Recent Publication on Use of Group A Plasma For Emergency Transfusion In Pediatric Patients

With increasing use of targeted agents for anticoagulation reversal and treatment of bleeding disorders, clinical scenarios requiring plasma transfusion have become more limited.^{1, 2,} While plasma transfusion has decreased in the United States for over a decade, use in the trauma setting is an important exception to this trend.  After a 2007 study³ showed improved survival in massively transfused combat patients receiving a balanced 1:1 ratio of red cells and plasma products compared to patients who received less plasma, published clinical guidelines support plasma transfusion in massive hemorrhage. 

Due to the lack of anti-A and anti-B, group AB plasma is regarded as universal and has historically been used for emergency transfusion when the patient’s blood type is unknown. However, only 4% of blood donors are group AB, leading to challenges in maintaining sufficient inventory to meet hospital demand.  Although ABO antibodies in incompatible donor plasma have the potential to hemolyze the red cells of a transfused patient, clinical experience with transfusing group A plasma to group B and AB adult trauma patients has not demonstrated an increase in adverse events. A 2015 survey of trauma centers showed that only 9% were stocking solely AB plasma for emergency transfusion with most (63%) using group A plasma for initial resuscitation of trauma patients of unknown blood type.  Several studies confirmed overall low risk of group A plasma transfusion in trauma patients.^4-6

Due to their smaller blood volumes, pediatric patients are hypothesized to have a higher risk of hemolysis from incompatible plasma transfusion.  Prior studies evaluating incompatible plasma transfusion have typically excluded pediatric patients. A team from Children’s National Hospital, a freestanding pediatric tertiary care hospital and Level I pediatric trauma center, recently published a retrospective study in Transfusion on their institutional experience with use of group A plasma for emergency transfusion for type-unknown pediatric patients.⁷

Study population:

The authors reviewed the charts of 161 patients for whom emergency-release plasma products were ordered.  The patient population included infants under age 1 year (29%), children ages 1-11 years (38%), and adolescents and adults ages 12 years and older (33%).  The indications for transfusion included trauma (41%), medical (37%) and cardiac (22%). A total of 122 patients received group A plasma. Excluding 6 patients whose blood type remained unknown, 23 of the remaining 116 patients (20%) were group B or AB, received incompatible group A plasma, and were in the age range of 0 to 21.3 years.

Study results:

1. No transfusion reactions were reported in any patient who received emergency plasma, and no complications were attributed to plasma transfusion.
2. When assessing patients who received incompatible vs. compatible plasma transfusion, patients had comparable 24-hour mortality rates, 30-day survival, overall survival, and median hospital length of stay.
3. Of patients who had total bilirubin and creatinine results (laboratory measures potentially indicating hemolysis and subsequent renal injury) monitored on admission as well as on day 1 and/or day 2 after admission, changes for recipients of compatible and incompatible plasma were similar.

Limitations of this study included the following:

1. This is a retrospective observational study conducted at one institution.  It was not designed to identify patient outcomes. Potential confounding variables were not able to be assessed. The number of patients who received incompatible plasma (23) was too limited for detection of rare adverse events or stratification by specific patient demographics (age, medical condition, plasma volume received, etc.).
2. Other significant lab values indicating potential hemolysis (direct antiglobulin test, haptoglobin, lactate dehydrogenase) were not included.
3. Transfusion reactions may be more likely to be undetected or underreported in critically ill or injured patients.
4. The hospital team did not track ABO group of platelet products, so it was not known whether patients in any group received some volume of incompatible plasma from platelet transfusion.

In summary, the published experience of Children’s National Hospital showed that its use of group A thawed plasma for emergency transfusion in pediatric patients was well-tolerated with no evidence of increased harm to patients.  Notably and as predicted based on population genetics, most patients receiving transfusion are blood group A or O, with whom group A plasma will be compatible.  Larger retrospective and prospective studies could assess for rare adverse events to which certain pediatric subpopulations (e.g., infants) may be more vulnerable.

References

1. Whitaker BI, Hinkins S. The 2011 National Blood Collection and Utilization Survey Report [Internet]. Rockville (MD): US Department of Health and Human Services; [cited 2024 Nov 26]. Available from: https://wayback.archive-it.org/3922/20190926121044/https:/www.hhs.gov/sites/default/files/ash/bloodsafety/2011-nbcus.pdf

2. Kracalik I. 2023 National Blood Collection and Utilization Survey. Paper presented at: 2024 AABB Annual Meeting; 2024 Oct 19-22; Houston, TX.

3. Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, Sebesta J, Jenkins D, Wade CE, Holcomb JB. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007;63(4):805-813. https://doi.org/10.1097/TA.0b013e3181271ba3. PMID: 18090009.

4. Dunbar NM, Yazer MH; Biomedical Excellence for Safer Transfusion Collaborative. A possible new paradigm? A survey-based assessment of the use of thawed group A plasma

for trauma resuscitation in the United States. Transfusion 2016;56:125-129. https://doi.org/10.1111/trf.13266

5. Dunbar NM, Yazer MT; Biomedical Excellence for Safer Transfusion (BEST) Collaborative and the STAT Study Investigators. Safety of the use of group A plasma in trauma: the STAT study. Transfusion 2017;57(8):1879–1884.

6. Stevens WT, Morse BC, Bernard A, Davenport DL, Sams VG, Goodman MD, Dumire R, Carrick MM, McCarthy P, Stubbs JR, Pritts TA, Dente CJ, Luo-Owen X, Gregory JA, Turay D, Gomaa D, Quispe JC, Fitzgerald CA, Haddad NN, Choudhry A, Quesada JF, Zielinski MD. Incompatible type A plasma transfusion in patients requiring massive transfusion protocol: Outcomes of an Eastern Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg 2017;83(1):25-29.

7. Jacquot C, Jones T, Bahar B, Cabacar J, Webb J, Mo YD, Tavares da Souza A, Delaney M. Use of group A thawed plasma in emergency transfusions at a pediatric quaternary care center. Transfusion 2024;64(10):1851–1859. https://doi.org/10.1111/trf.17985

8. Roback JD et al. American Association for the Study of Liver; American Academy of Pediatrics; United States Army; American Society of Anesthesiology; American Society of Hematology. Evidence-based practice guidelines for plasma transfusion. Transfusion. 2010 Jun;50(6):1227-39. doi: 10.1111/j.1537-2995.2010.02632.x. Epub 2010 Mar 19. PMID: 20345562.