Category Archives: Resuscitation

Resuscitation

Liquid Plasma vs FFP: Impact On Your Massive Transfusion Protocol

In my last post, I discussed the growing number of choices for plasma replacement. Today I’ll look at some work that tried to determine whether any one of them is better than the others when used in the massive transfusion protocol (MTP).

As noted last time, fresh-frozen plasma (FFP, frozen within 8 hours) and frozen plasma (FP, frozen within 24 hours) have a shelf life of 5 days once thawed. Liquid plasma (never frozen, LQP) is good for the 21 days after the original unit was donated, plus the same 5 days, for a total of 26 days.

LQP is not used at most US trauma centers. It is more commonly used in Europe, and a study there suggested that the use of thawed plasma increased short-term mortality when compared to liquid plasma. To look at this phenomenon more closely, a group from UTHSC Houston and LSU measured hemostatic profiles in both plasma types at various time points during their useful lives.

All products were analyzed using thromboelastography (TEG) and thrombogram, and platelet count, microparticles, clotting factors, and natural coagulation inhibitors were measured. They chose 10 units of thawed FFP and 10 units of LQP, and assayed them every 5 days during their useful shelf life.

Here are the factoids:

  • Platelet counts were much higher in day 0 LQP (75K) vs day 0 thawed plasma (7.5K). Even at the end of shelf life, the LQP was 1.5x higher than thawed (15K vs 10K).
  • Thrombogram showed that LQP had higher endogenous thrombin production until the end of shelf life
  • TEG demonstrated that LQP had a higher capacity to clot that gradually declined over time. It became similar to thawed plasma at the end of its shelf life.
                         (TEG MA for liquid (LQP) and thawed (TP) plasma
  • Most clotting factors remained stable in LQP, except Factors V and VIII, which slowly declined

Bottom line: Liquid plasma sounds like good stuff, right? Although there are a few flaws in the collection aspect of this study, it provides good evidence that never-frozen plasma has better coagulation properties than thawed plasma. Will this translate into better survival when used in the MTP for trauma? One would think so, but you never really know until you try it. Our hospital blood bank infrastructure isn’t prepared to handle this product yet, for the most part. What we really need is a study that shows the survival advantage of using liquid plasma compared to thawed plasma. But don’t hold your breath. It will take a large number of patients and some fancy statistical analysis to demonstrate this. I think we’ll have to look to our military colleagues to pull this one off!

Reference: Better hemostatic profiles of never-frozen liquid plasma compared with thawed fresh frozen plasma. J Trauma 74(1):84-91, 2013.

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Resuscitation

Liquid Plasma vs FFP: Definitions

I’ll spend the next two posts discussing plasma. This is an important component of any trauma center’s massive transfusion protocol (MTP). Coagulopathy is the enemy of any seriously injured patient, and this product is used to attempt to fix that problem.

And now, there are two flavors available: liquid plasma and fresh-frozen plasma. But there is often confusion when discussing these products, especially when there are really three flavors! Let’s review exactly what they are, how they are similar, and how they differ.

Fresh frozen plasma (FFP)
This is plasma that is separated from donated whole blood. It is generally frozen within 8 hours and is called FFP. However, in some cases, it may not be frozen for a few more hours (not to exceed 24 hours total), and in that case, it is called FP24 or FP. It is functionally identical to FFP. But note that the first “F” is missing. Since it has gone beyond the 8-hour mark, it is no longer considered “fresh.” To be useful in your MTP, it must be thawed, which takes 20-40 minutes depending on the technique.

Thawed plasma
Take a frozen unit of FFP or FP, thaw it, and keep it in the refrigerator. Readily available, right? However, the clock starts ticking, and this unit expires after 5 days. Many hospital blood banks keep this product available for the massive transfusion protocol, especially if other hospital services are busy enough to use it as it approaches expiration. Waste is bad and expensive!

Liquid plasma (never frozen)
This is prepared by taking the plasma separated from donated blood and placing it in the refrigerator, not the freezer. Its shelf life is that of the unit of whole blood it was taken from (21 days), plus an additional 5 days, for a total of 26 days. This product used to be a rarity, but is becoming more common because of its longer shelf life than thawed plasma.

Finally, a word on plasma compatibility. ABO compatibility is still a concern, but Rh is not. There are no red cells in the plasma to carry any of the antigens. However, the plasma is loaded with A and/or B antibodies, depending on the donor’s blood type. So the compatibility chart is reversed compared to what you are accustomed to when giving red cells.

Remember, you are delivering antibodies with plasma and not antigens. So a Type A donor will have only Type B antibodies floating around in their plasma. This makes it incompatible with people with blood types B or AB.

Type O red cells are the universal donor type because they have no antigens on their surface. Since Type AB donors have both antigens on their red cells, they have no antibodies in their plasma. This makes AB plasma the universal donor type. Weird, huh? Here’s a compatibility chart for plasma.

Next time, I’ll discuss the virtues of the various plasma types used for massive transfusion in trauma.

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Resuscitation

Massive Transfusion Cooler Etiquette

The Massive Transfusion Protocol (MTP) is one of the key life-saving tools that trauma professionals can utilize in their trauma centers. These are complex processes with specific triggers and logistics that vary by trauma center level, location, and volume. Because of this complexity, it is impossible to create a cookbook for designing your protocol.

However, there is one constant across all trauma centers regarding their MTP. I call it MTP cooler etiquette. This cooler is the center focus of the entire protocol, and the patient relies on good manners in its use for their life. Here are my thoughts about how to properly handle the MTP cooler.

  • Decide who carries it to and from the trauma bay / OR  ICU. At a few centers, blood bank personnel are responsible for bringing the coolers to the required location. However, the majority do not have enough spare lab techs to run coolers all around the hospital. Each center will need to decide who is best suited. Frequently, this falls to personnel from the ED or OR. However, in large medical complexes, it may be preferable to have security personnel handle this, as they are very familiar with the hospital layout.
  • Ensure the cooler is visible in the area it is used at all times. It is critically important that the cooler not be hidden in a corner or behind other equipment. This can lead to it being forgotten and to the wastage of the blood products inside. In the trauma bay, it should be located next to the team leader. In the operating room, it should be adjacent to anesthesia personnel. In the ICU, it should be located just inside the patient room door. This guarantees that everybody who enters and leaves the area can see it and will not forget to send it back when it’s no longer needed.
  • Place clear signage on the cooler to remind all personnel to call the blood bank when the MTP is over.
  • When moving the patient from area to area, place the cooler on the bed next to them. Placing it under the bed is a recipe for forgetfulness.
  • Empower everyone in the room to bring up the question of whether the cooler is no longer needed. Don’t wait until there are cobwebs on it and the blood products are at room temperature. Once the question is asked, call the blood bank immediately and let them know it is being deactivated.
  • Finally, decide who has the task of taking it back to the blood bank. Typically, this is someone from the area where it was last used. Anyone assigned to this task should recognize the importance of a timely return to the blood bank. Blood is a precious product and should be handled accordingly.

If you have some good suggestions on blood bank etiquette, please leave them in the comments below.

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Resuscitation

The “Double-Barrel” IO: Can It Work?

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Intraosseous lines (IO) make life easy. They are quicker to insert, have a higher success rate, and require less experience than a standard IV. And they can be used for pretty much any solution or drug that can be given through an IV.

But there are some limitations. They can’t be inserted into a fractured bone. The manufacturer cautions against multiple insertions into the same bone. A second insertion should not be performed in the same bone within 48 hours.

But, as with so many things in medicine, there is little in the way of proof for these assertions. They seem like good ideas for precautions, but that does not mean they are correct. No real research has been done in this area. Until now.

The concept of using two IO needles in one bone was explored in an animal model by researchers in Canada. They used a swine model (using the foreleg/humerus, to be exact), and tested several infusion setups.

Here are the factoids:

  • Infusing crystalloid using an infusion pump set to 999ml/hr took 30 minutes with a single IO, and 15 minutes with a “double-barrel” setup
  • Giving crystalloid using a pressure bag set at 300 mm/Hg took 24 minutes with a single IO, and 23 minutes with double the fun
  • The double-barrel setup also worked for a blood/drug combo. 250cc of blood and 1 gm of TXA in 100ml of saline infused via pump in 13 minutes.
  • Simultaneous anesthesia drugs (ketamine infusion in IO #1, fentanyl and rocuronium bolus in IO #2) without problems
  • Multiple fluid + drug infusion combinations were tested without incident
  • There were no needle dislodgements, soft tissue injuries, fractures, or macrohistologic damage to the bone or periosteum

Bottom line: Remember, these are pigs. In the ten years since this study, I’ve not seen any human research. So don’t do this in humans yet. However, this is pretty compelling evidence that the double-barrel IO concept will work in people. And it appears that infusion pumps must be used for effective, fast infusions. I recommend that prehospital agencies with inquiring minds set up a study in people to prove that this works in us, too.

Reference: Double-barrelled resuscitation: A feasibility and simulation study of dual-intraosseous needles into a single humerus. Injury. 2015 Nov;46(11):2239-42. doi: 10.1016/j.injury.2015.08.029. Epub 2015 Sep 11. PMID: 26372229.

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Resuscitation

Hypotensive Patient? You’ve Got 90 Seconds!

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You’re running a trauma activation, and everything is going great! Primary survey – passed. Resuscitation – lines in, fluid going. You are well into the exam in the secondary survey.

Then it happens. The automated blood pressure cuff indicates a pressure reading of 72/44 mmHg. But the patient looks so good!

You recycle the cuff. A minute passes, and another low pressure is noted, 80/52. You move the cuff to the other arm. Xray comes in to take some pictures. You roll the patient. 76/50. Well, you say, they were lying on the cuff. Recycle it again.

A minute later, the pressure is 56/40, and the patient appears gray, is very confused, and is diaphoretic. It’s real! But how long has it been really? An easy five minutes have passed since the first bad reading.

Bottom line: Sometimes it’s just hard to believe that your patient is hypotensive. They look so good! But don’t be fooled. If you get a single hypotensive reading, STOP! You have 90 seconds to figure out if it’s real, so don’t do anything else but. Check the pulse rate and character with your fingers. Do a MANUAL blood pressure check. It’s fast and accurate. If you have the slightest doubt, ASSUME IT’S REAL.

This tip also applies when you get an error reading or the cuff does not detect a pressure. You can take a moment to check central and peripheral pulses, but you must still get a real reading on a blood pressure cuff within 90 seconds. If you can’t, the hypotension is the real deal and must be treated appropriately. And immediately.

Don’t get suckered into trying to figure out what’s wrong with the cuff despite how good your patient looks. Remember, your patient is bleeding to death until proven otherwise. And it’s your job to prove it. Fast!

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