Page 1971 - Hematology_ Basic Principles and Practice ( PDFDrive )

Chapter 115 Transfusion of Plasma and Plasma Derivatives 1745

to form a 215 g powder in a sterile bottle. The plasma is then Indications
rehydrated for use via 200 mL of sterile water with soft agitation.
While not in use yet in the United States (but used in Europe), the Most guidelines consistently support plasma transfusions for cor-
product is being actively investigated for use in military situations. recting multiple acquired coagulation factor deficiencies, as seen
Early studies suggest that the product is safe and efficacious for in liver failure or disseminated intravascular coagulopathy (DIC),
treatment of war injuries. massive transfusion, reversal of warfarin effect, and certain indica-
tions as a replacement fluid in therapeutic plasma exchange (Table
115.1). However, according to one recent metaanalysis, there are no
Cryoprecipitate-Reduced Plasma published or ongoing trials regarding the optimal transfusion strategy
for these indications. As there are currently no evidence-based labora-
Cryoprecipitate-reduced plasma, also known as cryosupernatant or tory value “triggers” for plasma administration, any recommendation
cryoreduced-plasma, is the remaining supernatant after the removal needs to be carefully weighed against the patient’s presence, or risk,
of cryoprecipitate from FFP, which is subsequently refrozen. This of bleeding.
product is deficient in factor VIII, factor XIII, vWF, fibrinogen, Plasma is typically indicated when prothrombin time (PT) and/
and fibronectin. Cryoprecipitate reduced plasma is only indicated or partial thromboplastin time (PTT) are greater than 1.5 to 1.7
in the treatment of patients with thrombotic thrombocytopenic times normal paired with the presence of bleeding or anticipated
purpura (TTP), and thus cannot be used interchangeably with bleeding. The justification for these current recommendations is that
thawed plasma, FFP, or FP24. It can be thawed and stored for up there is compelling evidence that plasma transfusions are ineffective
to 5 days at 1°C to 6°C termed, thawed plasma cryoprecipitate in correcting mild to moderate abnormalities of coagulation screen-
reduced. ing tests. One study demonstrated that fewer than 15% of patients
with a pretransfusion PT between 13.1 and 17.0 seconds had some
correction after plasma transfusion, and less than 1% completely
Solvent-Detergent Plasma (SD-Plasma) normalized. Another study found that minimally prolonged inter-
national normalized ratios (INRs) decreased with treatment of the
SD-plasma is a product manufactured from ≤2500 pooled plasma underlying disease alone, and that the addition of plasma did not
products that has been treated with solvent (tri-η-butyl phosphate)/ statistically change the INR over time. On the other hand, marked
detergent (triton X-100) to inactivate lipid-enveloped viruses (HIV, reductions in substantially elevated coagulation studies can occur
hepatitis B, hepatitis C). The product is distributed in 200 mL with relatively modest plasma transfusion volumes. This variable
containers, frozen at −18°C with a shelf life of 1 year. The coagulation response to plasma can be largely explained because of the nonlinear,
factor levels are comparable to FFP and FP24, and SD-plasma has exponential relationship between clotting factors activity levels and
less viability between units. SD-plasma was recently approved by the coagulation test results (Fig. 115.1).
U.S. Food and Drug Administration (FDA), and has the added Audits of recent transfusion practices have consistently demon-
advantage of a substantially reduced risk of transfusion-related acute strated that plasma product use is inappropriately high. Recent esti-
lung injury (TRALI) and has a lower rate of allergic reactions. mates suggest up to 83% (reported range: 10–83%) of plasma
transfusions are not administered according to published guidelines.
The most commonly cited reason for plasma administration is a
Pathogen-Reduced/Inactivated Plasma preprocedural elevation in coagulation studies. This indication is not
evidence-based, especially when the coagulation abnormality is mild-
Other pathogen-reduction methods have been developed including moderate. Moreover, plasma should not be used as a volume expander
amotosalen photochemical treatment with ultraviolet (UVA) light, or as a source of nutrients. Clinical situations where plasma transfu-
which has recently been FDA approved. Riboflavin-treated plasma sions may be beneficial are further defined in the following sections.
with UVA light and methylene blue-treated plasma have also been
developed, but these have not yet been FDA approved, but are
approved in Europe. Studies in Europe show that these methods are Liver Failure
also quite effective at reducing the risk of viral contamination, but
are deficient in some clotting factors, such as fibrinogen and factor Patients with liver failure may develop low levels of the vitamin
VIII (approximately 80% retention in comparison with control K-dependent clotting factors (factors II, VII, IX, and X). These
plasma).

Recovered and Source Plasma TABLE Indications for Plasma Product Transfusion Indicated
(Plasma for Manufacture) 115.1
Disseminated intravascular coagulation
There are plasma products that are not used for transfusion, but are Liver failure
used for further manufacturing into plasma derivatives. These prod- Massive transfusion
ucts include recovered plasma (liquid plasma and “plasma”) that are Multiple acquired coagulation factor deficiency
derived from whole blood and are sent to a manufacturer from a Plasma infusion or exchange for thrombotic thrombocytic purpura and
collection facility through a “short supply agreement”. Liquid plasma, other thrombotic microangiopathies, diffuse alveolar hemorrhage, and
as noted previously, is defined as plasma that is separated from whole catastrophic antiphospholipid syndrome
blood at any time during storage at 1°C to 6°C, up to 5 days after Rapid reversal of warfarin effect when prothrombin complex concentrate
the whole blood expiration date. “Plasma” is defined as liquid plasma is not available
that is frozen at −18°C or colder with a frozen shelf life of 5 years. Replacement of an inherited single plasma factor deficiency for which
Source plasma, a FDA licensed product, is collected by apheresis no coagulation factor concentrate exists
which is intended for further manufacturing. The Plasma Protein Not Indicated
Therapeutics Association promotes safe collection and manufacturing Burns
practices of plasma derivatives. Source plasma can be collected more Immunodeficiency
frequently under special donor programs; the donors can be compen- Source of nutrients
sated for their time, and can be collected in an open or closed system. Volume expansion
Source plasma is frozen immediately in the United States and within Wound healing
24 to 72 hours in Europe.