What is the recommended use of spray dried plasma (SDP) in adult trauma patients with significant bleeding and coagulopathy?

Spray Dried Plasma in Adult Trauma Patients with Significant Bleeding and Coagulopathy

Spray dried plasma (SDP) is recommended as an alternative to fresh frozen plasma (FFP) in adult trauma patients with massive bleeding and coagulopathy, particularly in austere environments or when rapid administration is required.

Background and Rationale

Trauma-induced coagulopathy is a life-threatening condition that requires immediate intervention. Current guidelines recommend early administration of plasma products to address coagulopathy in bleeding trauma patients.

Indications for Plasma Products in Trauma

The European Society of Intensive Care Medicine (ESICM) and European Society of Anaesthesiology (ESA) guidelines recommend:

• Use of high-ratio transfusion strategies (at least 1:2 plasma:RBC ratio) in trauma patients with massive bleeding 1
• Initial administration of plasma (FFP or pathogen-inactivated plasma) or fibrinogen in patients with massive bleeding 1
• Plasma transfusion should be avoided in patients without substantial bleeding 1

Spray Dried Plasma vs. Fresh Frozen Plasma

Advantages of SDP over FFP:

• Logistical benefits:

  • Longer shelf life
  • Stability at room temperature
  • No need for freezers or thawing equipment
  • Reduced weight and volume (especially with hyperoncotic formulations) 2

• Clinical benefits:

  • Rapid reconstitution (minutes vs. 30-45 minutes for FFP thawing)
  • Immediate availability in emergency situations
  • Preservation of coagulation factors during the spray-drying process 3, 2

Efficacy:

• SDP has been shown to be as effective as FFP in reversing trauma-associated coagulopathy in animal models 3, 2
• French Lyophilized Plasma (a form of dried plasma) demonstrated faster and more pronounced improvement in coagulation parameters compared to FFP in trauma patients 4

Implementation in Clinical Practice

When to Use SDP:

1. Massive bleeding trauma patients with:

   • Evidence of coagulopathy (PT/aPTT >1.5 times normal or abnormal viscoelastic testing) 1
   • Need for massive transfusion (≥10 units RBC in 24 hours or ≥6 units in 6 hours) 5

2. Priority settings for SDP use:

   • Austere environments (battlefield, disaster settings)
   • Pre-hospital settings where FFP is impractical
   • Situations requiring rapid plasma administration

Dosing:

• Initial recommended dose: 10-15 ml/kg (similar to FFP dosing) 1
• For hyperoncotic formulations, adjust volume according to concentration (e.g., 1/3 volume for 3× concentrated product) 2

Monitoring:

• Monitor coagulation parameters (PT, aPTT, fibrinogen, viscoelastic testing) before and after administration
• Target fibrinogen levels >1 g/L 5
• Consider viscoelastic testing (TEG, ROTEM) for rapid assessment of hemostasis 1, 5

Special Considerations and Caveats

Pre-hospital Use:

• Evidence for pre-hospital plasma administration remains mixed 6
• Consider SDP for pre-hospital use when transport times are prolonged (>20 minutes) 1

Combination with Other Blood Products:

• SDP should be used as part of a balanced resuscitation strategy
• Maintain high plasma:RBC ratio (1:1 to 1:2) in massive bleeding 1, 5
• Consider platelet transfusion to maintain counts >50×10⁹/L (>100×10⁹/L in traumatic brain injury) 1

Potential Limitations:

• Limited large-scale clinical trials comparing SDP to FFP in trauma patients
• Cost considerations may limit widespread implementation
• Availability varies by country and institution

Conclusion

SDP represents an effective alternative to FFP for treating trauma-associated coagulopathy, with particular advantages in austere environments or situations requiring rapid administration. Its hemostatic properties are preserved through the spray-drying process, and it offers significant logistical advantages over traditional FFP.