Transfusion - Science topic

Avoiding and monitoring transfusion-transmissible diseases (TTDs) is crucial to ensure the safety of blood transfusions and protect both donors and recipients. Here are several strategies to prevent and monitor TTDs, especially in the face of rising concerns:

Regular updates to screening and testing protocols based on scientific advancements and epidemiological data are essential in this effort.

Regenerate

There can be a number of factors as to why the Cytomegalovirus is not routinely tested in developing countries like Nigeria. According to Ahmed( 2022), the prevalence of CMV is lower on much developed countries and higher on developing countries because of poor personal and environmental sanitation. The reasons like the lack of resources which results to poor accuracy of rapid tests and unavailability of more advanced techniques.

Source: Ahmed, S. G. (2022). Transfusion Services in Tropical Africa: Challenges and Prospects from the Nigerian Perspective. Niger J Haematol, 3, 1-17.

The research entitled Red blood cell transfusion for hematologic disorders by Chang Liu and Brenda Grossman studied the RBC transfusion practices on specific hematologic disorders. The review focuses on autoimmune hemolytic anemia, thalassemia, myelodysplastic syndrome and hematopoietic stem cell transplantation. The relatively safe hemoglobin thresholds of 7-8 g/dL to serve as a guide for restrictive transfusion of red blood cells. However, with patients suffering from the mentioned disorders this approach is yet to be defined and due to the diverse nature of anemia, there is complexity in the different levels of transfusion dependency. It is concluded that questions still arise regarding these disorders and how we can broaden the blood donor criteria to promote risk free blood transfusions.

Reference:

Liu, C., & Grossman, B. J. (2015). Red blood cell transfusion for hematologic disorders. Hematology, 2015(1), 454–461. https://doi.org/10.1182/asheducation-2015.1.454

According to URMC, patients with transfusion overload may suffer from shortness of breath and other symptoms from patients similar with cardiac diseases. This may also lead to Transfusion-Associated Circulatory Overload (TACO). Taking diuretics may ease the following symptoms associated with transfusion overload.

Sources: https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=135&contentid=315#:~:text=Too%20much%20blood%20in%20the,in%20people%20with%20heart%20problems.

"CROSSFIRE FOR MOBILITY & RELIABILITY, THAT IS PREMIERSHIP & GUARANTEED ARE ALL ABOUT" Elizabeth Holmes

Thanks

The choice of sampling method and formula for sample size calculation depends on several factors, such as the research question, study design, expected effect size, level of statistical power, and desired level of precision.

In general, for a comparative study design like the one you described, a randomized controlled trial (RCT) would be an appropriate study design to compare the safety and efficacy of Thalidomide vs Hydroxyurea in Transfusion dependent Thalassemia in children. The sample size calculation for an RCT can be based on the following formula:

n = (Zα/2 + Zβ)^2 (p1q1 + p2q2) / (p1-p2)^2

where:

To estimate the expected proportions of the outcome, you will need to conduct a pilot study or review the literature to identify the expected effect size. The effect size is typically expressed as a difference in means, odds ratio, or relative risk.

For a more precise sample size calculation, you may want to consult with a statistician or use a sample size calculator that takes into account the specific details of your study design and expected effect size.

When on that side click on the dimensions and it should take you to the dimensions.ai website where you can see each article that referenced you

In a study conducted by L. Thurn, et. al., entitled, "Incidence and risk factors of transfusion reactions in postpartum blood transfusions", the increase of HLA antibodies observed in most pregnancies, especially in multiparous women may increase the risk of transfusion reactions during pregnancy.

Another study, entitled, "Transfusion-related mortality: the ongoing risks of allogeneic blood transfusion and the available strategies for their prevention" by E. C. Vamvakas, et. al., suggests that in 65% to 90% of TRALI cases, WBC (including class I and II HLA or neutrophil-specific) antibodies have been identified in the plasma of the implicated donor and that most of these implicated donors have been multiparous women.

Thurn, L., Wikman, A., Westgren, M., & Lindqvist, P. G. (2019). Incidence and risk factors of transfusion reactions in postpartum blood transfusions. Blood advances, 3(15), 2298–2306. https://doi.org/10.1182/bloodadvances.2019000074

Eleftherios C. Vamvakas, Morris A. Blajchman; Transfusion-related mortality: the ongoing risks of allogeneic blood transfusion and the available strategies for their prevention. Blood 2009; 113 (15): 3406–3417. doi: https://doi.org/10.1182/blood-2008-10-167643

Good Day!

To answer your question, a study was conducted by Dehn, J. et. al. entitled "Selection of unrelated donors and cord blood units for hematopoietic cell transplantation: guidelines from the NMDP/CIBMTR" which introduces "selection guidelines" for Unrelated Cord Blood (CB) Units. The authors described that the "Optimal CB graft selection criteria must consider unit quality and cryopreserved cell dose, as well as HLA match." They also added that the "unit quality is a result from banking practice that has increasingly been recognized as a critical factor in unit selection because unit quality is highly associated with unit potency, including postthaw CD34+ cell viability and recovery."

I hope this answer your question. Also, here is the link of the following study, https://www.sciencedirect.com/science/article/pii/S0006497120714114

Reference: Dehn, J. et. al. (14 December 2020). Selection of unrelated donors and cord blood units for hematopoietic cell transplantation: guidelines from the NMDP/CIBMTR. ScienceDirect. Retrieved February 23, 2022 from https://www.sciencedirect.com/science/article/pii/S0006497120714114

Hello Aradhana Rani

You may refer to the article attached below. This review describes the toxicities caused by CAR T-cells and reviews the published approaches used to manage toxicities.

Toxicities caused by CAR T-cells are diverse and not fully understood. Management requires vigilant monitoring, aggressive supportive treatments, and, in some cases, intensive care. Administering immunosuppressive agents to decrease toxicity is an evolving practice. Overall improvement in the field of CAR T-cell therapies could be achieved by improving the management of CAR T-cell toxicity.

Best.

O blood group contains both anti-A and anti-B antibodies then can not be transfuse O Blood group to other blood group types. Only RBCs of O group can be transfuse to any ABO group. Similarly AB plasma can be transfuse to any group. .

Agree with Lewis S Coleman

good work

Interested

best of luck

When you have ABO typing discrepancies . First you resolve the ABO discrepancy than transfuse ABO compatible cells or plasma .

Watch for 5 minutes for transfusion adverse effect , than you can transfuse as fast as required for maintained the critical parameters

I would suggest you a few options that can allow you to compare the deformability of two or more RBC samples:

1.mechanical fragility;

2. osmotic fragility;

3. membrane concentration of stomatin;

4. for stored RBC, vesicles concentration in the storage medium.

Methods for determining these features are given in the following publications.

Hi! Don't forget to evaluate their Shock Index (HR/SBP). If greater than approx. 0.7, that is one indication for the need for massive transfusion. We can also look at whether or not the shock is Pressor-dependent. If it requires pressors, that is another worrying sign. When looking at the labs, if the Hgb is *normal* with the heavy bleeding, that is a sign of a very active bleed where the H&H has not yet caught up to display the downward spiral. Activate your Massive Transfusion protocol and also consider Cyroprecipitate, IV Calcium, and warming blankets. Often forgotten. IV TXA is also a good plan.

Though it does sound like a good idea, inventory and distribution might not make it as cost-effective.

Briefly saw your table and question. So ur unit does something differently and has better results than literature. My first strategy would be to look locally or across site if a group of patients were dealt by conventional practice and compare.... even if not rct setup but a comparison group will make statistics easy.

Ur sample is big. I note ur grams resection is on average lesser than others, would that be the cause of ur short admission.

You could do a subset analysis here splitting groups in a few categories by grams resected..I'm just assuming here it may have no relevance.... But you could then compare with other similar studies...

Getting a stat test p value by comparing to others studies...hmmm not sure.. read into one proportion Z test. Anova I think u will need raw data of others aswell which u wont have... dunnets test runs with anova I vaguely recall....

lastly as Charalampos suggested.. stick to simple numbers and compare without stats.

We have not consistently recorded this information, but it could be interesting doing so (also on a retrospective basis). Hence, what I am saying is purely empirical. Transfusion increments are widely around 1 g/dl, sometimes the benefit is minimal, sometimes around 2 g/dl. Of course values may be subject by a host of different variables: test variables (timing of second hb determination - during transfusion - sampling error - or just after transfusion? infusion of packed RBC requires some time - maybe in older patients more - to redistribute fluids from the extravascular compartment to "dilute" the concentrated RBC transfused; type of determination - with CBC or with POCT/ABG testing?), besides patient's variables that I assume may be of some importance (body size, state of hydration and of concomitant i.v. fluid/diuretic therapy, ongoing overt/occult bleeding...)

Moreover sometimes physicians administer a pro re nata dose of i.v. diuretic (eg furosemide) in patients with congestive heart failure after the transfusion to counteract the possible haemodynamic consequence of an acute expansion of circulating volume, so it is possible that further haemoconcentration may be due to this practice.

Rats has own blood group system . (Like ABO and MNSs in humans .Specially Antigen A and M , So before transfusion compatibility test is must.

Hello,

Initially, SARS COV-2 virus when enters to the blood stream then it generally find the Angiotensin Converting Enzyme receptors (ACE-2) that are present upon the outer cell membrane. Virus spike protein gets attached to the ACE-2 receptor and then gets entered to the cell for its further replication process for the formation of its virions. Now, consequently it affects the another mechanism in the body which is regulated by ACE-2 receptor i.e. Renin angiotensin system that helps in the negative feed back inhibition to carry out homeostasis (to maintain blood pressure) in the body. As renin enzyme gets bind to the receptor and converts Angiotensinogen (inactivated protein form, zymogen form) to Angiotensin and then this protein makes a pressure to the arteriole cells to sustain the body blood pressure which has been fluctuated. But in the presence of bound virus, such system halts and fluctuates the homeostasis conditions.Therefore, it's more associated with the blood system as comparable to the respiratory tract. Here, one more thing is that to cause respiratory syndrome by affecting lungs, Virus needs to first infect blood cells and then the produced virions by such infection attached to the cilia of respiratory tract and blocks the oxygen/CO2 exchange mechanism due to the inflamation caused over there. So, we can analyse that it's an alternative approach of virus to infect the body for its own living.

Dear Kammar,

As per my little understanding, the term ROC stands for Receiver Operating Characteristic. ROC curves were first employed in the study of discriminator systems for the detection of radio signals in the presence of noise in the 1940s, following the attack on Pearl Harbor.

ROC curves are frequently used to show in a graphical way the connection/trade-off between clinical sensitivity and specificity for every possible cut-off for a test or a combination of tests. In addition, the area under the ROC curve gives an idea about the benefit of using the test(s) in question. 

ROC curves are used in clinical biochemistry to choose the most appropriate cut-off for a test. The best cut-off has the highest true positive rate together with the lowest false positive rate.  

As the area under an ROC curve is a measure of the usefulness of a test in general, where a greater area means a more useful test, the areas under ROC curves are used to compare the usefulness of tests.

Now ROC curves are frequently used to show the connection between clinical sensitivity and specificity for every possible cut-off for a test or a combination of tests. In addition, the area under the ROC curve gives an idea about the benefit of using the test(s) in question.

Hope the followings help you to chalk out your problems to determine or calculate the sample size in a very brilliant way.

1. https://www.who.int/ncds/surveillance/steps/resources/sampling/en/

2.

3. https://apps.who.int/iris/handle/10665/40062

Please find the manual "Sample size determination" as an attached file.

Happy researching..

Leuko-reduced or leuko-depleted blood or blood components are helpful in solving the problem

Foe cancer (solid tumour) to spread, definitely it is at stage 3 and above and never found in an asyptomatic individuals. Certainly, tumour cells metastasize through the blood and lymphatic systems and there is possibility to transfuse them, but ask me, I will tell the two instances put together are nothing but theoretical. In clinical practice, a malignant growth upto that stage will never leave an individual healthwisely free to be settled for transfusion and thus can never be symptomless.

The mechanism of Heyde Syndrome is increased blood flow velocity through sclerotic stenosed aortic valve and acquired von Willebrand syndrome whereas coagulopathy in TR is mainly due to liver dysfunction caused by hepatic dysfunction.

In view of the points raised by Mr. Muttuswamy there is a need of quick one step test (like to check the compatibility of blood) for blood considered to be safe for transfusion. Otherwise recipient's life can not be put on risk.

Unfortunately leukoreduction is not practiced universally and still recipients are exposed to febrile, immunologic reaction and exposed to increased risk of disease transmission. It should be a mandatory practice all over the world. Lekocytes are lysed and some are filtered out but still can induce this type of reactions.

Dear Siva,

I completely agree with you!

Kind regards. Pedro.

Thank you very much. Both are helpful, but the Thai study included good number of patients

Regards

Of course. In days past in isolated communities we also used to use PRV patients as donors, but this has long been forbidden due to potential of passing on an unknown virus.

I think it depends largely on the situation of the patient at the time of transfusion.

The categories of patients we see in our facility are essentially transfusion dependent for their disease and in some instances may have to take emergent transfusions in places that are far removed from their place of primary care, e.g. during vacations.

We therefore rely more on the traditional pre-grouping and crossmatching to ensure that any new clinically significant antibod(ies) that might have formed are not missed.

The JIT protocol is probably more ideal for previously antibody screen negative individuals, with no prior history of transfusion(s) or pregnancy.

What you call intermediate surgeries encompass a vast majority of procedures, some of them being with a higher risk of unexpected hemorrhages. So, In my practice, pre-op Hb for similar operations is mandatory in order to avoid troubles when unexpected bleeding occurs. Moreover, we have in the algorityms and protocols of our health care system such a requirement for lab minimum parameters for different grade of surgeries. It should be fulfilled.

Group O persons are universal RBC donors. Plasma is transfused, if at all, in low amounts, that too if the antibody titer is low. The benefit of transfusing O red cells far exceeds the slight damage that may be caused by low titer antibodies present in the plasma. O red cells have neither A nor B antigens and , therefore, will not react either with anti-A nor with anti-B of Group B and Group A recipients respectively. Group AB persons are universal recipients because their plasma contains neither anti-A nor anti-B antibodies.

Here I am repeating the question

Dear Maarten 

In the Blood transfusion filter is used for leukoreduction ( types are pr- storage and at the time of transfusion) because WBC is harmful to the Patients and cause so many adverse event including TRALY. Size of recent filters are appositely 4 µm that retains the leukocytes (8-12 µm diameter) and

RBC (2.5 µm thickness) and tiny platelets passes through filter. Previously 170 - 200  µm size filter was used to trap the Platelet + Leukocytes + fibrin aggregates which is not useful to prevent the TRALY.

 Dear Ashique Ali,

Yes you are right

Thanks for responding 

Dear Dr. Sharma,

The IgM antibodies are produced against primary infection and the production of other types such as IgG requires reinfection. The IgM antibodies against blood group antigens are produced by allergens, bacteria or other food components during the early life, in which the immune system and innate barriers for infections are at developing stage and it is a short span of time. Once the immune system and the innate barriers are completely developed, the reinfection with a bacteria or exposure to allergens is difficult due to the fully developed innate physical barriers. Since the production of IgG antibodies needs the antigen exposure to the specific B cells, it is impossible for many antigens to cross these barriers. IgG antibodies against blood group antigens are formed only in the case of mismatched blood transfusion or mother-child blood group mismatch during delivery. 

I could not find any direct references for this explanation. It is just my understanding after spending some time on this question. I think more experienced immunologists can add more insights on it.

Thanks for the question.

Best regards,

RB

Dear Khaled ,

Your question is

Is transfusion of vcABO comparable blood more hazardous than ABO identical blood ?

No, it is not the truth. When you are transfusing  RBC , It should be saline wash RRCs than no harm to transfuse ABO compatible cells. and in the cases of plasma & Platelets AB is universal   donor. By this you will also manage excess or shortage of different ABO blood group. For this you should have well equipped Component separation setup including sterilized tube connecting device. We are issuing ABO compatible component to the patients safely.

The underdevelopment of the ABO antigens in neonates is irrelevant when it comes to neonatal transfusion and transfusion of the infants own blood group should not be a problem as long as it is antigen negative for any IgG class blood group antibodies the mother may have. This includes IgG anti-A , IgG anti-B and or IgG  anti-A,B which most pregnant women have (unless they are group AB of course).

The ABO antibodies from the maternal plasma /serum would have to be neutralised before cross matching a unit of blood which is the babies group but ABO incompatible with the mother. These tests can be 'haphazard, unsuccessful, time consuming and difficult to validate so for convenience and clinical safety, group O is selected routinely.

Also, even though the laboratory cross match may indicate compatibility, there is no easy way to estimate if the infant has passively acquired IgG maternal ABO antibodies.

So it is easier in practice to give group O but there is no reason why the infant should not receive their own blood group if it is compatible with the mother eg Mum is group A and so is baby - infant can receive group A.

The maturity of the ABO antigens in the infant is of no consequence - as always with blood transfusion, it is the antibodies which cause the problem

Though there is risk of donor exposure, we are doing this practice in routine . one can add human albumin  in plasma to increase the albumin sites. As we are doing the exchange transfusion, will Human albumin serve the purpose of plasma. Is human albumin is isotonic solution . My article on this subject is 

Dharmesh Chandra Sharma, et al  Efficacy of Whole Blood Reconstituted (WBR) in Exchange Transfusion (ET) in Hemolytic Sisease of New Born (HDN) – A study of 110 Cases.Open Journal of Blood Diseases, 2013;   3(1): 15-20.  DOI: 10.4236/ojbd.2013.31004,

I think question is related with Packed RBCs / Whole blood. Prior transfusion, Worming of unit is neither required nor permissible. 

Transfusing sickle cell patients with donor blood with a normal Hb (ie HBAA) is ABSOLUTELY essential. Some people who are HbAS (sickle trait) can be accepted as blood donors, but if their blood is transfused to a HbSS person, especially during sickle crisis or anaesthetic, the transfused cells would also sickle and contribute to the already existing problem.

If a transfusion is needed, please ensure you inform the supplying blood bank of the sickle problem. They will then select HbAA donors for transfusion.

Systolic blood pressure is the best indicator in the prehospital care environment.   In-hospitable blood pressure and HCT are good indicators. If you don't use a ratio of 1:1:1 red cells, plasma, platelets, monitoring pt, ptt and platelets will help prevent dilutional coagulopathy.  You can add more sophisticated testing but they take time, and in the face of acute blood loss, simple is better. You might also consider reinfusing any blood collected from the chest.  

Hello, I agree with Nahid.

SSP is the simplest technique you can use in HLA. We have been doing organ and bone marrow transplants for years based on SSP results (Life Technologies / Thermo Fisher), but now we are shifting to SOP due to the increased workload.

Nevertheless, we use it while on call for solid organ transplants and sometimes to verify ambiguous results of SOP.

To perform SSP you need a good DNA, in larger quantities than in some other techniques. But I find it is not so sensitive to DNA quality as other techniques: For years we have been extracting DNA by hand using the modified salting out procedure without major problems. The instructions booklets included are fairly simple and well explained, and it is a technique that doesn't need particularly advanced laboratory skills. 

So if you want to start in the field, probably is the best way to start, and then you can migrate to more complex tests. Don't forget that SSP is more and more limited as more and more alleles are found. 

dear Dr jose

thanks for your replay but i mean with consideration of huge and locally advanced tumor and expectation of remarkable bleeding during surgery ,I want to find a way to keep and save the patient blood before surgery outside in order to infuse during or after surgery.

As a Trauma Surgeon there are ample data that support the early administration  of plasma and platelets  for the critically injured trauma patient.  This may not be relevant to the critically ill medicine patients.

Sadly none of the instruments/laboratory assays provide an adequate real-time picture of the patient's coagulation status.  Even from TEG and ROTEM have issues related to patients with depleted fibrinogen stores and more importantly cold patients.  Many critical care physicians failed to recognize that when a battery of coagulation tests  are drawn and sent to the laboratory the laboratory warms the sample to 37°C.  Trauma patients owe as much as 50% of the coagulopathy to hypothermia.

Consequently, the answer is clinical judgment.  As a clinician you must take into account the injuries with their estimated blood loss and the patient's temperature and premorbid complicating medical conditions to determine when to give plasma.  As a rule sooner is better than later and warmed is better than cold.

On a separate note we are currently using type A plasma in addition to AB plasma.   The safety of this has now been documented but originally stems from the use of uncrossed matched platelets which carry with them a significant plasma store.  I'm curious how many facilities have liberalize their use of type A plasma to expand the store of fresh plasma for their trauma patients?

Respectfully

John

In our experience blood collected in citrate tubes (blue cap) works right for most dental and surgical procedures. Platelet rich plasma can be obtained with any anticoagulant you want to use, it only depends on the centrifugation protocol. However, citrated plasma is the best if you want to analyse platelets or prepare a platelet gel later on. Then, a blue cap tube is the best, because it will save you all the trouble gettin sterile tubes, etc etc.

I fully agree with Tracy; so the benefit would be marginally for the clinician. Especially, since the increase in hemoglobin after transfusion relies on so many factors including the recipient (body weight, normovolemia, organ sizes (liver, spleen), blood loss, etc.).

Therefore, a non-invasive hb measurement, which is fully reliable (the current available systems are not really), cheap and not disturbing to the patient (e.g. a sort of a band-aid, which can be affixed to the skin and which is able to transmit the data wireless) would be a good solution. 

Immucor solid phase

Hi Tanya,

thanks for this very interesting question. First of all, I have never operated  a cell saver myself. However, there are some aspects to this problems which I want to discuss.

Blood is sucked from the wound, and heparin is added immediately quite close to the tipp of the suction. If this heparin rate is too low, coagulation might occur, especially if fibrinolysis is blocked by tranexamic acid (plasmin cannot "cut" fibrin fibrils any longer).

In the machine, however, there should be a filter taking out clots, bone fragments, fatty lumps and similar debris from the wound. Further down the line, the "product" is washed, and in the end there should be something similar to an erythrocyte concentrate not containing much plasma or other cells. However, you can never get rid of all plasma or thrombocytes. Did your technician make sure that the "product" contained enough anticoagulant? Was it really clotting you observed, or could it have been agglutinates (patients with autoantibodies reacting in the cold, for example)?

Again, I have never run a cell saver all by myself. However, I think it could be possible that tranexamic acid might require higher rates of heparin in the cell saver system.

Last question: Those three patients did not have a (recent) history of HIT, did they?

 i have been using tautologous blood transfusion since 1997 to date before giving heparin we take one or tow unit then after giving protamin  we transfuse blood back to the patient it is perfect for homeostasis i usually remove all chest tube within 16 hrs and ambulate pt after that   

Why not?

Make another three possible and simple questions:

one) who can justify the "unversal" transfusion of the "two units pack" of red cell concentrates?

two) who can justify that a patients admitted at the surgical waiting list during months could come anemic to the operation room?

three) who can justify to do not use autologous blood? why do not recover intra or post surgical bleeding and reinfuse after wash it?

Please, do not ask if we follow, ask youself why you do not follow the blood management guidelines?

Dear Sandra,

I am not aware of any official regulations/guidelines on blood components (e.g. platelet concentrate or cryoprecipitate) specifically for topical use. For autologous applications, you have a number of medical devices which got approval (e.g. CE marking) in various countries based on a number of quality specification and absence of toxicity of the device. In the case of allogeneic applications, the clinicians use a platelet concentrate, plasma, or cryoprecipitate that meet the national requirements for transfusion, and which are produced by blood establishments. I hope this helps. Best, Thierry

In Australia,we have started to follow/implement the new guidelines published recently which include some recommendations where sufficient evidence was available and practice points in abscence of enough evidence. You could find the details in

Yes

Of course!

There is a decrease of several coagulation factors, but also an umpaired anticoagulation proteins realease and cleavage!, and a fbrinolysis disbalance, with a trend to hyperfibrinolisis and disfibrinogenemia!

Unnecessary plasma transfusion (with citrate as anticoagulant) could modify this fragil balance

Hi Anique,

Here is the translated Italy Questionnaire that we print for every Donor of Blood and Components. I added, in the last part of the document a survey questionnaire to understand problems or trigger points for a blood donor candidate. I agree with Torsten and Markus that you have to give a look DOMAINE group and EBA but I am sure that the questionnaire adopted in Italy is perfectly aligned, as well as German Blood Donor Questionnaire, with European Community standard guidelines updated continuously.

I hope it was helpful for You.

Hi Hitoshi

Yes the UK has considered implementing a prion filtration system for blood transfusions. Below I have posted one link to a surveillance trial (there are other interesting articles and papers which can easily be found online if you are interested in reading more) http://www.nhsbt.nhs.uk/clinicaltrialsunit/current-trials/prion-filter-pms/

Best

Daryl

Dear Oliver,

Please let me quote some recent publications:

- “… Hanging crystalloid, followed by RBCs and some plasma is passé and likely contributed to the epidemic of compartment syndromes and excess death over the last 40 years. …” Holcomb JB. A Novel and Potentially Unifying Mechanism for Shock Induced Early Coagulopathy. Editorial. Ann Surg 2011;254:201-202

- “The safest transfusion remains the one not given.” Murthi S et al. Transfusion medicine in trauma patients: an update. Expert Rev Hematol 2011; 4(5): 527–537

- restrictive transfusion strategy: “… i.e. transfuse only what is really necessary (RBCs, plasma or platelets) and only when it is really necessary.” 1A (strong recommendation, high quality evidence) (p.298) Kozek-Langenecker S et al. Management of severe perioperative bleeding. Guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2013; 30:270–382

- “Combined with the 2004 review, 80 RCTs (in 50 years, inserted by me) have investigated FP with no consistent evidence of significant benefit for prophylactic and therapeutic use across a range of indications evaluated.” Yang L et al. Is fresh-frozen plasma clinically effective? An update of a systematic review of randomized controlled trials. Transfusion 2012;52:1673-1686

- "Recommendation: We suggest (not: recommend, inserted by me) that plasma be transfused to trauma patients requiring massive transfusion (quality of evidence = moderate)." Roback J et al. Evidence-based practice guidelines for plasma transfusion. Transfusion 2010;50:1227-1239

These quotations can be continued for hours!

There is no doubt, that RBC will increase oxygen carrying capacity (to a certain degree).

There is no doubt, that PC will increase the number of platelets.

There is no scientific evidence, that FFP will optimize coagulation in any way! Probably with the sole exception of massive transfusion.

So, there seems to be only one solution, if you want to work "evidence-based":

Every single transfusion (i.e., RBC, PC and especially FFP) has to be indicated seperately!

FFP is only indicated in massive transfusion, but here it should be given early, in large quantities (at least 6 FFP for adults, >30 ml/kgBW and FFP:RBC >1:2 ), and fast (i.e.,~50 ml/min).

The recent discussion on side effects of HAES seems to show a class effect of all colloids in patients with compromised endothelial function. Personally, I believe, FFP will soon only be acceptable as an integrated part of an escalating management algorithm for massive transfusion.

Best wishes and a happy Christmas,

Heiko

Methylene blue inactivated plasma has been associated with severe allergic reactions, and I fully agree that it should be avoided. Solvent Detergent (SD) treated plasma is a pooled pathogen reduced fresh frozen product with standardized volume and content of coagulation factors and coagulation inhibitors. More than 12 million 200 ml bags of the SD plasma, Octaplas (including licensees), have been produced and transfused to ca. 4 mill patients without a single documented case of TRALI and about 70% reduced frequency of allergic/immunologic reactions.

Accepted indications for the use of fresh frozen plasma are :

1. Bleeding in congenital coagulation deficiencies for which there are no specific coagulation factors.

2. Massive bleeding leeding to aquired multiple coagulation deficiency. The use of transfusion packages (i.e. 4 units of red blood cells, 4 units of plasma and 1-2 units of platelets) has been advocated.

3. Immediate rewersal of Warfarin effect in patients with active bleeding in need of volume

4. Thrombotic thrombocytic purpura (TTP)

5. DIC or consumptive coagulopaty with active bleeding

Most agree that liquid or delayed frozen plasma should not be used.

It is a pity that the above guidelines often are not followed and plasma used unnecessarily.