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September 2019

Should Group A Plasma Be Used in Massive Hemorrhage Protocols Instead of Group AB Plasma?

Author: Michelle P. Zeller MD FRCPC MHPE DRCPSC, Assistant Professor; McMaster University, Program Director Transfusion Medicine AFC Diploma; McMaster University, Director Operations, Transfusion Medicine; Hamilton Regional Laboratory Medicine Program, Medical Officer; Canadian Blood Services

Group AB plasma is the universal plasma group with 73% transfused to non-AB recipients.1 A survey of blood centres in the United States showed a 27% increase in demand for AB plasma in 2011 when compared to 2006 data; the increase was disproportionate relative to other plasma groups.2 Canadian data shows the same disproportionate increase in AB plasma use (Figure 1). Only 3-4% of Canadian and American donors are group AB making Group AB plasma a scarce resource of increasing demand.

What accounts for the increase in demand?

Implementation of massive hemorrhage protocols (MHPs) is becoming the standard of care across many jurisdictions with improved delivery and reduced wastage of blood products and beneficial impact to patient survival.3–5 With increased MHP adoption there has been concurrent, disproportionate increase in AB plasma use compared to other plasma groups. In an international multicentre study, plasma transfused in the Emergency Department accounted for the highest percentage of group AB plasma units transfused to non-AB recipients.1 As a means of conserving Group AB plasma, there has been a move towards provision of Group A plasma in MHPs instead of Group AB plasma.6

What are the risks of transfusing Group A plasma to an ABO incompatible recipient?

Group A plasma contains anti-B antibodies; if given to a group B or group AB patient there is potential for an acute hemolytic transfusion reaction (AHTR). Donor antibodies bind host RBCs, activate the complement cascade leading to anemia, and in severe cases can result in disseminated intravascular coagulation, acute renal failure, and death. In Canada, a transition to Group A plasma from Group AB plasma in MHPs has potential to negatively impact ~12% of the population who are Group B and AB.

Why would we consider incompatible plasma transfusion if there is risk?

Incompatible plasma is transfused routinely, as it is common practice to transfuse platelets to recipients without matching for ABO group. Studies on ABO incompatible platelet transfusions report an extremely low risk of hemolytic reactions.7–10 All reports of hemolytic reactions were caused by products containing Group O plasma, while there were no documented cases of hemolysis from products containing Group A plasma.7,8,10 As an added protective effect, trauma patients can develop acquired immunosuppression. 11 Furthermore, use of group O whole blood in trauma patients of unknown ABO group did not show hemolysis or renal failure among non–group O recipients.12

What have others found in using Group A plasma for MHPs?

A single centre retrospective review of all trauma patients receiving emergency release plasma (Group A) from 2008 to 2011 reported no significant differences in outcomes for 254 patients: 35 (14%) received ABO-incompatible and 219 (86%) received ABO-compatible plasma transfusions.8 A multicentre retrospective study of 8 trauma centres in the US (2012-2016) compared compatible to incompatible (A plasma to Group B and AB patients) plasma transfusion in the context of MHP activation. They included 1573 patients; 92% compatible vs 8% (120) incompatible and found no hemolytic transfusion reactions, no significant difference in acute respiratory distress syndrome, thrombotic events, sepsis, acute renal failure and no significant difference in mortality at 6 or 24 hours, nor at 28 days.13

A survey on use of Group A plasma in trauma of 61 trauma centers (mostly Level 1) found that most maintain an inventory of immediately available Group A plasma.14 The majority (63%) use Group A plasma in the initial phase of the resuscitation of trauma patients of unknown ABO group; 50% of group A plasma usage is a relatively new practice having started in 2015; 62% do not limit amount of group A plasma administered to trauma patients; and, only 21% consider anti-B titer when choosing group A plasma units.14

A large multicentre study, Safety of the use of group A plasma in Trauma (STAT Study) retrospectively collected data on consecutive injured group A, B, and AB patients admitted to adult Level 1 or 2 trauma centers.6 Results from 17 trauma centers (16 US and 1 UK) from 2008 to 2015 reported on 1163 trauma patients: 809 (70%) group A patients in the identical group, 354 (30%) group B or AB patients in the incompatible group. They found no significant difference in in-hospital mortality and no AHTR were reported (though hemolytic markers were not specifically collected).

What happens at your centre? Will you make the switch?

Some Canadian trauma centres have already transitioned to use of Group A plasma in their MHPs while others continue to use Group AB plasma. Use of Group A plasma in MHPs is not yet standard of care and evidence remains retrospective and observational; however, it is an important strategy to keep in mind in the event of Group AB plasma shortage.

Figure 1. Fresh Blood Components Distribution Trends Q4 2017/18 (Source: Canadian Blood Services)

  1. Zeller MP, Barty R, Dunbar NM, et al. An international investigation into AB plasma administration in hospitals: How many AB plaSma units Were INfused? The HABSWIN study. Transfusion. 2018;58(1):151–157
  2. Yazer M, Eder AF, Land KJ. How we manage AB plasma inventory in the blood center and transfusion service. Transfusion. 2013;53(8):1627–1633.
  3. Cotton BA, Au BK, Nunez TC, et al. Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. J. Trauma – Inj. Infect. Crit. Care. 2009;66(1):41–48.
  4. Cotton BA, Reddy N, Hatch QM, et al. Improvement in Survival in 390 Damage Control. Ann. Surg. 2013;254(4):1–15.
  5. Khan S, Allard S, Weaver A, et al. A major haemorrhage protocol improves the delivery of blood component therapy and reduces waste in trauma massive transfusion. Inj. Int. J. Care Inj. 2013;44(5):587–92.
  6. Dunbar NM, Yazer MH, Carey PM, et al. Safety of the use of group A plasma in trauma: the STAT study. Transfusion. 2017;57(8):1879–1884.
  7. Mair B, Benson K. Evaluation of changes in hemoglobin levels associated with ABO-incompatible plasma in apheresis platelets. Transfusion. 1998;38:51–55.
  8. Zielinski MD, Johnson PM, Jenkins D, Goussous N, Stubbs JR. Emergency use of prethawed Group A plasma in trauma patients. J. Trauma Acute Care Surg. 2013;74(1):69–74; discussion 74-5.
  9. Cooling L. Going from A to B: The safety of incompatible group A plasma for emergency release in trauma and massive transfusion patients. Transfusion. 2014;54(7):1695–1697.
  10. Cooling L. ABO and platelet transfusion therapy. Immunohematology. 2007;23(1):20–33.
  11. Kimura F, Shimizu H, Yoshidome H, Ohtsuka M, Miyazaki M. Immunosuppression following surgical and traumatic injury. Surg. Today. 2010;40(9):793–808.
  12. Seheult JN, Triulzi DJ, Alarcon LH, et al. Measurement of haemolysis markers following transfusion of uncrossmatched, low-titre, group O+ whole blood in civilian trauma patients: initial experience at a level 1 trauma centre. Transfus. Med. 2017;27(1):30–35.
  13. Stevens WT, Morse BC, Bernard A, et al. Incompatible type A plasma transfusion in patients requiring massive transfusion protocol: Outcomes of an Eastern Association for the Surgery of Trauma multicenter study. J. Trauma Acute Care Surg. 2017;83(1):25–29.
  14. Dunbar NM, Yazer MH. A possible new paradigm? A survey-based assessment of the use of thawed group A plasma for trauma resuscitation in the United States. Transfusion. 2016;56(1):125–129.

Evening Symposium: Choosing Plasma Wisely: When and When Not to Use Plasma

Author: Stephanie Cope, Regional Project Coordinator, ORBCoN Central Region, Allison Collins MD FRDPC, Physician Clinical Project Coordinator, Ontario Regional Blood Coordinating Network

The Spring Symposium is a collaborative event held by the Ontario Regional Blood Coordinating Network (ORBCoN) and Canadian Blood Services (CBS) which began in 2007. This is an accredited, continuing medical education opportunity for those in the field or with an interest in Transfusion Medicine, and for clinicians who prescribe blood and blood products.

The theme of the event, frozen plasma utilization was selected as provincial frozen plasma audits (conducted by ORBCoN in 2008 and 2013) identified a high rate of inappropriate plasma use, even after the introduction of recommendations and tools aimed at improving the appropriate use of plasma were created and disseminated to Ontario hospitals (via licensed laboratories) following each audit. The top five inappropriate uses of plasma based on the 2013 audit results were reviewed and formed the basis for the symposium. In an attempt to increase our reach, we approached Choosing Wisely Canada who agreed to collaborate with us. Choosing Wisely Canada has created a campaign aimed at promoting the avoidance of unnecessary tests, treatments and procedures which includes the unnecessary utilization of blood and blood products.

Top 5 inappropriate uses of plasma (ORBCoN, 2013)

  1. Reversal of warfarin or vitamin K deficiency in the absence of bleeding or urgent major invasive procedure (within 6 hours)
  2. Treatment for trivial abnormalities of laboratory test results that are not associated with an increased risk of bleeding
  3. Reversal of coagulation defect with elevated INR in the absence of bleeding or urgent invasive procedure
  4. Heparin reversal
  5. Rapid reversal of anticoagulant therapy

Given the fact that recommendations and tools were made available in 2013 with relatively no positive change in the inappropriate usage of plasma, the planning committee decided to include a small knowledge retention exercise to ensure the needs of our stakeholders were being met. Case-based clinical scenarios, using the five categories above, were included in a pre and post survey sent to registrants of the symposium.

Example of a case-based clinical scenario

Patients with liver failure have a rebalanced hemostatic system, and are at risk of either bleeding or thrombosis as a result. The INR does not predict the risk of bleeding in these patients. Prophylactic plasma transfusion is of unproven benefit in the setting of minor invasive procedures, such as central line insertion, paracentesis, and thoracentesis, all of which carry a very low risk of bleeding. Because plasma transfusion is not without adverse effects, it is prudent to reserve plasma transfusion for the rare patient who bleeds during or after a procedure. The risks of prophylactic plasma transfusion in this setting include transfusion-associated circulatory overload (TACO), elevation of portal venous pressure (which may cause or exacerbate bleeding), and the risks associated with delaying the procedure itself. For further details, see Dr. Callum’s presentation in the ORBCoN Presentation Library Here.

ORBCoN will continue to promote and support utilization improvement activities and will use auditing as a means to highlight opportunities to improve appropriate utilization of blood and blood products. The formats of our spring symposiums have changed throughout the years as we conform to our target audience and the needs of our community. Did you attend this event? We value any feedback regarding this event, past events and welcome any suggestions for future events!

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