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New Rapid-Deployment Plasma Protocol Effectively Treats Trauma Patients

Guidelines allow delivery of plasma three times faster than traditional method

Traumatic injury is the leading cause of death among people younger than 45 years of age, but if trauma physicians could deliver plasma to these injury victims within minutes of their arrival in the emergency room, more of them would stand a better chance of survival.

When they arrive at the hospital, trauma victims can often wait 30 minutes or longer to receive plasma because the traditional way of administering plasma involves two time-consuming steps: testing for the patient’s blood type and then thawing frozen plasma.

“There’s a golden hour after trauma where you need to be able to stabilize the patient,” said Deborah Novak, MD, of the University of Arizona, Tucson, lead author of a new study on a rapid-deployment plasma protocol.

The study was conducted at 12 urban trauma centers. The researchers found that trauma teams could consistently deliver plasma to trauma patients three times faster than the traditional delivery method. The results from the Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) clinical trial showed that the participating trauma centers were able to use a new clinical guideline to have thawed plasma delivered to the trauma patient’s bedside within 10 minutes of arrival. The report was published online in Transfusion.

The investigators evaluated the utility of guidelines for massive transfusion developed by the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP). Approximately 4,700 units of plasma were given to the 680 patients enrolled in the trial.

Whole blood, used for transfusions when patients lose excessive amounts of blood, is divided into its three key components, which makes it easier to store the blood and keep it fresh: plasma, platelets, and red blood cells.

Traditional trauma resuscitation involves giving the patient non-blood fluids, called crystalloid fluids, and red blood cells early on, and then administering plasma and platelets later. Plasma is typically stored frozen and thawed only when the trauma staff requests it. While this method successfully treats most trauma victims with mild or moderate injuries, military and civilian researchers have found that individuals with massive bleeding benefited when they received plasma at the same ratio as red blood cells. “A renewed look at the process resulted in the concept of transfusing plasma earlier, with red blood cells and plasma in ratios that approximate the reconstitution of the original unit of whole blood,” Novak said.

PROPPR focuses on the use of universal-donor plasma — that is, plasma that can be given to all blood types — but because thawed, universal-donor plasma can be scarce at times, three trial sites used blood type A plasma instead without complications. This approach was an important side note of the trial, according to Novak. “What we found out and what other places have found is that trauma teams can safely use AB or limited amounts of A plasma for that small window when the patient’s blood type is not yet known,” Novak said. That finding could be significant in sustaining supplies of unthawed plasma for trauma use, she added.

But the challenge is to have plasma thawed and ready when the patient arrives at the emergency room. Thawed plasma must be discarded after 5 days, whereas frozen plasma can last up to a year. “So any hospital endeavoring to maintain a pre-thawed plasma inventory could experience additional wastage,” Novak said. “The key to controlling the amount of wastage depends on balancing the amount of plasma pre-thawed, and the amount of plasma used daily in the facility.”

Eleven sites reported thawed plasma wastage of less than 10% of units. Only one of 12 sites reported having to discard about 25% of the thawed plasma. The other sites reported no increase, illustrating that with careful inventory management, wasted plasma need not increase while clinical outcomes can improve, Novak said.

Overcoming the challenge of getting thawed plasma rapidly into the trauma unit was an essential component of the PROPPR trial. Eleven of the 12 sites were able to consistently delivery six units of thawed plasma to the patient’s bedside within 10 minutes of arrival. The twelfth site, which had only two trauma patients a month, was able to do so within 15 minutes.

The blood bank guidelines spelled out by the ACS TQIP enabled these centers to achieve the goal of delivering thawed plasma within 10 minutes, noted coauthor Bryan Cotton, MD, MPH, FACS, professor of surgery at University of Texas Health Sciences Center in Houston. “That step really brought those centers the ability to deliver and pull off the massive transfusion protocol and meet those TQIP guidelines in such a dramatic fashion,” Cotton said.

Future studies using the PROPPR data will closely evaluate problems with inflammation and clotting after trauma, and will be used to influence the guidelines regarding the way massively hemorrhaging trauma patients receive transfusions, the authors said.

Source: ACS; May 28, 2015.

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