# Presentation: 207432

## Clinical Use of Plasma for Transfusion

**Irma Szymanski, MD**
**Professor of Pathology, Emerita**
**University of Massachusetts Medical School**

## Fresh Frozen Plasma (FFP)

Thawed Plasma

Plasma Frozen within 24 hours of Collection (FP24)

Liquid Plasma

Plasma, Cryoprecipitate Reduced (Cryo-poor Plasma)

Cryoprecipitated AHF (Cryoprecipitate, Cryo)

Fibrin Glue

**Thawed Plasma**
**Plasma Frozen within 24 hours of Collection (FP24)**
**Liquid Plasma**
**Plasma, Cryoprecipitate Reduced (Cryo-poor Plasma)**
**Cryoprecipitated AHF (Cryoprecipitate, Cryo)**
**Fibrin Glue**

**PLASMA PRODUCTS FOR TRANSFUSION**

## Preparation of RBC, FFP, FP24, and Liquid Plasma

- Spin at 4C

**Hold at 1-6 C**

- Up to 8 hrs

- Up to 24 hrs

- Up to 5 days following
- WB Expiration date

**FFP store -18 C**

**FP24 store -18**** C**

**Liquid Plasma at 1-6 C**

**RBC store at 1-6 C**

**Whole Blood**

## Preparation of RBC, FFP, and Platelets

**Whole Blood. **
**Hold at 22C for up to 8 hrs**

**Soft Spin at 22C**

**RBC at 4C**

**Platelet Rich Plasma**

**Hard Spin at 22C**

**Platelet Concentrate, at 22C**

**FFP at -18C**

## Outdates of FFP, FP24, Thawed Plasma, Liquid Plasma, Cryoprecipitate and Cryo-poor Plasma

**thaw**

**Frozen Storage at -18C for up to 1 yr.**

**  ****Storage before transfusion at 4C**

**FFP**

**24 hrs**

**FP24**

**Thawed Plasma, 4 days**

**Cryoprecipitate**

**Pools, 4 hrs at 22C**

**Cryo-poor Plasma**

**24 hrs**

## Which factors influence the recovery of proteins in plasma separated from whole blood? 

## Rate of cooling to the temperature of the Hold

**Temperature and Length of Hold**
**Rate of cooling to the temperature of the Hold**
**Rate and Temperature of freezing plasma**
**Length and Temperature of frozen storage**
**Temperature and Length of Storage after thaw**

## Chemicals in the Currently used anticoagulants (mg in 63 mL) added to 450 mL of whole blood (AABB Technical Manual)

| Anticoagulant | CPD | CP2D | CPDA-1 |
| --- | --- | --- | --- |
| Chemical |  |  |  |
| Sodium citrate | 1660 | 1660 | 1660 |
| Citric acid | 188* | 188* | 188* |
| Dextrose | 1610 | 3220 | 2010 |
| Monobasic Na phosphate | 140 | 140 | 140 |
| Adenine | 0 | 0 | 17.3 |

**** *****206 mg stated on the label of bags**

## What affects the recovery of  factors V and VIII in plasma separated from RBC?

**When WB is kept at 4C for 8 hours, FV decreases very little, but FVIII...(according to A. Farrugia, PhD)**

| Cooling temperature | FVIII, IU/mL |
| --- | --- |
| 0 – 4 C (n=9) | 0.45 ± 0.05 |
| 20 C (n=9) | 0.84 ± 0.1 |

## Delayed blood processing. Percentage of FVIII remaining when blood kept at 4C or 22C *

| Length of the delay (hours) | Blood at 22C | Blood at 4C |
| --- | --- | --- |
| 6 | 90 | 84 |
| 12 | 80 | 68 |
| 18 | 65 - 70 | 56 |

*** Hughes et as. Transfusion 1988;28:566-70**

## Slide 11

## Cryoprecipitated AHF (Cryoprecipitate)

**Cryoprecipitate is ****the cold insoluble portion of plasma**** that remains when FFP is thawed at 1-6 C. ****The supernate (Cryo-poor Plasma)**** is removed by centrifugation and the cryoprecipitate, in a small volume of plasma (about 15 mL), is refrozen and stored at -18C.**
**Different  ****technical variables**** of separating plasma from whole blood, such as the temperature and length of whole blood storage before separation, as well as the method of freezing (temperature, rate of freezing)  influence ****the amount of cryoprecipitable proteins**** in the cryoprecipitate.**
**CFR states that each bag of cryoprecipitate shall contain no less than ****80 units of FVIII per bag****.**

## Cryoprecipitated AHF (Cryoprecipitate). Total amount of different proteins per bag prepared in different centers.

| Protein | Center A,
ARC, NE | Center B,
Puget Sound | Center C,
ARC, PA* | Center D,
Inst. Tx. Med |
| --- | --- | --- | --- | --- |
| FVIII, IU/bag | 80 – 100 | 100 | 197 | 80 – 100 |
| vWF, IU/bag | Significant | 100 | 197 | 80 – 100 |
| Fibrinogen,
mg/bag | 150 – 200 | 150 – 200 | 445 | 150 – 250 |
| FXIII, IU/bag | Significant | Some | Not done | 50 – 100 |
| Fibronectin,
mg/bag | Not stated | Some | Not done | 50 - 60 |

*** Flash freezing used**

## Cryoprecipitated AHF (Cryoprecipitate)

**Uses for:**
**Treatment of Bleeding in ****Congenital hypo- or dysfibrinogenemia.**
**Not used for treatment of hemophilia A or vWD because purified products are available.**
**Recommended for treatment of ****congenital FXIII deficiency.**** Purified product, Fibrogammin P (Aventis (Behring)) is available in Europe.**
**Source Material**** for purification of coagulation factors.**

## Fibrin Glue

**Definition: Fibrin glue is a ****biological tissue adhesive**** used by surgeons; it initiates the final stages of coagulation, when a solution of human fibrinogen is activated by thrombin.**
**Fibrin glue is prepared during ****surgery**** by combining equal volumes of ****cryoprecipitate**** (usually one or two bags) and ****thrombin**** solution containing ****CaCl****2**** and sometimes ****antifibrinolytic agents**** (Tranexamic acid* or epsilonaminocaproic acid, EACA). The concentrations of the ingredients vary in different reports.**
**Commercial preparation”Tisseel VH”**** (Baxter Healthcare) is available.**

***Not available in USA**

## Fibrin Glue

**              ****Used to seal:**** **
**potential leaks in dura mater**
**Large traumatized bleeding surfaces in life-threatening conditions, e.g., liver trauma, cardiac surgery, leaking vascular suture lines**
**Middle ear or microsurgical procedures**
**Plastic surgery**
**            ****Problems:**
**Use of bovine thrombin  may cause immunization to thrombin and FV.**
**     **
**     ****Human thrombin is used in Europe, recombinant human thrombin is going to be available in future in the USA.**

## FFP/FP24 transfusions. Role of the blood group.

**ABO group**** of the FFP should be ****identical**** to that of the patient.**
**The next choice is to give ****“compatible FFP”,**** the isoagglutinins of which do not sensitize patient’s RBC.**
**It is said that Rh group identity is not important. However, I want to bring to your attention, that**
**Rh negative patients, who have anti-D, may develop autoimmune hemolysis when given Rh+ FFP.**
**This is because FFP may contain some RBC stroma.**
***IO Szymanski, V Smith. Transfusion 2003;43, No 9S, S75-040A **

## ImmediateTransfusion Reactions to Plasma

**Allergic**
**Usually mild urticaria. Exact cause often not known.**
**Sometimes patient has high levels of IgE.**
**??Storage-induced changes in plasma proteins. **
**Anaphylactic **
**Usually patient has antibodies to IgA.**
**Needs FFP without IgA.**
**Febrile non-hemolytic**
**Reason: recipient suspected to have WBC antibodies.**
**Reactions not eliminated by WBC-poor blood products **
**Why?? (Release of pyrogens from WBC during Hold?)**
**TRALI**
**Donor plasma contains antibodies to recipient’s WBC.**

## Are FFP and FP24 infused correctly?

**Although guidelines for transfusion of plasma products have been published, ****UK ****data indicate that between 1993 and 2000, ****34% of FFP transfusions were outside the guidelines****.**
**In the ****USA****, Dr. Dzik et al. reported in 2004 that at the Massachusetts General Hospital, ****about 30% of the FFP transfusions were given to “prepare” patients with an increased INR for an invasive procedure.**** The authors could not find any published evidence that such transfusions reduce bleeding at the time of the procedures.**

## Clinical Indications for FFP Transfusions

**   **_**Category **__**A**_**: In patients with a single coagulation factor or plasma protein deficiency, whenever purified, virus-reduced, components are not available**
**A1,**** Congenital FV  deficiency, ****Rare, autosomal, recessive disorder**** **
**FFP**** recommeded for ****bleeding**** **
**Bleeding due to inhibitors to FV:**
**Platelets (contain FV),  immunosuppression, maybe PEX    **

## Indications for FFP/FP24 Transfusions, Category A, cont.

**A2****, Congenital F XI deficiency****, ****autosomal recessive inheritance, occurs mostly in Ashkenazy Jews. Mild to moderate bleeding tendency related to trauma. Severity of bleeding site-related, because FXI prevents clot lysis.**
**FFP or FP24**** should be given for ****major surgery**** at sites with high local fibrinolytic activity (****dental, urological****), together with antifibrinolytic agents.**
**Dental extraction does not require replacement therapy, only antifibrinolytic agents.**
**Virus-inactivated FXI concentrates (exist in Europe) are not used because of a chance of DIC.**

## Indications for FFP/FP24, Category A, cont.

**A3****, ****Thrombotic Thrombocytopenic Purpura (TTP)**
**Definition:**** This is a serious condition resulting in over 90% mortality if not treated correctly.**
**Cause:**** Congenital or acquired ****deficiency of the vWF metalloprotease, ADAMTS13,****  which may also be at low levels because of autoantibodies to ADAMTS13.**
** **
**Treatment:****  Plasma exchange therapy with a replacement solution containing ADAMTS13.**

## A3,Thrombotic Thrombocytopenic Purpura, (TTP)

**Which is the best replacement solution?**
**Some recommend the use of ****Cryo-poor Plasma****, because it contains less vWF multimers than ****FFP****. Recent data, however, show that FFP and Cryo-poor Plasma are equally effective*. **
**SD/FFP**** contains practically no vWF multimers, and causes less allergic reactions, but because of reduced level of Protein S, its use has been associated with ****thrombosis****.  **
**I have found the following protocol very useful: during PEX replace the first half of patient’s plasma with 5% albumin, and the last 50% with FFP or with Cryoprecipitate Reduced Plasma.**

**Zeigler ZR et al. J Clin Apheresis 2001; 16:19-22**

## Indications for FFP/FP24, Category A, cont.

**A4,**** ****C-1 esterase inhibitor deficiency**
**FFP is recommended to treat angioedema**
**Or prevent angioedema **
**during airway manipulation.**
**A purified concentrate, “Cetor”, exists,**
**Not yet available in the USA.**

## Indications for FFP/FP24 Transfusions, Category B: Multiple coagulation factor deficiencies.

**B1****; Disseminated Intravascular Coagulation (DIC)**
**Causes:**** various causes may trigger the hemostatic system. It can be only a laboratory abnormality or result in microvascular bleeding or microvascular thrombosis. Platelets and all coagulation factors are depleted.**
**Treatment:****  Treat the primary cause, but when ****bleeding occurs****, blood component therapy is indicated. This includes platelets, ****Cryoprecipitate, FFP (or FP24?),**** with careful clinical and coagulation test follow-up q 8 hr.**
**Replacement therapy in the absence of bleeding is not necessary **

## Indications for FFP/FP24 Transfusions, Category B, cont.

**           ****B2****, ****Liver disease**** **
**Clotting factor synthesis,  PT, aggravated by dysfibrinogenemia, thrombocytopenia, and  fibrinolysis. Bleeding occurs due to a trigger, i.e. surgery, liver biopsy, or variceal rupture.**
**If ****bleeding ****occurs, transfusion of FFP (?FP24) and cryoprecipitate is indicated. Prothrombin Complex Concentrates may confer a risk of DIC.**
**Many clinicians do not want to attempt liver biopsy without FFP infusions if PT is more than 4 sec. over normal. However, there is no evidence that this is beneficial.**
**Before and during liver transplantation, large amounts of FFP are transfused. **

## Indications for FFP/FP24 Transfusions, Category B, cont.

**           ****B3****, ****Massive Transfusions (MT).**
**Replacement formulae should be avoided.**
**Fibrinogen deficiency**** is the first coagulation factor deficiency which develops after the loss of about 150% of blood volume*.**
**If bleeding occurs, Cryoprecipitate, FFP (or FP24), (and platelet) ****transfusions should be guided by coagulation tests**** to reach a PT and PTT ratios of 1.5 and fibrinogen concentration above 100 mg/dL.**

*** Hiippala ST et al. Anesthesia and Analgesia 1995;81:360-65**

## Indications for FFP/FP24 Transfusions, Category B, cont.

**     ****B4, ****Open heart surgery**
**    ****Most patients do not need any transfusions. The large amount of heparin used during surgery is usually well handled by anesthesiologists. In our hospital, ****ATIII**** may be requested when ****heparin**** alone does not produce sufficient anticoagulation.**
** **
**   ****We have observed ****fibronectin consumption**** in patients during CABG surgery when they need transfusions.**
**   ****Post operative bleeding from chest tube could indicate surgical blood loss rather than coagulation factor deficiency.**

## Slide 29

## Indications for FFP/FP24 Transfusions, Category B, cont.

**B5****, Reversal of Warfarin Effect**
**Anticoagulation by Warfarin is caused by inhibition of vitamin K-facilitated carboxylation of ****FII, FVII, FIX and FX****, and ****Proteins C and S****.  **
**Overanticoagulation ****causing ****INR of 10 or more and/or**** ****bleeding,**** or when patient requires ****urgent surgery,**** is treated by ****1.****withdrawal of the drug, ****2.**** Vitamin K p.o. or s.c., and  ****3.**** FFP or FP24. **
**? rFVIIa.**

## Summary

**The ****purpose**** of plasma transfusions is to correct ****deficiencies**** of plasma proteins and coagulation factors causing ****serious, even life-threatening symptoms****.**
**For purposes of ****preparation and storage of Plasma Products**** the optimum methods should be ****defined on the basis of current knowledge and accurate data**** on the specific protein content - eventually, also ADAMTS13- in the final products prepared by the current and newly described methods (including flash freezing).**

## Summary, cont.

**Since the current use of Plasma Products deviates from the guidelines established worldwide, more **** research**** about the effectiveness of ****Plasma Transfusions**** should be conducted to provide data for clear guidelines, acceptable to physicians both in clinical and laboratory specialties.**
**To guide ****clinicians**** in Plasma transfusion therapy, they ****need to know the content of specific proteins in Plasma Products**** and use ****point of care tests**** to monitor the effectiveness of therapy.**