plasma transfusion current evidence and future …dn3g20un7godm.cloudfront.net/2011/am11sa/65.pdf•...
TRANSCRIPT
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www.BloodManagement.comBloodManagement.com
The Leader in Blood Management Consulting, Education and Informatics Solutions
© 2006 - 2011 Strategic Healthcare Group LLC. All rights reserved.
PLASMA TRANSFUSION
Current Evidence and Future Directions
Carolyn Burns, M.D.
Medical Director, Transfusion Services
Strategic Healthcare Group LLC
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At the conclusion of this educational activity,
participants will be able to:
• Understand preparation, types and content of
plasma products
OBJECTIVES
© 2006 - 2011 Strategic Healthcare Group LLC. All rights reserved.
• Gain knowledge as to appropriate dose, volume,
timing and monitoring of plasma transfusion
• Review current evidence-based guidelines for
plasma transfusion
• Discuss adverse reactions/complications of
plasma transfusion
2
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• General comments
• Content and preparation of plasma products
• Dosing, timing and monitoring
• Indications for plasma transfusion
• Adverse reactions and complications of plasma
OUTLINE
• Adverse reactions and complications of plasma
transfusion
• Final comments
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• Transfusion of plasma in the U.S. is growing &
exceeds use in other developing countries
• General lack of education exists for healthcare
professionals
• Need to examine the risk:benefit ratio for plasma
GENERAL COMMENTS
transfusion
• Blood resources are not indefinite or assured
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• Plasma separated from WBD requires
centrifugation processes
• FFP = plasma frozen within 8 hrs., expiration 1
yr.
• Plasma 24 = plasma from WBD frozen within 24
PREPARATION & TYPES OF PLASMA PRODUCTS
hrs.
• Thawed plasma = plasma thawed, then stored @
1-6 degrees C. for 5 days
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• Cryo-poor plasma = plasma with cryoprecipitate
removed (vWF)
• Solvent detergent treated plasma = plasma
specially treated to eliminate lipid enveloped
viruses
PREPARATION & TYPES OF PLASMA PRODUCTS
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• Plasma contains the protein fractions of whole
blood including albumin, Ig, fibrinogen &
coagulation factors
• Volume of each prepared unit of plasma = 200 –
300 mls.
CONTENT OF PLASMA
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• Typical dose = 10 – 15 mls./kg body weight
• Roughly 2 – 4 unit dose for adults
• Each unit should increase factor activity by
roughly 20%
• Plasma should be ABO compatible
DOSING, TIMING, MONITORING OF PLASMA TRANSFUSION
• Plasma should be ABO compatible
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• Transfuse using standard administration set
within 4-6 hrs. of planned procedure
• Follow-up testing within 15 min. to 1 hr.
• Testing may include PT/INR, aPTT, & fibrinogen
DOSING, TIMING, MONITORING OF PLASMA TRANSFUSION
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• Normal coagulation is maintained if factor
concentrations > 25-30% and fibrinogen > 100
• Absence of either exogenous or endogenous
inhibitors (e.g. heparin, coumadin, acquired
CAVEATS
inhibitor Abs)
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• British Committee for Standards in Haematology
• College of American Pathologists
• American Association of Blood Banks
• American Society of Anesthesiologists
• Circular of Information
INDICATIONS FOR PLASMA TRANSFUSION
• Circular of Information
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• Management of patients with coagulopathy or
acquired coagulation factor deficiency for which
specific factors are not available
• Management of bleeding patients who require
replacement of multiple coagulation factors (e.g.
DIC, liver failure)
INDICATIONS FOR PLASMA TRANSFUSION
DIC, liver failure)
• During massive transfusion protocol
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• Bleeding patients on warfarin who need invasive
procedures before Vitamin K can reverse effect
• Therapeutic plasma exchange in TTP
• Rare plasma protein deficiencies ( e.g. C1
esterase inhibitor)
INDICATIONS FOR PLASMA TRANSFUSION
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• Volume expansion or nutrition
• DIC without bleeding
• Reverse Vitamin K antagonist without bleeding
• TPE not associated with TTP
CONTRAINDICATIONS FOR PLASMA TRANSFUSION
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• To prevent periventricular hemorrhage in
premature neonates
• By formula in massive transfusion
• Mild to moderate elevations of PT/INR or aPTT
without bleeding
CONTRAINDICATIONS FOR PLASMA TRANSFUSION
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• Throughout the 1990s to current years multiple
studies point to a LACK of evidence that
perioperative patients with slight increases in
PT/INR confers an increased incidence of
bleeding than those with “normal” studies.
PLASMA TRANSFUSION: CURRENT EVIDENCE
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• Transfusion of small quantities of plasma in these
perioperative patients confers little benefit and
actually increases the risks of adverse events
resulting from the use of plasma products
• Brit. Comm. for Stds. in Haematol., 2004
PLASMA TRANSFUSION: CURRENT EVIDENCE
• Brit. Comm. for Stds. in Haematol., 2004
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• Donor plasma units from WBD may have
distribution of INR just < 1.4 (Holland et. al.,
Transfusion, 2005)
• Subsequent study by same group (AJCP, 2006)
showed little to no change in INR with plasma
PLASMA TRANSFUSION: CURRENT EVIDENCE
showed little to no change in INR with plasma
transfusion if the initial patient INR was < 1.7.
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• Retrospective study ( Abdel-Wahab et.
al.,Transfusion, 2006) with greater than 300 units
of plasma transfused to 121 patients with initial
INR 1.1-1.85, showed little change in post
transfusion INR (0.07-0.2)
PLASMA TRANSFUSION: CURRENT EVIDENCE
• Two additional studies mirrored these findings
(Youssef et. al., Am. J. Gastroenterology, 2003 &
Cheng et. al., Can. Transf., 2007)
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• Welsh study (Chowdhury et. al., Brit. J. Haem,
2004) found correction of INR with doses 30
mls/kg ; this is twice current dosing
recommendation
• No assessment of clinical outcomes or adverse
PLASMA TRANSFUSION: CURRENT EVIDENCE
• No assessment of clinical outcomes or adverse
reactions
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• Meta-analysis by Dzik and Segal (Transfusion,
2005) of 25 studies addressing this issue
• Studies included clinical outcomes (i.e. bleeding
episodes)
• Procedures included liver/kidney biopsy, venous
PLASMA TRASNFUSION: CURRENT EVIDENCE
catheter placement, paracentesis, bronchoscopy
• Correlated INR with % coagulation factors
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• This meta-analysis found NO significant
difference in bleeding risks with these procedures
between those with normal INR vs. mild to
moderate elevations.
• Stanworth (Brit J Haem, 2004) similar meta-
PLASMA TRANSFUSION: CURRENT EVIDENCE
• Stanworth (Brit J Haem, 2004) similar meta-
analysis that revealed NO decrease in EBL or
transfusion requirement when those with mild
increase INR were compared to controls.
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• Patients with ESLD given plasma transfusion will
only infrequently correct INR as a reflection of
coagulopathy (Youssef et. al.)
• This was described in the early 1990s in several
PLASMA TRANSFUSION: CURRENT EVIDENCE
studies (McVay & Toy, Transfusion; Foster et al.,
Arch of Surg; Docaflur et al., Chest)
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• Editorial, Transfusion, 2006, (Triulzi): “Taken as
a whole, the data…do not support the efficacy in
treating bleeding or as prophylaxis for invasive
procedures in patients with mild coagulopathy
defined as an INR < 2.0.”
PLASMA TRANSFUSION: CURRENT EVIDENCE
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• 2010 studies, Mayo & Emory – questioned the
benefit of high plasma ratios in MTPs and
association of plasma transfusion with ALI
respectively
PLASMA TRANSFUSION: CURRENT EVIDENCE
• “Evidence-based Guidelines for Plasma
Transfusion”, (Roback, JD et al., Transfusion,
2010) GRADE method to evaluate six questions
surrounding plasma transfusion including MTP,
ratios, ICH etc.
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• AABB Commission – data not available to
correlate plasma transfusion with degree of
coagulopathy
• AABB Technical Manual - comment on target INR
PLASMA TRANSFUSION: CURRENT EVIDENCE
of 1.3-1.5 is without factual basis
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AABB TECHNICAL MANUAL, 17TH ED.
INR/COAG FACTORS
INR
Exponential relationship of INR to percentages of factor levels. (Used with permission
Wayne Chandler, MD, University of Washington Department of laboratory Medicine.)
INR
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• The multitude of evidence points to the clinical
inefficacy of plasma transfusion in patients with
mild to moderate increases in INR even in the
face of invasive procedures
PLASMA TRANSFUSION: CURRENT EVIDENCE
• This calls into question the clinical utility of
coagulation testing in the assessment of bleeding
risk.
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• Used to aid in the diagnosis of coagulation
disorders
• To monitor therapeutic effect of anticoagulation
therapy or after plasma transfusion
• NOT used to predict bleeding risk
COAGULATION TESTING
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• Results of coagulation tests (triggers) are NOT to
be used to predict risk of bleeding or to solely or
absolutely define the need for plasma transfusion
• TREAT PATIENTS NOT LABORATORY VALUES
• True need for plasma transfusion MUST be
COAGULATION TESTING
based on clinical assessment, evaluation of
risk:benefit in conjuction with lab testing
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• PT/INR instituted to standardize reporting of PT
results between labs
• Utilized as a therapeutic monitor NOT as a
diagnostic tool to predict bleeding risk
• Coagulation testing does not predict who WILL
COAGULATION TESTING
bleed nor who WILL NOT bleed
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• In 2008, the British Commission for Standards in
Haematology proposed guidelines on
assessment of bleeding risk prior to surgery or
invasive procedures and determined that
coagulation screening in most instances is
inefficient, costly, and may delay surgery as well
PLASMA TRANSFUSION: CURRENT EVIDENCE
inefficient, costly, and may delay surgery as well
as causing unnecessary patient concern.
• Clinical & family history are key
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• Wide variation in practice is seen with plasma
transfusion
• Study in UK, 2010, showed in over 2500
admissions to 29 ICUs, 34% plasma txns were
PLASMA TRANSFUSION: CURRENT EVIDENCE
for INR <1.5 with no bleeding & 29 episodes had
NO documented INR (Walsh, TS et al. Crit Care
Med)
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• 2009 data, INR level associated with plasma
transfusion: 54% for INR < 1.7, (correlates
w/Cheng, Transfusion, 2007)
• Liver transplant algorithm begun in 2002 utilizes
INR > 1.9 as indication for plasma transfusion;
avg. plasma use <10 units for cases over past 9
PLASMA TRANSFUSION: JH EXPERIENCE
avg. plasma use <10 units for cases over past 9
yrs.
• Current shift to INR >1.9 for fulminant liver failure
patients needing ICP monitor (Jl Neurosurg,
2010)
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80
100
120 107
<1.7
1.7-3.0
FFP TRANSFUSION COMPARISON TO PATIENT INR RESULT
2009 YEAR-TO-DATETOTAL NUMBER OF PATIENTS MONITORED = 198 (THRU DECEMBER)
INR/PLASMA TXN - JH
0
20
40
60
80
<1.7 1.7-3.0 3 4 5 6 > 7.00
49
15
6 7 59
INR RESULT
1.7-3.0
3
4
5
6
> 7.00
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80
100
120 111
<1.7
1.7-2.9
INR/PLASMA TXN - JH
FFP TRANSFUSION COMPARISON TO PATIENT INR RESULT
2011 JANUARY-JULYTOTAL NUMBER OF PATIENTS MONITORS-223
72% TRANSFUSED AT INR>1.7
0
20
40
60
80
<1.7 1.7-2.9 3 4 5 6 >7
62
22
114 1
12
1.7-2.9
3
4
5
6
>7
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• PT/PTT with INR<= 2.0
• Fibrinogen > 100 mg/dl
• TEG < 15 min reaction time
• PT/PTT with INR > 2.0
LIVER TRANSPLANT ALGORITHM
Component shortages (ALERT SYSTEM) will be
communicated to the Transplant Coordinator
WATCH PRESSOR AGENTS
REPEAT LABS, TEG’s prn
RECORD ALL PRODUCTS, TIMES
GIVEN LABS, (sent and rec’d results)
INCLUDE CELLSAVER AND RAPID
INFUSION COMPONENTS
No FFP
1. 4 units FFP• PT/PTT with INR > 2.0
• Fibrinogen > 100 mg/dl
• TEG > 15 min reaction time
• Platelet count < 75,000/ uL
• TEG MA < 40 mm
• Platelet Aggregation < 50% (Platelet Works)
• Fibrinogen < 100 mg/dl
• Active bleeding/fibrinolysis
1. 4 units FFP
2. Wait 10 -15 mins
1. 1 Single donor pheresis platelet
1. 1 pooled Cryoprecipitate (5 units)
2. Consider Amicar
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PLASMA IN LIVER TX
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• EDUCATION AND INTERACTION IS KEY!
• Studies from UTSW, Providence and Italy, found
that PROSPECTIVE review using guidelines can
decrease use, M&M, and cost without increases
in bleeding events
PLASMA TRANSFUSION: CURRENT EVIDENCE
in bleeding events
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• Allergic
• Anaphylactic
• ABO mismatch
• Transfusion -transmitted diseases
• Transfusion -related acute lung injury (TRALI)
COMPLICATIONS & ADVERSE REACTIONS
• Transfusion -related acute lung injury (TRALI)
• Transfusion -associated circulatory overload
(TACO)
• Transfusion -related immune modulation (TRIM)
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• Acute lung injury associated w/all blood products
esp. plasma-containing components
• Sxs of respiratory
distress, hypoxia, fever, hypotension (ARDS)
• Incidence 1:400-50,000 units transfused
TRALI
• HLA and granulocyte Abs/cytokines implicated
• Supportive care usually resolves w/in 72 hrs
• Still w/significant mortality rate
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• Circulatory overload associated with high volume
transfusion
• Estimated incidence 1:200 – 10,000 units
transfused
• Adjust volume for size of patient and consider
TACO
comorbid cardiopulmonary disease
• Slower rates of transfusion, O2, diuretics
• Difficult to separate from TRALI (BNP?)
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• Numerous articles re: TRIM with RBC transfusion
• Increase in infections, LOS, CA recurrence
• Sarani et. al. (Crit Care Med, 2008) found
increased infectious complications in patients
receiving plasma transfusion
TRIM
• Watson et al. (Jl of Trauma, 2009) found increase
risk of MOF and ARDS in those who received
plasma transfsuion
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ZONES OF RESPONSE TO BLEEDING RISK
INR
Zone of prophylactic treatment; or
treatment before procedure or surgery
Zone: treat bleeding but prophylaxis
not required
4.0
3.5
3.0
2.5
2.0
44
Platelet number x% function Figure 1-7. Zones of response to bleeding risk at the time of invasive procedures. The x-axis is meant to depict the product
of both platelet number and functional activity. Patients with normal laboratory values are represented by the smallest
rectangle. A large number of patients with mild-to-moderate abnormalities of preprocedure laboratory tests are in the zone
of physiologic reserve and are not likely to derive any benefit from preprocedure transfusion therapy.
0.75
not required
Zone of normal hemostasis
Normal lab values
2.0
1.5
1.0
10,000 50,000 100,000 200,000 300,000
Transfusion Therapy: Clinical Principles and Practice 3rd Edition
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• Better assessment of bleeding risk
• Correction of drug-induced coagulopathy or other
bleeding abnormalities
• In-house efforts to limit plasma transfusion
• Education!!!!
PLASMA TRANSFUSION: WHERE DO WE GO, WHAT CAN WE DO?
• Education!!!!
• RCTs for prophylactic plasma transfusion
(NHLBI/TMH Network, SHIP Study)
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• Current evidence and risk:benefit assessment in
a significant number of clinical situations
suggests a more restrictive practice for plasma
transfusion (mirrors TRICC Trial for RBC
transfusion)
PLASMA TRANSFUSION: CURRENT EVIDENCE
• Continued effort to provide quality and safe
transfusion practice across all areas of
component therapy
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TRANSFUSION MUST REPRESENT:
• THE RIGHT PRODUCT for
• THE RIGHT PATIENT @
• THE RIGHT TIME for
• THE RIGHT REASON
THE 4 R’s
• THE RIGHT REASON
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