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Use of Plasma in Central Nervous System Bleeding: Consensus Recommendations

This document outlines the consensus recommendations developed by Dr. Ira A. Shulman, MD, regarding the use of plasma in managing Central Nervous System (CNS) bleeding. Highlighting challenges related to data quality and the heterogeneity of blood products, the recommendations stress the importance of recognizing the various plasma types—such as Fresh Frozen Plasma (FFP) and Plasma Frozen within 24 Hours (FP24)—and their impact on therapeutic outcomes. It also addresses the risks associated with plasma transfusions and offers insights into effective therapeutic strategies.

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Use of Plasma in Central Nervous System Bleeding: Consensus Recommendations

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  1. Use of Plasma in Central Nervous System Bleeding: Consensus Recommendations Ira A. Shulman, MD Professor and Vice Chair of Pathology, KSOM of USC Director USC Transfusion Medicine Service Group Laboratory Director, LAC+USC Medical Center

  2. Notice of Faculty Disclosure In accordance with ACCME guidelines, Dr. Shulman has disclosed the following financial relationships with commercial interests:

  3. CHALLENGES TO CREATING CONSENSUS RECOMMENDATIONS FOR USE OF PLASMA IN CNS BLEEDING • QUALITY OF DATA • PUBLISHED DATA IS OFTEN BASED ON FFP USAGE • TODAY, PHYSICIANS ORDER FFP, BUT PATIENT OFTEN GETS SOMETHING ELSE

  4. BLOOD COMPONENTS TRANSFUSEDIN THE US IN 2011 * Heterogeneous Product Lines THE 2011 NATIONAL BLOOD COLLECTION AND UTILIZATION SURVEY REPORT

  5. Each Donor is Different Collection Methods Vary

  6. Heterogeneous Product Lines • FRESH FROZEN PLASMA (FFP): frozen within 8 hours of collection • Plasma Frozen within 24 Hours (FP24): frozen within 24 hours of collection • Thawed Plasma (TP): derived from thawed FFP or thawed FP24 and maintained for a maximum of 5 days in the refrigerator

  7. OTHER PLASMA PRODUCTS

  8. Plasma Collected in US FFP from WB; 1,813K (31%) FP24 from WB; 2,802K (47%) THE 2011 NATIONAL BLOOD COLLECTION AND UTILIZATION SURVEY REPORT

  9. Types of plasma transfused, 2008-2011 THE 2011 NATIONAL BLOOD COLLECTION AND UTILIZATION SURVEY REPORT

  10. FFP VS. FP24FACTOR LEVELS Decline in clotting factors is not significant except for FVIII; levels are significantly lower in PF24 than FFP but within ‘normal’ range

  11. Thawed FP 24 Coagulation LevelsDay 0 to Day 5 Triulzi et al, Transfusion, vol.48 Dec 2008 pg 2525

  12. Scott E, et al. Transfusion 2008;49:1584-91 Thawed FFP vs Thawed FP24 NE = not established PC = Protein C Only results from group O products were used for statistical comparisons of factor VIII

  13. THAWED PLASMA FACTOR LEVELS The activity of all factors assayed, except for Protein S, were within the normal range during the 5-day storage period, supporting comparable factor assay levels in thawed plasma from FFP and FP24 Yazer, et al. Transfusion 2008;48:2525

  14. Thawed at 30-37ºC Stored frozen colder than -18°C 4ºC Handling Options for FFP / FP24 FFP / FP24 FFP / FP24 Thawed >24 h Thawed Plasma Good up to 5 d after thawing

  15. Plasma Transfusions can be ‘risky business’ Hazards of plasma transfusion, include… • Hemolytic Reaction • Volume Overload (TACO) • TRALI • Allergic/Anaphylactic • Disease Transmission

  16. VOLUME OF PLASMA TRANSFUSED TO ACHIEVE THERAPEUTIC GOAL CAN BE VERY LARGE 1500 mL (6 U) FFP to reduce INR from 6.0 => 3.0 1500 mL (6 U) FFP to reduce INR from 3.0 => 1.7 1500 mL (6 U) FFP to reduce INR from 2.0 => 1.5 2500 mL (10 U) FFP to reduce INR from 2.0 => 1.3 Holand LL, Brooks JP. Am J Clin Pathol 2006;126:1-7

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