COMING SOON TO A HELICOPTER NEAR YOU...
Why is Air Care starting to transport and infuse plasma? Multiple studies, many from military combat zones, strongly suggest that clinical outcomes are improved by administration of plasma alongside RBCs in a 1:1 ratio. (1,2) Furthermore, the concept of damage control resuscitation advocates for minimizing crystalloid infusion and maximizing early aggressive resuscitation with blood products in patients with life threatening hemorrhage. Recent unpublished analysis suggests that expanding these resuscitation principles to the prehospital environment via helicopter EMS was associated with improved outcomes. (2) Although this balanced transfusion strategy of plasma and RBCs was first implemented for bleeding trauma patients, it has since been adopted by other medical specialities, such as gastroenterology and ob-gyn in treatment of a variety of hemorrhaging patients. (3)
What kind of plasma will we have on Air Care? Air Care will carry type A plasma. (Type A emergency release plasma can be given to all blood types. It does result in ABO-incompatible transfusions but this has little effect on clinical outcomes) Remote based helicopters (AC 2 & 3) will carry 2 units of liquid plasma. Air Care 1 while based at UCMC will carry 2 units of type A thawed plasma.
***See this article: J Trauma Acute Care Surg. 2013 Jan;74(1):69-74; Emergency use of prethawed Group A plasma in trauma patients.
What is the difference between FFP, thawed plasma, and liquid plasma?
Plasma - the liquid, noncellular portion of whole blood, which contains coagulation factors, water, electrolytes, and fibrinogen.
Fresh Frozen Plasma (FFP) - plasma that is separated and prepared from whole blood and then frozen within 8 hours of collection to allow long-term storage. Prior to administration, FFP must be thawed to a liquid state, which takes approximately 45 minutes. The delay created in thawing FFP limits its use in the emergency situations frequently encountered in the prehospital and transport environment.
Thawed Plasma - FFP that has been... thawed for administration. It has a shelf life of approximately 5 days.
Liquid Plasma (LP) - plasma that is separated and prepared from whole blood in a liquid state and is never frozen. It is FDA approved and is stored at 1-6°C for up to 40 days. Because LP is stored in a liquid state, it is ready for immediate administration, and is thus ideal for use in the prehospital and transport environment.
*** See this article: J Trauma Acute Care Surg. 2013 Jan;74(1):84-90 Hemostatic profiles of never-frozen liquid plasma compared with thawed fresh frozen plasma
When should I initiate plasma transfusion during transport?***AIR CARE PLASMA WILL BE TYPE A WHICH SHOULD ONLY BE GIVEN TO ADULT PATIENTS WHO ARE > 50 kg***
Evidence of or concern for severe internal or external hemorrhage based on history of present illness, physical exam, or mechanism of injury. (ex: ejection from automobile, fall > 20 feet, pedestrian struck, bleeding requiring a tourniquet, penetrating injury to head, neck, torso, etc.)
Presence of hemodynamic instability or acute coagulopathy of trauma as evidenced by any of the following criteria
Systolic Blood pressure < 90mmHg or < 100mmHg if patient age is > 55 years)
Pulse rate > 110 beats per minute
Tachypnea > 24 breaths per minute
Clinical findings of peripheral vasoconstriction including cool, pale skin & capillary refill of > 2 seconds
INR > 1.5
Base deficit < -6mmol/L
Hemoglobin < 11 g/dL
Platelets < 200,000
2) MEDICAL HEMORRHAGE
Liquid plasma administration is strongly encouraged along with pRBC in a 1:1 ratio for treatment of hemodynamically unstable (SBP < 90mmHg) medical hemorrhage such as:
Massive gastrointestional bleeding
Ruptured abdominal aortic aneurysm
Spontaneous retroperitoneal hemorrhage
Life threatening bleeding from any source with an INR > 1.5
Anticipated emergent or urgent invasive/surgical procedure with an INR > 1.5
Acute disseminated intravascular coagulation (DIC) and active life threatening hemorrhage
Liquid plasma administration is strongly encouraged for those patients with CT documented TBI (epidural/subdural hematoma, subarachnoid hemorrhage, or contusion) or spontaneous intracerebral hemorrhage with an INR > 1.5
Should I give one or two units of plasma? When transfusing plasma for the treatment of massive, life-threatening hemorrhage, we should transfuse pRBC and Plasma in a 1:1 ratio with the goal of maintaining a permissive hypotension resuscitation strategy. (See previous LIT for more details)
When transfusing plasma for the reversal of a coagulopathy (INR > 1.5) in the setting of an ICH etc the adult dose of plasma is typically quoted as 15cc/kg. Air Care will transport approximately 400-500cc of plasma (2 units x 200-250cc each) Thus for the adult patient who weighs more than 50kg, both units of plasma would be indicated.
What are the contraindications?
Patients < 16 years old and or ≤ 50kg
Documented intolerance to plasma or its components
Congenital deficiency of IgA in the presence of anti-IgA antibodies. (This information will rarely be known for patients transported by ACMC, thus it is imperative that crew members monitor for signs of anaphylaxis with initiation of plasma transfusion)
For a trauma patient what should I give first pRBC, plasma, or TXA? We should always strive to initiate all three life-saving therapies during transport of the critically ill trauma patient. However, in reality these patients often have limited vascular access, short flight times, and require other life-saving interventions. Thus if you find yourself in a situation where you have to choose what therapy gets administered first, it is the preference of ACMC that transfusion of products (RBC and Plasma) take priority over TXA. In choosing between RBC and Plasma, it is recommended that a PLASMA FIRST transfusion strategy be utilized in the bleeding trauma patient. Keep in mind that all of these therapies can be administered through an IO when time is short and access limited.
What if I have a bunch of questions about this new therapy? For the medical/clinical aspects of this protocol please do not hesitate to contact Ryan Gerecht, MD or Bill Hinckley, MD. For questions regarding the operations of blood storage/replacement etc. contact Ruda Jenkins.
Acknowledgements Many thanks go to our colleauges in the UCMC Blood Bank and to Ruda Jenkins for their tireless work/cooperation in operationalizing plasma for use on Air Care. Our future patients who will undoubtedly benefit from this therapy, thank you!
***For more information on storage and replacement of plasma, please see the attached ACMC Plasma Policy***
Phan HH, Wisner DH. Should we increase the ratio of plasma/platelets to red blood cells in massive transfusion: what is the evidence? Vox Sanguinis 2010;98:395-402.
Holcomb J Pati S. Optimal trauma resuscitation with plasma as the primary resuscitative fluid: the surgeon’s perspective. Hematology 2013: 656-659
Burtelow M, Riley E, Druzin M, et al. How we treat: Management of life-threatening primary postpartum hemorrhage with a standardized massive transfusion protocol. Transfusion Medicine Reviews. 2009;23:255-65.