What are the guidelines for administering plasma in medical treatments?

Guidelines for Plasma Transfusion in Medical Treatments

Fresh frozen plasma (FFP) should not be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures. 1

Indications for Plasma Transfusion

Bleeding Patients

Massive Bleeding/Hemorrhage

• Suggested use of plasma in fixed, high-ratio transfusion (1:1:1 ratio of RBC:plasma:platelets) for trauma patients with massive bleeding 1
• No recommendation for fixed high-ratio transfusion outside of trauma settings due to limited evidence 1
• Initial administration of plasma or fibrinogen is recommended in patients with massive bleeding 1
• Optimal plasma:red blood cell ratio of at least 1:2 is suggested if further plasma is administered 1

Non-Massive Bleeding

• No recommendation for restrictive versus liberal plasma transfusion strategy in non-massively bleeding patients with or without coagulopathy 1
• One small RCT showed no mortality benefit but increased sepsis with liberal plasma transfusion in non-massively bleeding trauma patients 1

Cardiac Surgery

• Either viscoelastic testing or conventional coagulation testing can be used to guide transfusions in bleeding cardiac surgery patients 1

Non-Bleeding Patients

• Plasma transfusion should be avoided in patients without substantial bleeding 1
• Not recommended for routine volume replacement 2
• Not recommended for prophylactic correction of mild-moderate coagulation abnormalities in non-bleeding patients 2

Specific Clinical Scenarios

Warfarin Therapy-Related Bleeding

• Suggested for patients with warfarin therapy-related intracranial hemorrhage 3
• Prothrombin complex concentrates should be preferred over plasma for rapid reversal of oral anticoagulation 4

COVID-19 Convalescent Plasma (CCP)

• Suggested for hospitalized COVID-19 patients who lack SARS-CoV-2 antibodies at admission 1
• Suggested for hospitalized COVID-19 patients with preexisting immunosuppression 1
• Not recommended for unselected hospitalized persons with moderate or severe COVID-19 1
• Not recommended for prophylactic use in uninfected persons with close contact exposure 1

Dosing and Administration

• Rapid infusion of at least 10 ml/kg of body weight is required to significantly increase clotting factor levels 4
• For therapeutic plasma exchange in TTP or adult HUS: 40 ml/kg of body weight 4
• Standard dose: 10-15 ml/kg, with consideration for lower volumes in patients at risk for transfusion-associated circulatory overload (TACO) 2
• When administering plasma, consider:
  • Reducing volume
  • Slowing infusion rate
  • Close monitoring for signs of fluid overload during and after administration 2
  • Diuretic preparation in high-risk patients before administration 2

Complications and Risks

Plasma administration is associated with significant complications:

• Transfusion-related acute lung injury (TRALI) - most frequently associated with FFP and platelet concentrates 2
• Transfusion-associated circulatory overload (TACO) 2
• Allergic reactions 2
• Infectious disease transmission (viral, bacterial, prion diseases) 2
• Hypocalcemia due to citrate binding calcium 1
• Increased incidence of post-injury multiple organ failure 1

Risk Reduction Strategies

• Use pathogen-inactivated plasma when available 1
• Consider male-only plasma to reduce TRALI risk 2
• For patients born after 1996 (UK), use FFP sourced outside UK with viral inactivation 2
• Ensure ABO compatibility 2
• Monitor ionised calcium levels during massive transfusion (maintain >0.9 mmol/l) 1
• Use prothrombin complex concentrates (PCCs) for warfarin reversal when appropriate 2
• Use specific factor concentrates when available instead of FFP 2

Special Considerations

• Avoid FFP in patients with ascites and pleural effusions unless there is active bleeding with coagulopathy 2
• FFP is not routinely needed before large volume paracentesis, even in patients with coagulopathy 2
• For ECMO patients with non-massive bleeding, either viscoelastic testing or conventional coagulation testing can guide transfusion decisions 1

Common Pitfalls to Avoid

1. Using plasma for prophylactic correction of laboratory abnormalities without bleeding
2. Delaying plasma administration in massive hemorrhage
3. Failing to monitor for and prevent complications like TRALI and TACO
4. Using plasma when specific factor concentrates would be more appropriate
5. Not maintaining adequate calcium levels during massive transfusion
6. Overlooking the increased risk of sepsis with liberal plasma transfusion strategies

The evidence supporting plasma transfusion practices varies in quality, with most guidelines based on moderate to very low quality evidence. Clinicians should carefully weigh the benefits against the risks in each individual case, particularly in non-bleeding patients where the evidence for benefit is limited.