Plasma Products Flashcards
What are the two main types of frozen plasma used?
Octaplas - pooled plasma
fresh frozen plasma - single donor
What are he differences between octaplas and fresh frozen plasma?
Octaplas:
- made from pooled plasma
- hence only ABO grouped not Rh -> as no red cells present thus only concerned with what antibodys are present
FFP:
- made from a single donor
- will be Rh typed as there will be a small amount of red cell contamination
What is the new kind of plasma were looking at using?
Thawed plasma
What is thawed plasma, whats different about it to ffp?
This is frozen plasma which has been thawed and kept for about 5 days in the fridge
Thawed plasma has considerably different coagulation factors but you dont need 100% factor activity for good activation of coagulation pathway
how much % factor activity is needed for activation of the coagulation pathway?
About 25% only is needed
What two POC devices are used to monitor need for plasma transfusion?
TEG or ROTEM
-> these look at coagulation factors to guide the use of ffp
Talk about the use of cryoprecipitate?
We dont use it in Ireland anymore - we use products instead
Most of th world still use cryoprecipitate made from their own plasma though
When was ffp first put into use, what was its initial use
FFP has been available since 941
It was initially used as a volume replacement
Plasma used to be given on a formulaic bases e.g. one unit given for x amount of red cells etc -> this isnt done anymore but can often be seen in major haemorrhage packs because of this
When did we stop using FFP as a volume expander?
When albumin and hydroxyethyl starch became more available
Nowadays when do we use FFP?
We have a better understanding that FFP is contraindicated for volume expansion and instead we use it in cases of excessive bleeding or to prevent bleeding in patients with abnormal coagulation tests that are undergoing an invasive procedure
We usually wont give plasma if patient is bleeding unless there is a coagulopathy
Why did we stop using donor plasma in Irealnd
Studies showed that plasma was a major source of prions in 68% of cases while only 26% were present on platelets and the remainder on red cells and leucocytes -> however this sudy has since been contested
There has never been a case of plasma transmitted vCJD
How many mls is a ffp unit when derived from a whole blood donation?
1 uni = 250mls
How do we make cryoprecipitate?
Made by frezing plasma from whole blood donation
Then thawing the pack to 4 degrees whereby a white precipitate will form in the pack
This precipitate can then be separated and taken off to form cryoprecipitate and cryoprecipitate depleted plasma
What is cryoprecipitate composed of?
Its mostly fibrinogen and some von willebrand factor hence why its great for coagulation
Is cryo still available in Irealand?
Yes you can still order it from the IBTS
Its used to treat TTP
What is the difference between the treatment of octplas and ffp?
Octplas is pathogen reduced by solvent detergent treatment
How is plasma treated in the UK?
SD treated using methylene blue
How is fresh frozen plasma produced
Separation and freezing to -30 degrees within 6-8 hours of donation
What are the two different types of fresh frozen plasma that can be made, how do they differ from each other?
FFP from a whole blood donation
FFP from an apheresis donation
From whole blood only 200-220 mls
Apheresis can be up to 600mls
Apheresis can be stored at -18 degrees for 1 year
How is ffp utilised?
Thawed at -37 degrees celsius in a waterbath
Must be transfused asap within 2-4 hours
How can octaplas be stored after thawing
can be stored at room temperature for up to 4 hours but can be kept at 4 degrees for up to 8 hours
what is the shelf life of octaplas
Since july 2005 it an be stored at -18 degrees celsius for up to 4 years
How is dosage of ffp determined?
Dosage depends on the clinical situation but its typically 10-15mls/kg body weight
Clinical response may be the best monitor but lab tests also important
Talk about the use of the new product, thawed plasma and its storage?
Thawed plasma stored at 4 degrees for up to 5 days
NB in trauma packs in the US as well as ireland
What factors have the shortest half lifes?
Factor VIII (half life of 12 hours)
Factor VII (half life of 5 hours
i.e. half of the factor is gone after x amount of hours post transfusion -> factors dont remain in patients system for long -> need to be aware of this if patient has a specific deficiency, will need to top up prior to transfusion and need to make sure patient wont run out in the mean time
From who do we get plasma donations?
We use volunteer donors from america
Talk about the affect of thawing on plasma, how are factors affected
Thawed plasma can be stored for up to 5 days
-> there is no affect on fibrinogen concentration
-> only a 1% drop in FII
-> 16% drop in FV
->20% drop in FVII
->41% drop in FVIII
->6% drop in FX
What is fp24?
Frozen plasma which has not been frozen within the initial 24 hours post donation
fp24 ha less FV and protein C but will have more FVIII than fresh frozen plasma
What is the minimum % activity of FV needed for haemostasis?
25% activity
What is the minimum activity for haeemostasis of FVIII?
30%
What is the main challenge with using plasma?
Plasma can be a life saving therapy for patients in need of haemostatic assistance but there is a lack of consensus around definition of the circumstances when this component will truly benefit a patient
How should you choose the right plasma group?
FFP is labelled with ABO and RhD groups
First choice would be the same ABO group but if not available then give A or B or vice versa
Avoid group O with high - titre -> should only be given to group O as it will have anti-A and anti-B
AB plasma is very useful and can be given to all -> AB Octaplas was previously known as Uniplas
Talk about factor level differences between blood groups
FVIII and vWF levels are up to 25% lower in group O individuals
This increases risk of venous and arterial diseases in A, B and AB individuals
ABO group may effect the rate of synthesis or release of vWF from endothelial cells
ABO Group may affect the proteolytic cleavage of vWF - related to the level of a protease called ADAMTs13 which is higher in group Os
There are ABO sites on both vWF and on ADAMS13 protease
What group is ADAMTS13 highest in?
Highest in group Os
Deficiency of ADAMTS 13 results in what condition?
TTP
What is ADAMTS13?
A protease which is responsibly for the proteolytic cleavage of vWF
How is TTP treated?
Cryodepleted plasma is used as it lacks VWF
Exchange transfusion with this plasma
This gives patient the plasma they need without the VWF causing the thrombus
What happens after ADAMTs13 cuts vwf
They go around the body attached to factor 8
But there are problems with this in group O
When was octaplas introduced into Ireland
Octaplas, a FFP substitute was introduced into Ireland in 2002
This was to help preven the possible transmission of vCJD
Talk about Octaplas
A blood specific plasma product
It contains up to 1,500 single donations from unpaid, screened donors
This undergoes a solvent/detergent treatment process
AB Octaplas is not blood group specific though
What is AB Octaplas made of?
70% A
20% B
10% AB
What are the steps in the manufacture of octaplas
fast thawing
complete cell, cell debris and aggregate removal hrough a 1um filter
SD treatment for 4 hours at 30 degrees
oil extraction and phase separation
clear filtration
hydrophobic bio-interaction chromatography to remove triton x
sterile 0.2um filtration
aseptic sealing and filling of bags
fast freezing to -60 degrees
storage below -30 degrees
complete quality control and batch release
what does SD treatment of octaplas involve?
treatment for 4 hours AT 30 degrees of:
- 1% TNBP
- 1% TRITON-X
Why is the oil extraction and phase separation step of octaplas production needed
this is needed to remove the TNBP
How is TRITON-X removed from octaplas
Hydrophobic bio-interaction chromatography
What can be the benefit of using octaplas over fpp from an individual donor
You can get the exact coagulation factor levels for a batch of octaplas but you cant for fresh frozen plasma as this is from an individual donor
What are some of the indications for the use of octaplas?
In bleeding or pre-op patients for:
- replacement of single factor deficits
- neonates with coagulopathy who are bleeding or are facing an invasive procedure
- inherited deficiencies of inhibitor of coagulation where specific concentrates are not available -short term fix
- liver disease
- hereditary angioneurotic oedema
Give an example of where plasma can be used in replacement of a single factor deficit
e.g. factor V deficiency
We have no virus-safe factor V commercially available
Give an example of where inherited deficiencies of inhibitors of coagulation can be treated with plasma
AT 111
Deficiencies of inhibitors such as protein C and protein S
Certain hospitals will have concentrates available but other labs wont
FFP should be used though and not octaplas
Can also be used for DIC coagulapathy to stop coagulation -> less of these factors in octaplas
Talk about plasma for liver disease
PT is used as a guide however plasma is debatable
Plasma is justifiable if liver biopsies are performed with high PTs -> 1.5 x midpoint of reference range in seconds
NB: liver disease is the same as being on warfarin in terms of factors affected
what is hereditary angioneurotic oedema?
A congenital deficiency of C1-esterase inhibitor
What was plasma previously used or
Warfarin reversal
-> its use for this today is questionable
-> only really done if evidence of bleeding
what product is now used in place of plasma for warfarin reversal?
Prothromplex -> known as octaplex in ireland
What factors are present in prothromplex?
FII, VII< IX and X
What are the some specific indications for use of plasma
Warfarin reversal where bleeding is evident
DIC if in bleeding stage
Massive transfusion
TTP -> cryoprecipitate
Convalescent plasma for Ebola
When is plasma indicated for DIC?
Only if bleeding with raised PT/APTT and low fibrinogen
Talk about plasma for massive transfusion
Has to be guided by lab tests
Also through use of ‘near patient’ devices such as TEG
What does TEG stand for?
Thromboelastogram
Talk about plasma for TTP
Plasma as an exchange proecudre is used
Cryo or HMV-VWF poor plasma is ideal
Talk about uses of convalescent plasma
Was used in covid - used in early treatment - over 1 million units were given in the USA but we neer did this in ireland
Only way of treating Ebola
Talk about a use of plasma exchange other than TTP
Plasma exchange for myasthenia gravis
- Autoimmune condition caused by antibodies which can be removed through exchange to treat the condition
ITP -> platelets cross placenta during pregnancy
What are two POCT devices used to guide plasma transfusion
TEG -> used more than rotem nowadays
ROTEM sigma
How does ROTEM work
sample is loaded into a cuvette
a sensor pins detects clot formation by detecting restriction of pin movement as clot develops
How does thromboelastography TEG work?
Look this up
How does ROTEM present results?
Presents different’wine bottle’ shaped results
When is plasma not indicated
formulaic replacement -> overuse common if this is done
Hypovolamia -> use cheaper crystalloids/colloids instead to increase blood volume
Immunodeficiency states - use of Ig is preferred
Vitamin K deficiency - corection with vitamin K reversal in 6-12 hours
What are the adverse effects of plasma
Allergic reactions
Overload
Haemolysis due to potent ABO antibodies (FFP)
TRALI
HIV, Hep B, C and bacterial agents (negligible)
Anti-T antibodies when treating infants with necrotising enterocolitis
vCJD -< P-Capt filter from MacoPharma prevents this getting through
Talk about allergic reactions to plasma transfusions
Anaphylactic reactions
1 in 20,000 recipients is at risk for this reaction since IgA deficiency is the most common congenital immunodificiency
What causes TRALI in plasma transfusions?
Granulocyte antibodies in plasma causing acute pulmonary injury -> only occurs with FFP and not octaplas
Talk about anti-T antibodies
T antigens are part of the MNs group
Bacteria with neuramidase enzymes can expose T antigens
Since all adults naturaly have anti-T antibodies against these crypt antigens
When plasma from adult donors is given to children suffering from certain bacterial infections they can have very serious reactions
What are the three main strategies of viral inactivation of plasma?
Solvent/detergent treatment -> done on large pools
Methylene blue with visible light -> done on single units
Amotosalen -> an alternative to MB FFP fr single-donor virus-inactivated FFP and cryoprecipitate
Where is Amotosalen licensed currenly
Licensed in Europe
Currently under consideration in the UK
What pathogen inactivation is carried out on our products in Ireland
All other countries do some kind of vira inactivation of platelets but ireland doesnt do any
Only our octaplas is SD treated in Ireland
What does SD treatment involve, how does it work/what does it affect?
Tri(n-butyl) phosphate TNBP + Triton-X
This disrupt the ‘lipid’ sructure of enveloped viruses e.g. HBV, HCV, HIV
Non-eveloped viruses are not affected e.g. HAV, Parvovirus B19 not affected
Even though SD treatment doesnt work on non-enveloped viruses, why are we not concerned with these
Even if there was parvovirus present in the pooled plasma there would be enough anti-parvo antibodies present to negate it -> isnt a problem when transfused
How does SD treatment affect clotting factors?
There is some loss of clotting factors
Particularly VWF multimers are lost
Protein S functional activity and reduced FVIII activity
How does methylene blue with UV light work as a orm of viral inactivation
MB has an affinity for nucleic acids and viral core proteins
Visible light illumination then leads to the formation of singlet oxygen, hence photo-oxidative inactivation
Can be used to treat single units
Both enveloped and non-enveloped viruses are disrupted
How are coagulation factors affected by Methylene blue
30% loss of fibrinogen and of FVIII activity
What is theraflex-MB plasma
This is a method of MB-visible light vira inactivation
Intercalation of MB into nucleic acids
Excitation of MB by visible light
Oxidation of Guanosine
Degradation of nucleic acids
This blocks transcription and replication of viral RNA and DNA
What kind of reaction is the MB + light reaction?
Photodynamic process
How is MB removed from plasma?
Removed by filtration with Blueflex
Then frozen
What is the principle of Amotosalen
Blocks the reproduction of pathogens by crosslinking DNA and RNA
What are the four steps Amotosalen
Amotosalen targets helical regions of nucleic acid
Docking into DNA strands
Permanent crosslinking of DNA
Locked DNA/RNA now unable to replicate
What is the Intercept system
the method of carrying out SD treatment of plasma using Amotosalen HCL
-> Amotosalen added, illuminated, CAD added and storage etc
What is the new method of viral inactivation being looked at
Riboflavin and UV light
Talk about Riboflavin and UV light viral inactivation
No removal after treatment is required as its just vitamin B6
Riboflavin damages any nuclear material when light is shone on it
Talk about Riboflavin and UV light viral inactivation
No removal after treatment is required as its just vitamin B6
Riboflavin damages any nuclear material when light is shone on it
Why dont we use riboflavin in Ireland
The IBTS trialed this for platelets but werent impressed with the platelet quality
Talk about the concept of FFP donor retested
This concept allows for a window period after supposed infectivit of donor
Donor isnt paid for first donation
First unit is stored frozen for approximatelt 112 days
Donor is recalled to donated and is tested again
If still negative then your presuming first was negative
What is the ideal product for TTP
Cryo-reduced plasma
How many precipitates are pooled to make a pack of croprecipitate?
Between 4 and 6 units are pooled
Where is cryoprecipitate commonly used?
Commonly used in the UK
What do we use instead of cryoprecipitate in Ireland
We use commercial fibrinogen
However this is a lot more expensive so were looking at using cryo again
Talk about the discovery of cryo
Originially developed in the 1960s as an advance on fresh whole blood treatment for haemophilia A
Prepared bby ‘slow thawing’ of FFP at 4 degrees/24 hours
Formed the source of fibrinogen for primitive ‘fibrin sealants’
What exactly is cryoprecipitate?
An insoluble precipitate containing significants amount of fibrinogen, FVIII, vWF, FXIII
What are currently the issues with using cryoprecipitate?
Difficult to virally inactivate
Difficult to standardise the factor content
What are some indications for the use of cryoprecipitate?
Deficiency of fibrinogen, FVIII or vWF in massive bleeds
When should cryo be used to replace fibrinogen
In congenital fibrinogen deficiency
In massive transfusion
Less often in DIC -> if bleeding
When did we discontinue use of cryoprecipitate?
July 2009
What did we replace cryoprecipitate with in Ireland?
Haemocomplettan P
RiaSTAP
Talk about RiaSTAP
Most commonly used commercial fibrinogen
Fibrinogen of human origin
Heat and detergent treated unlike cryoprecipitate
When was lyophilised plasma first used, why was it discontinued
First described and used in the 1930s
Became contraindicated as novel Blood-borne pathogens were discovered
How is lyophilised plasma used?
Its reconstitued at point of transfusion within hospitals or in a pre-hospital setting
Who uses lyophilised plasma today?
Only Germany and wales
Lyoplas-W-N by German Red Cross
-> lyophilised plasma from individual donors
-> used in flying squad -> for use in ‘golden hour’ -> can be the difference between someone bleeding out on a montain and making it through air lift to hospital etc
How is lyophilised plasma stored?
Stored at 2-8 degrees for up to 2 years
Reconstituted in 200ml sterile water -> totoal preparation of 10 minutes
What are the advantages and disadvantages of lyophilised plasma?
advantages:
- reduced preparation time
- ease of storage
- administration
disdvantages:
- no prion removal
- 10% reduction of clotting factor activity
- has same risk of adverse reactions as liquid plasma
What is the alternative to lyophilised plasma now being looked at?
Spray Dried Plasma
Talk about spray dried plasma
Forms a fine powder
redissolves much quicker than lyophilised -> less effort to reconstitute
250mls of saline needed
Not in use anywhere as of yet -> only being tested atm
