation factors
  • PT or PTT gt 1.5 times mean normal
  • (Not for INRs of 1.2 or 1.3!!!!!)
  • Diffuse microvascular bleeding in patient
    transfused gt 1 blood volume (massive transfusion)
    (but check platelets first!)
  • Therapeutic apheresis for TTP

24
Plasma mistransfusion
  • 2 units of plasma may be insufficient to correct
    significant coagulopathy. Patients with INR gt2
    typically need 10-15cc/kg
  • If fibrinogen is very low (lt50) you probably
    cant transfuse enough FFP to correct
    coagulopathy-you need a concentrated fibrinogen
    source instead cryoprecipitate
  • INRs lt 1.5 rarely need correction and correction
    is rarely achievable by FFP transfusion!

25
MBC-HCMC- Plasma usage reduction project
26
FFP transfusions volume Tx
  • Transfusion (2006) 461921 Population-based audit
    of fresh-frozen plasma transfusion practices
    Riikka Palo et al.
  • Clearly, physicians order FFP in multiples of 2
    instead of a more physiologic order of 10-15
    ml/kg!

27
TABLE 1. FFP and RBC use per 1000 population and
FFP use per 100 RBC units
Transfusion (2006) 461921 Population-based audit
of fresh-frozen plasma transfusion practices
Riikka Palo et al.
 
28
Mean INR of Fresh Frozen Plasma (n  20 units)
Fresh frozen plasma is ineffective for correcting
minimally elevated international normalized
ratios L L. Holland, T M. Foster, R A. Marlar, J
P Brooks, Transfusion 2005 45 1234 
29
Change in INR after plasma transfusion
N10 within transfusions guidelines
(INRgt1.6)(open circles) N68 units outside of
guidelines, 22 Pts, 10 mL/kg (mean INR pre1.37,
post1.32)
Fresh frozen plasma is ineffective for correcting
minimally elevated international normalized
ratio. L L. Holland et al Transfusion 2005
45 1234 
30
Dzik . Chap 1. 2005 Mintz. Transf Ther AABB.2005
p 5
31
Effect of FFP on PT in pts with mild coagulation
abnormalities
  • Abdel Wahab O, Healy B, Dzik WH (Transfusion
    (2006) 461279-1285
  • Reviewed all cases of FFP transfusion in patients
    with PT 13-17 (INR 1.1-1.85)
  • ONLY 0.8 of patients (N121) normalized!
  • ONLY 15 achieved ½ way correction
  • Median decrease was 0.2 seconds (INR0.07)

32
The effect of fresh frozen plasma in severe
closed head injury
  • Etemadrezaie H, Clin Neurol Neurosurg.
    (2007)109166
  • METHODS Double-blind randomized clinical trial.
    90 patients in two parallel groups FFP or normal
    saline (N/S). Severe closed head injury (GCS lt
    8), no mass lesion required evacuation and no
    history of coagulopathy.
  • RESULTS 44 FFP 46 N/S. New intracerebral
    hematoma more common in the FFP (p0.012). Both
    groups showed similar frequency of poor outcome
    (p0.343). The mortality was significantly more
    common in the FFP group than in the N/S group
    (63 versus 35) CONCLUSION early empirical FFP
    lead to adverse effects, including an increase in
    the frequency of delayed traumatic intracerebral
    hematoma and increased mortality.

33
FFP in trauma
  • Multiple studies both in military and civilian
    trauma document correlation of better outcomes
    with prevention of dilutional coagulopathy in
    massive, and especially blunt trauma
  • Meta-analyses of trauma trials do observe trends
    toward superior outcome

34
Ratio of Blood Products Transfused Affects
Mortality in Patients Receiving Massive
Transfusions in Civilian Hospitals
Write a Comment
User Comments (0)
About PowerShow.com