Plasma Transfusion Practice in Adult Surgical Patients: Systematic Review of the Literature

Abstract

Background: Plasma transfusions are most commonly used therapeutically for bleeding or prophylactically in nonbleeding patients prior to invasive procedures or surgery. Although plasma transfusions generally seem to decline, plasma usage for indications that lack evidence of efficacy prevail. Summary: There is wide international, interinstitutional, and interindividual variance regarding the compliance with guidelines based on published references, supported by appropriate testing. There is furthermore a profound lack of evidence from randomized controlled trials comparing the effect of plasma transfusion with that of other therapeutic interventions for most indications, including massive bleeding. The expected benefit of a plasma transfusion needs to be balanced carefully against the associated risk of adverse events. In light of the heterogeneous nature of bleeding conditions and their rapid evolvement over time, fibrinogen and factor concentrate therapy, directed at specific phases of coagulation identified by alternative laboratory assays, may offer advantages over conventional blood product ratio-driven resuscitation. However, their outcome benefit has not been demonstrated in well-powered prospective trials. This systematic review will detail the current evidence base for plasma transfusion in adult surgical patients.

Ex vivo hemostatic and immuno‐inflammatory profiles of freeze‐dried plasma

“…10 Plasma transfusion is an essential part of this approach and remains a considerable logistical challenge in both civilian and military prehospital settings, hence the need for a reliable, shelfstable, easy-to-carry, and administer plasma product. 21 Freeze dried or lyophilized whole plasma and plasma fractions provide a promising alternative to FP for remote prehospital resuscitation of traumatic shock and coagulopathy; FDP is easy to store at ambient temperatures, transport, and reconstitutes quickly and efficiently, resulting in a rapid time-to-transfusion. 31,55 These logistic (reduced weight and cube) and other potential therapeutic advantages have led to renewed interest in the use of FDP, particularly in austere far-forward military trauma environments.…”

“…66 Transfusion of blood products, e.g., red blood cells, FFP, platelet concentrates for trauma has been conducted in prehospital settings although definitive outcome benefit has not been demonstrated in well-powered prospective randomized trials. 21,67 In addition, a variety of new hemostatic agents, surgical adjuncts, and blood products have been designed for prehospital control of lifethreatening non-compressible hemorrhage. 68 Collectively, these agents may have contributed to reduced mortality on the battlefield.…”

“…81 The current findings demonstrating that the relatively low concentrations of immuno-inflammatory proteins present in FP were preserved in FPD, are consistent with the literature suggesting that freeze-drying or lyophilizing processes do not greatly enhance or disrupt the macromolecular stability of commonly detectable inflammatory cytokines, chemokines and other bioactive mediators. 21,84,85 Similarly, results from experimental animal models, administering dried or lyophilized plasma, indicate that FDP likely does not exacerbate existing harmful immune-inflammatory dysregulation after trauma and may in fact, confer beneficial anti-inflammatory effects that result in less blood loss and subsequent organ dysfunction. 25,[86][87][88] Moreover, findings from pre-clinical models of hemorrhage and resuscitation do not indicate that in vivo or ex vivo use of FDP adversely affects the functional interplay between coagulation and inflammatory systems.…”

“…11,15,19,20 Timely plasma administration replaces depleted clotting factors, promotes hemostasis, and restores intravascular volume without the risk of initiating dilutional coagulopathy. 6,[21][22][23] This approach also helps protect against down-stream complications by ameliorating the endotheliopathy and immuno-inflammatory dysfunction of trauma. [24][25][26] Thus, in the setting of acute trauma care, initial plasma-directed therapy provides a superior resuscitative strategy to conventional fluids and may lessen TIC.…”

Plasma trial: Pilot randomized clinical trial to determine safety and efficacy of plasma transfusions

“…4,5 However, there is no definitive clinical trial evidence to substantiate this practice. 6 We conducted a pilot randomized clinical trial with the aims of gathering experience necessary to plan and conduct a large pragmatic trial to assess the benefits (less bleeding) and risks (transfusion associated cardiac overload [TACO] and transfusion related acute lung injury [TRALI]) of administering plasma prior to invasive procedures. This was necessary because prior clinical trials were unsuccessful in recruiting an adequate number of patients.…”