Early Plasma Transfusion Research Articles

Indications for Early Fresh Frozen Plasma, Cryoprecipitate, and Platelet Transfusion in Trauma

Massive blood transfusion can be lifesaving in the treatment of severe trauma. Guidelines for the use of non-RBC blood components in the early phase of trauma resuscitation are largely based on extensions of expert recommendations for general surgery. The logic and evidence for the use of plasma, platelets, and cryoprecipitate early in the course of massive transfusion for trauma were reviewed. Large series of consecutive patients were sought. Resuscitation of the most severely injured and massively hemorrhaging patients usually starts with crystalloid fluids and progresses to uncross-matched RBC. Low blood volume, insensible losses, consumption, and resuscitation with plasma poor RBC concentrates rapidly lead to plasma coagulation factor concentrations of less than 40%. This typically occurs before 10 U of RBC have been transfused. Early initiation of plasma therapy is often delayed by its lack of immediate availability in the trauma center. Platelets usually fall to concentrations of 50-100 x 10(9)/L after 10-20 units of RBC have been given, but platelet concentrations in individual patients are quite variable and can decrease more quickly. Ideal platelet concentrations in trauma patients are not known, but are generally held to be greater than 50 x 10(9)/L. Cryoprecipitate can rapidly increase the concentrations of fibrinogen and von Willebrand's factor, but the advantages of higher than normal concentrations are speculative. Early use of plasma and platelets at the upper end of recommended doses appears to reduce the incidence of coagulopathy in massively transfused individuals.

Cumulative Risks of Early Fresh Frozen Plasma, Cryoprecipitate and Platelet Transfusion in Europe

Both fresh frozen plasma (FFP) and platelets are heavily used in massive transfusion. Although FFP can partially correct abnormal coagulation, a recent systematic review revealed no randomized trials showing clinical benefit. Although the overall risks of FFP and platelets are low, they are the least safe blood components, due to immunologic reactions such as allergy/anaphylaxis, transfusion-related acute lung injury (TRALI) and hemolysis due to anti-A or anti-B if transfused across ABO groups. TRALI, an acute syndrome of dyspnoea, hypoxia and pulmonary 'white-out' is now a major cause of transfusion-related death. Since it is usually triggered by donor HLA antibodies, selecting non- immune donors for FFP production may be beneficial. For platelet components, risks may be reduced by platelet additive solution, allowing removal of 70% of plasma. Platelets have the additional hazard of bacterial contamination, with donor skin the predominant source. Improved arm cleansing, divert pouches for the first 30-50 mL blood and bacterial screening have been adopted internationally. Virus risks are now vanishingly low, although new agents e.g. West Nile virus can still appear. Pathogen reduction for FFP is now well established in Europe, with solvent detergent and methylene blue methods licensed, and the psoralen amotosalen in trial. Loss of clotting factors and natural anti-coagulants are recognized side effects. Amotosalen is also licensed for platelet concentrates, with the added benefit of bacterial killing. In the UK, concern regarding vCJD has led to importation of US FFP for children.