Questions of the Week for 2/20/2024

Author: Christian Gerhart

Q: What groups of patients should receive irradiated blood products?

  • The main purpose of administering irradiated blood products is to inactivate residual lymphocytes in the blood that can cause graft versus host disease in the recipient. This is necessary when administering packed red blood and platelets, whereas fresh frozen plasma and cryoprecipitate do not carry this risk.

    The most common groups of patients we will encounter in the ED who require irradiated blood products are those with stem cell transplant recipients, patients receiving certain chemotherapeutic agents (purine analogs such as fludarabine, cladribine) and patients who with Hodgkin lymphoma. Additional indications we would less commonly see are neonatal exchange transfusion, those with congenital cell-mediated immunodeficiency syndromes, donations from first- or second-degree relatives, and in-utero transfusions.

Q: What is the “universal donor” for

  • Packed red blood cells?

  • Fresh frozen plasma?

  • Platelets?

  • Whole blood?

  • Plasma: AB+

    Packed red blood cells: O-

    Platelets: AB+

    Whole blood: Low titer O

    The concept of a “universal donor” is a controversial one.5 There does seem to be a consensus that O- is the safest packed red blood cell product for hemorrhagic shock patients who require uncrossmatched blood. Remember that for men and women beyond childbearing age (usually around 50ish) generally O+ blood is preferred in order to preserve O- (unless for some reason you already know they have anti-Rh antibodies).

    The ABO typing of platelets does not seem to matter nearly as much as for RBCs (this matters A LOT) and one study estimated that approximately 30% of all platelet transfusions in the US are ABO incompatible. It can be challenging to find type specific platelets since they typically have a shelf life of about 5-7 days. If a patient fails to increase their platelet count after receiving a platelet transfusion, they may need type specific platelets as incompatible platelets often are not as effective. 2,3,4 Based on our population data, we usually use A+ FFP at our institution as the availability of AB+ is not sufficient to meet transfusion needs and. The STAT study did not find a significant difference in outcomes in patients who received A+ plasma who were A+ vs. another blood type and this practice is currently thought to be safe and acceptable. 13

 Q: You have a patient in hemorrhagic shock and activate trauma massive transfusion protocol (MTP). What is in each box of MTP? What components can be pulled from the TCC fridge?

  • TCC fridge:

    2 units of low titer type O whole blood

    4 units of type A+ plasma

    6 units of O+ packed red blood cells

    6 units of O- packed red blood cells

    First trauma MTP box:

    6 units of whole blood

    Second box:

    6 units of packed red blood cells (specify type when you order it)

    6 units of fresh frozen plasma

    1 pack of platelets

    Third box:

    6 units of packed red blood cells (specify type when you order it)

    6 units of fresh frozen plasma

    1 pack of platelets

    10 units of cryoprecipitate

    *Remember that at this point we are only using whole blood for trauma MTP. If non-trauma MTP is activated then the first box and second box of MTP will be the same.*

Q: You continue to resuscitate your patient with MTP. Which components of MTP should NOT be run rapidly through the Belmont/Level One rapid transfuser?

  • It is generally thought that platelets should not be run through the rapid transfuser as this can lead to degranulation and inactivation.8 Though it is possible to do so, it is advisable to avoid this practice as it has been shown to lead through decreased platelet count and function.

Q: You are resuscitating a trauma patient and hear someone ask if vasopressors should be started. What evidence is there to support this practice?

  • In 2019 there was a JAMA study that analyzed vasopressin administration in traumatic hemorrhagic shock. The authors found a decrease in the need for blood transfusions and a trend towards decreased ICU length of stay without a statistically significant difference in mortality. Vasopressin administration in hemorrhagic shock is theorized to address an acute arginine vasopressin deficiency leading to platelet dysfunction and vasoplegia. This is still a controversial topic that requires further study. Remember that our current institutional protocol does not permit peripheral vasopressin, though this may be changi

Q: What level of fibrinogen should you target for a patient with hemorrhagic shock and how should this be replaced?

  • The target level for fibrinogen in a hemorrhagic shock resuscitation is not clearly defined. Dr. Musleh recommends shooting for 200 mg/dL (if Amjad says you should do it then you should probably do it). On most lab read outs, 150 mg/dL is the lower limit of normal but in the acute setting it is likely better to replete this more aggressively. Hypofibrinogenemia (<150 mg/dL) has been associated with increased mortality in retrospective studies of trauma patients. The CRYOSTAT2 trial randomized patient to receive standard of care treatment for hemorrhagic shock vs. standard of care + cryoprecipitate.11 This particular trial did not find a statistically significant difference in outcomes.

    To replete fibrinogen, we typically use cryoprecipitate. This comes in the third MTP box at our institution. 10 units (which is what is in the MTP box) is usually a good starting dose and should increase the fibrinogen 50-100 mg/dL. Cryoprecipitate also contains Factor VIII, Factor VIII, and von Willebrand factor.

Q: What is the volume of

  • One unit of packed red blood cells?

  • One unit of fresh frozen plasma?

  • A pack of single donor platelets?

  • Cryoprecipitate?

  • Whole blood?

  • PRBC: 300-350 mL, should increase hemoglobin by 1 point, hematocrit by 3% points per unit

    FFP: 200-250 mL

    Platelets: 250-300 mL (usually 6 units of single donor platelets)

    Cryoprecipitate: 15 mL (150 mg fibrinogen)

    Whole blood: 500 mL


References:

  1. Treleaven J, Gennery A, Marsh J, et al. Guidelines on the use of irradiated blood components prepared by the British Committee for Standards in Haematology blood transfusion task force. Br J Haematol. 2011;152(1):35-51. doi:10.1111/j.1365-2141.2010.08444.x

  2. Dunbar NM. Does ABO and RhD matching matter for platelet transfusion?. Hematology Am Soc Hematol Educ Program. 2020;2020(1):512-517. doi:10.1182/hematology.2020000135

  3. Kaufman RM, Djulbegovic B, Gernsheimer T, et al. Platelet transfusion: a clinical practice guideline from the AABB. Ann Intern Med. 2015;162(3):205-213. doi:10.7326/M14-1589

  4. Gottschall J, Wu Y, Triulzi D, et al. The epidemiology of platelet transfusions: an analysis of platelet use at 12 US hospitals. Transfusion. 2020;60(1):46-53. doi:10.1111/trf.15637

  5. Refaai MA, Cahill C, Masel D, et al. Is It Time to Reconsider the Concepts of "Universal Donor" and "ABO Compatible" Transfusions?. Anesth Analg. 2018;126(6):2135-2138. doi:10.1213/ANE.0000000000002600

  6. Sims CA, Holena D, Kim P, et al. Effect of Low-Dose Supplementation of Arginine Vasopressin on Need for Blood Product Transfusions in Patients With Trauma and Hemorrhagic Shock: A Randomized Clinical Trial. JAMA Surg. 2019;154(11):994-1003. doi:10.1001/jamasurg.2019.2884

  7. Richards JE, Harris T, Dünser MW, Bouzat P, Gauss T. Vasopressors in Trauma: A Never Event?. Anesth Analg. 2021;133(1):68-79. doi:10.1213/ANE.0000000000005552

  8. Hoyos Gomez T, El Haddi SJ, Grimstead-Arnold SL, Schreiber MA. The effect of the Belmont rapid infuser on cold stored whole blood coagulability. Injury. 2023;54(1):29-31. doi:10.1016/j.injury.2022.09.033

  9. eizoso, Jonathan P MD, MSPH; Moore, Ernest E MD, FACS; Pieracci, Fredric M MD, MPH, FACS; Saberi, Rebecca A MD; Ghasabyan, Arsen MPH; Chandler, James BS; Namias, Nicholas MD, MBA, FACS; Sauaia, Angela MD, PhD. Role of Fibrinogen in Trauma-Induced Coagulopathy. Journal of the American College of Surgeons 234(4):p 465-473, April 2022. | DOI: 10.1097/XCS.0000000000000078

  10. Richards J, Fedeles BT, Chow JH, Scalea T, Kozar R. Raising the bar on fibrinogen: a retrospective assessment of critical hypofibrinogenemia in severely injured trauma patients. Trauma Surg Acute Care Open. 2023;8(1):e000937. Published 2023 Jan 25. doi:10.1136/tsaco-2022-000937

  11. Davenport R, Curry N, Fox EE, et al. Early and Empirical High-Dose Cryoprecipitate for Hemorrhage After Traumatic Injury: The CRYOSTAT-2 Randomized Clinical Trial. JAMA. 2023;330(19):1882-1891. doi:10.1001/jama.2023.21019

  12. Hanna M, Knittel J, Gillihan J. The Use of Whole Blood Transfusion in Trauma. Curr Anesthesiol Rep. 2022;12(2):234-239. doi:10.1007/s40140-021-00514-w

  13. Dunbar NM, Yazer MH; Biomedical Excellence for Safer Transfusion (BEST) Collaborative and the STAT Study Investigators. Safety of the use of group A plasma in trauma: the STAT study. Transfusion. 2017;57(8):1879-1884. doi:10.1111/trf.14139


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