I recently had the pleasure of sitting down with my co-EMS fellow, Dr. Ryan Gerecht, to discuss his experience with the implementation of a new blood product on our HEMS service: Liquid Plasma. Ryan was responsible for this implementation while serving as a Resident Assistant Medical Director during his last year of EM training at UC (2013-2014).
Here is what Ryan has to say…
In the Emergency Department, ICU, or operating room what do you resuscitate the hemodynamically unstable, bleeding trauma patient with? What about the patient with a massive GI bleed or ruptured AAA? How do you manage the patient with an intracerebral hemorrhage on Coumadin? (assuming you don’t have PCC’s readily available)
In most hospital-based clinical environments the answer to all of these questions in some form includes the use of PLASMA.
For the “transport resuscitationist” the question then becomes how do you manage these same patients in the prehospital environment? The “transport resuscitationist” asks why should the care of these critical patients be any different at the scene of an accident or during transport?
Earlier this year as a result of the hard work of many dedicated professionals at UC Health Air Care & Mobile Care and the University of Cincinnati Medical Center, each of Air Care’s 3 helicopters began transporting 2 units of type A plasma to complement its existing 2 units of pRBC’s and TXA.
In this podcast, we discuss some of the important logistics in bringing this advanced transport medicine to the patient. Additional details and resources are below. Please feel free to contact EMS Fellow and Flight Physician Ryan Gerecht, MD, CMTE at firstname.lastname@example.org with any questions.
- Plasma: the liquid, noncellular portion of whole blood, which contains coagulation factors, water, electrolytes, and fibrinogen.
- Fresh Frozen Plasma (FFP or FFP24): plasma that is separated and prepared from whole blood and then frozen within 8-24 hours of collection to allow long-term storage. Prior to administration, FFP must be thawed to a liquid state, which takes approximately 45 minutes.
Traditional obstacles to utilizing plasma in the prehospital environment:
1) As noted above, it takes approximately 45 minutes to thaw FFP for administration. This delay created in thawing FFP as well as the logistical obstacles of actually thawing plasma in a helicopter, limits its use in the emergency situations frequently encountered in the prehospital and transport environment.
2) Once thawed from its frozen state, plasma has a shelf-life of only 5 days. Thus for remote based air craft that may be a considerable distance from a blood bank, this requires a complex and costly courier system to constantly replenish and recirculate the plasma prior to expiration while ensuring such a valuable resource is not wasted.
The solution: Liquid Plasma or “never frozen plasma”
Liquid plasma is 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 1-6ºC for up to 40 days. Because liquid plasma is stored in a liquid state, it is ready for immediate administration, thus making it ideal for the transport environment.
In addition, research suggests that its hemostatic profile is as good if not better than thawed plasma.
See: Better Hemostatic profiles of never-frozen liquid plasma compared with thawed fresh frozen plasma. By Matijevic et al. J Trauma Acute Care Surg. 2013 Jan;74(1): 84-90
Air Care Logistics:
- 2 remote based helicopters with 2 units of type A liquid plasma + 2 units pRBC’s + TXA
- 1 hospital based helicopter with 2 units of type A thawed plasma + 2 units pRBC’s + TXA
- Plasma and pRBC’s are stored in a portable cooler with ice packs during transport. These coolers have been tested and approved by the blood bank to ensure that it maintains the appropriate temperature for several hours.
- pRBC’s are already affixed with a temperature dot to monitor temperature of all blood products contained within the cooler.
- At the helicopter base, the blood cooler is maintained in a blood bank calibrated refrigerator.
- At the time of donation, plasma that is going to be made into liquid plasma has to be treated a little differently than plasma that is going to be frozen. Thus it requires some pre-planning on behalf of the blood bank.
- Air Care & Mobile Care is the only department at University of Cincinnati Medical Center (UCMC) that uses liquid plasma.
- Air Care buys liquid plasma from the blood bank for $65 per unit.
- Liquid plasma is labeled with an imaged paper system for permanent tracking/record keeping by the blood bank.
- The blood bank at UCMC keeps on hand 5-7 units of replacement liquid plasma for Air Care utilization 24/7.
Why type A plasma?
AB plasma is the universal donor; however, its supply is inherently scarce compared to other blood types. Further decreasing the supply of AB plasma is the utilization of only male plasma as part of TRALI reduction strategies.
On the other hand, Type A plasma is more plentiful & statistically more likely to match a recipient blood type. The anti-B present in type A plasma is known not to be as strong an antibody as the anti-A present in type O or B plasma. Furthermore, the anti-B in type A plasma is thought to be diluted out in the recipients circulation and could be bound to the patients own soluble antigens since 80% of the population makes soluble A or B antigens. Thus to meet the growing plasma demands, major trauma centers around the US are switching to type A plasma.
See: Emergency use of prethawed Group A plasma in trauma patients. By Zielinski et al. J Trauma Acute Care Surg. 2013;74(1):69-74
*** By protocol and at the request of our blood bank, Air Care does NOT transfuse type A liquid plasma on patients who weight < 50kg. The concern is that the anti-B antibodies present in type A plasma could have an adverse effect simply because there is not as much circulatory volume in these smaller adults / pediatric patients.***
Air Care & Mobile Care Transfusion Strategy
Air Care strives to achieve the following goals when resuscitating the acutely bleeding trauma patient.
- 1:1 plasma and pRBC transfusion ratio
- When possible transfuse plasma and pRBC simultaneously. If this is not possible secondary to limited IV/IO access then transfuse plasma first
- Transfusion of blood products (plasma and pRBC) take precedence over TXA when IV/IO access is limited
- Except in patients with concomitant TBI, resuscitation is guided by a permissive hypotension strategy.
See attached Air Care & Mobile Care Plasma Protocol
A special thank you to Dr. Bill Hinckley, Ms. Ruda Jenkins, Dr. Bryce Robinson, Dr. Patricia Carey, and Ms. Helen Hancock who together made plasma on Air Care a reality.
- Holcomb, J. & Pati, S. (2013) Optimal Trauma Resuscitation with Plasma as the Primary Resuscitative Fluid: The Surgeon's Perspective. American Society of Hematology. 656-659. doi: 10.1182/asheducation-2013.1.656
- Hess, J., Lelkens, C., Holcomb, J. & Scalea, T. (2013) Advances in Military, Field, and Austere Transfusion Medicine in the Last Decade. Transfusion and Aphresis Science. 49. 380-386. http://dx.doi.org/10.1016/j.transci.2013.06.015
- Matijevic, N., Wand, Y., Cotton, B., Hartwell, E., Barbeau, J., Wade, C., & Holcomb, J. (2013) Better hemostatic profiles of never-frozen liquid plasma compared with thawed fresh frozen plasma. Journal of Trauma and Acute Care Surgery. 74(4). 84-90. doi: 10.1097/TA.0b013e3182788e32
- Zielinski, M., Johnson, P., Jenkins, D., Goussous, N., Stubbs, J. (2013) Emergency use of prethawed Group A plasma in trauma patients. Journal of Trauma and Acute Care Surgery. 74(1). 69-74. doi: 10.1097/TA.0b013e3182788f8e
About the Authors
Dr. Ryan Gerecht is also an EMS Fellow in the University of Cincinnati Department of Emergency Medicine. He is a graduate of the UC Department of Emergency Medicine Residency Training Program and former Resident Air Care Medical Director. He is a past winner of the Jean Hollister EMS Award presented by SAEM (2013)
Follow him on Twitter @RGerecht