Expert study on massive transfusion recipients and ABO-incompatible FFP
Outcomes of adult massive transfusion recipients administered ABO-incompatible fresh frozen plasma (FFP) from the Australian and New Zealand Massive Transfusion Registry have recently been published. The cohort included predominantly non-trauma patients for which studies are lacking.
Historically, group AB ‘universal’ plasma components (which don’t contain anti-A or anti-B) have been used during critical bleeding emergencies prior to determination of the patient’s ABO group. AB is the least prevalent ABO group (only around 4% of Australian donors), which places strain on supply and hospital inventories. Clinical plasma is also only collected from male donors (to reduce TRALI risk) and at collection centre locations that enable freezing within the regulated time frame.
In recent years, there has been increasing use of emergency release of incompatible FFP (defined as group A to group B and AB patients) based on growing overseas evidence of relative safety in trauma settings. From 2016, Australia and New Zealand Society of Blood Transfusion (ANZSBT) guidelines allowed use of A group plasma products (such as FFP) with low titre anti-B as an alternative to group AB in adults in emergencies or trauma, when the patient’s ABO group is unknown.
Existing international studies to support this practice have focused on massive transfusion (MT) in trauma settings with limited evidence in the more variable non-trauma MT group. Utilising data from the Australian and New Zealand Massive Transfusion Registry (ANZ-MTR), Loh and colleagues sought to assess the prevalence of ABO-incompatible FFP in MT recipients, as well as the characteristics and outcomes of trauma and non-trauma patients who received ABO-compatible or incompatible FFP.
Adult patients (aged ≥18 years) who received ≥5 red cell units within any 4-hour period during their admission between April 2011 and October 2018 were included in this retrospective cohort study. Patients transfused incompatible FFP were defined as those who received ≥1 unit of ABO minor or bidirectional mismatched FFP in the first 24 hours after MT initiation.
Throughout the study period, a total of 7,340 patients (5,609 non-trauma) across 28 participating hospitals in Australia and New Zealand were included in the final analysis. Within the first 24 hours following the commencement of MT, only 77 (1.1%) patients received incompatible FFP (n=26 trauma, n=51 non-trauma). These patients were found to be more likely to have markers of a higher acuity presentation. Within the first 24 hours, patients who were transfused incompatible FFP had received more FFP than those transfused compatible FFP (median of 7 vs. 5 units, p = .005). Overall, a total of 226 incompatible units were transfused (n=204 group A).
Transfusion of incompatible FFP within the first 24 hours from MT initiation in this study cohort was not independently associated with a higher in-hospital mortality. Although only a small number of patients (1%) received ABO-incompatible FFP in the study period (ending during 2018), it serves as an important baseline before the practice was more widely adopted and allows comparison with the upcoming National Transfusion Dataset, the first integrated national dataset of blood use in Australia.
A range of possible reasons for the low rate of emergency use of ABO-incompatible FFP during the study period in this cohort are outlined by the authors within the discussion.
Reference:
- Loh JB-E et al. Outcomes of massive transfusion recipients administered ABO-incompatible fresh frozen plasma. Transfusion. First published: 31 December 2024 (early view) https://onlinelibrary.wiley.com/doi/abs/10.1111/trf.18070
Related reading:
- Yazer et al. Wider perspectives: It’s a changing world—The use of ABO-incompatible plasma for resuscitating massively bleeding patients. Br J Haematol. 2023;200:291–296. https://onlinelibrary.wiley.com/doi/epdf/10.1111/bjh.18460
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