Restrictions to the use of thawed plasma versus FFP

A colleague in Southern California comments that one of his institution's current approaches to minimizing wastage of thawed FFP is to convert thawed FFP to thawed plasma, if a unit of thawed FFP is not used within 24 hours of being thawed. The institution will then dispense the thawed plasma to fill a request for FFP except for patients who are in any of the following groups:

• pregnant women
• children 12 years and younger
• patients with hemophilia A
• patients with DIC
• patient requiring replacement of labile (factor V or factor VIII) clotting factors

The above approach is just one of many for the use of thawed plasma (see examples of this strategy in prior discussions at:

Relabeling thawed FFP as thawed plasma
and
Minimizing Wastage of Unused Thawed FFP

The inquiring colleague wonders if his institution's restrictions to the use of thawed plasma are medically justified, because the technologists at this institution hesitate to use thawed plasma at all, since they usually have to go through the above list of conditions with the physician who is ordering FFP, in order to determine if the patient is restricted for thawed plasma use. Consequently, it is "easier" for the technologists to thaw a unit of FFP, and not worry about calling the physician to see if a unit of thawed plasma is OK to issue. Consequently, this institution is not taking full advantage of maintaining a thawed plasma inventory. The inquiring colleague wonders if other institutions restrict thawed plasma to each of the patient groups shown above. If not, why not? The technologists claim that if it were 'easier' to issue thawed plasma (i.e., fewer restrictions), that it would be more acceptable to them to maintain an inventory of the product.

The following comments have been received.

ADDENDA April 5, 2004

1. A transfusion medicine colleague in Boston reports that her hospital is in the process of changing their FFP thawing practices. Their new protocol permits them to label all thawed units of FFP as 'thawed plasma', which is then stored at the appropriate temperature as liquid plasma that has a 5-day outdate. The blood bank will no longer routinely offer "thawed FFP" as a product; only thawed plasma will be offered. It is their belief that thawed FFP (with a storage duration of 24 hours) has an advantage over thawed plasma (with a storage duration of 5 days) only in rare cases of factor V deficiency. In cases of factor V deficiency the hematologists have been instructed to order "freshly thawed FFP" and the blood bank records would indicate the patient has a special need for thawed plasma that is less than 24 hours old.
   
   
2. A transfusion medicine physician in Michigan reports that his academic medical center uses thawed plasma interchangeably with FFP and that they have not had any problems with this approach. He comments that even if they had a patient with known factor V deficiency he would not hesitate to dispense thawed plasma in that clinical scenario, because, according to the responding physician, the half-life of Factor V at 4C is 10-14 days, much longer than the storage period of thawed plasma. He also comments that in his opinion, a factor V level of 25-30% activity is sufficient for surgery, which can be easily achieved with thawed plasma. In addition, he points out that platelet factor V is probably most important for treating known factor V deficiency, so that platelet transfusion (not plasma transfusion) in factor V deficiency can provide hemostasis for 5-6 days. Since adopting this policy their plasma outdate has dropped to virtually zero.

ADDENDA April 6, 2004

3. A transfusion medicine physician in Dallas, Texas reports that his hospital has been using thawed plasma for over 2 years without any restrictions. He knows of no medical reason to limit the use of thawed plasma for pregnancy or children less than 12 years of age when there is need for transfusion of FFP. He adds that a patient with hemophilia A should NOT be treated with FFP or thawed plasma to raise factor VIII levels, as there are factor concentrates (purified and recombinant) and if these are unavailable, the best alternative product is CRYO, not FFP. He adds that in DIC, generally there is a sufficient level of FVIII due to acute phase reaction. If a patient is bleeding due to consumption of factors in fulminant DIC, their local approach would be to use plasma along with CRYO.
   
   He adds that thawed plasma has 66% of normal levels of Factor V activity on day 5, and therefore is sufficient to maintain hemostatic level (approx. 25%) in Factor V deficient patients. (Downes, K; Wilson, E; Yomtovian, R; Sarode, R. Serial measurement of clotting factors in thawed plasma stored for 5 days. Transfusion 2001; 41(4):570).
   
   At his institution they keep 4 units of group O and group A, and 2 units of group AB plasma thawed at all times in support of a busy trauma center. They rarely waste any units of thawed plasma, as compared to wasting approximately 50-60 units per month before implementing the above inventory strategy. Presently they store their plasma for only 72 hours, but they will increase the storage duration to 5 days once they have new validated computer system.
   
   
4. A colleague in San Francisco at an academic medical center reports that they have been using thawed Plasma (5-day outdate) interchangeably with FFP for years. They first validated that levels for Factor V and Factor VIII remained acceptably high (75-95% for Factor V, 45-75% for Factor VIII) in a small in-house study. In their Clinical Laboratory Manual they list thawed plasma, explain its composition and that it will be issued interchangeably with FFP. They recommend that thawed plasma should not be used as sole source of Factor V or Factor VIII replacement in patients with isolated deficiencies of these factors but they do not inquire about the specific reason for an order of FFP when they receive one. Among their patient population they rarely see such cases; the majority of their plasma use is in trauma (where at least Factor VIII levels tend to be high) and in patients with liver disease. They report having no problems with this policy and they believe it makes a substantial difference in keeping their outdate rate for FFP low. The San Francisco colleague admits that initially some physicians reacted unfavorably when they heard that 'thawed plasma' was going to be issued when FFP was requested. However, after these clinicians learned that at the 5 day storage limit the thawed plasma contained reasonably high Factor V and Factor VIII levels, the clinicians supported the new policy.

ADDENDA April 8, 2004

5. A Transfusion Medicine and Coagulation Medical Director from Michigan states that her facility has used thawed plasma for the last 3 years for trauma, surgical and other urgent requests for FFP, based upon the same references cited by other respondents. The only restriction is that it not be used for Factor VIII replacement in hemophiliacs. She comments that they presented the data cited by the other respondents to the physicians that would be supplied with the product, and they found it acceptable, particularly since they could provide the product much faster than thawing FFP upon request. Her facility keeps a standing inventory of A, B & AB thawed plasmas on a separate shelf in the crossmatched blood refrigerator. Wastage of FFP went from over 4% to less than 1% since they began this protocol.
   
   
6. A Medical Director from an academic medical center in Minnesota states that for some years now they have ceased issuing FFP and only use frozen plasma (frozen within 24 hr of donation, usually frozen at an average of 11-12 hr from donation) with one exception that was permitted to get it easily approved by the transfusion committee. To placate the pediatric hematologist/pediatric intensivist on the committee, they included the provision that neonates can have FFP. No one else receives FFP except in a very rare isolated incident when the blood bank physician decided to use it (one small child for complex cardiac surgery with an unexplained coagulopathy whose INR did not correct at previous surgeries despite plenty of plasma given). For some years they too have been issuing thawed plasma (up to 3 days after thawing) as equivalent to frozen plasma and have no added restrictions for recipient selection purposes.

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