Implementation of a prehospital air medical thawed plasma program: Is it even feasible? Adams PW, Warren KA, Guyette FX, Yazer MH, Brown JB, Daily BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Witham WR, Putnam AT, Zuckerbraun BS, Neal MD, Sperry JL; PAMPer study group. J Trauma Acute Care Surg. Nov 2019; 87(5): 1077-1081.
The most common cause of preventable death following traumatic injury remains massive hemorrhage. According to an analysis of data from the PROPPR trial, most deaths from hemorrhagic shock occur within the first three hours following injury. One recent study to address this problem was the PAMPer trial, a prospective, multicenter, randomized trial comparing resuscitation with up to two units of thawed plasma to standard resuscitation with crystalloid or red blood cells during air evacuation following injury. Patients treated with plasma had significantly lower rates of 30-day mortality (23.2% vs. 33.0%, p=0.03) compared with those receiving standard therapy. Although the improvement in mortality is significant, there is reason to worry that such a program may be impractical, given the logistical strain likely to be caused by the 5-day shelf life of thawed plasma. Adams et al, sought identify the costs and resource requirements associated with implementation of an air medical thawed plasma program in order to answer this question.
The authors performed a secondary analysis of data obtained from the PAMPer trial. Cost data, consisting of courier costs for transport of plasma to the air bases, was identified using billing and payment records from trial accounting. Additional prices were calculated based on the cost of plasma ($60/unit). Blood bank data was available from 5 of 6 trauma centers, although data on subsequent transfusion of returned plasma was available from only one center.
Over the 42-month study period, 501 patients were enrolled through 6 trauma centers and 27 air bases. During the trial, only 7.2% of the plasma units distributed were transfused during air transport. The remainder were either returned to the blood bank (72.8%) or lost as waste (20.0%). Of the plasma returned to the blood bank, the only center with subsequent transfusion data reported a further 41.7% loss rate due to expiration. Overall cost estimates in the study ranged from $24,343/base to $30,077/base.
Adams et al offer an important analysis of the data from the highly influential PAMPer study. While the survival improvement associated with the use of prehospital plasma resuscitation in the trial was substantial, it comes with significant cost and resource utilization. Furthermore, it may be expected that centers and air teams wishing to implement a prehospital plasma program will need to incur additional capital expenses in order to facilitate plasma storage. The loss rate of thawed plasma is also high at 20%. This may be as high as 50% based on loss rates of returned plasma. Overall, the manuscript identifies potential cost barriers to prehospital plasma use and the need for less perishable/costly alternatives to thawed plasma.
A novel protocol to maintain continuous access to thawed plasma at a rural trauma center. Hannigan C, Ologun G, Trecartin A, Colom L, Bloomdahl R, Seyer A, LaRock L, Tubby B, Cagir B, Granet J, Behm R. J Trauma Acute Care Surg. 2019 Aug 5.
Early plasma administration is associated with significant improvement in mortality following severe injury. Although other studies have recently addressed earlier administration of plasma through the prehospital setting (PAMPer, COMBAT), one opportunity to expand early plasma administration occurs at rural trauma centers. Data from previous NTDB reports identify that nearly 10% of trauma patients are injured in a rural setting. Rural trauma centers though, may be unable to support the use of continuously available thawed plasma due to cost concerns. Hannigan et al sought assess the cost and usage of plasma with the introduction of a new protocol to provide continuously available thawed frozen plasma at their rural, level II, trauma center.
Over a 12-month period starting in 2017, two units of universal donor thawed plasma were made available in the trauma bay of the author’s 254-bed hospital. The thawed plasma was made available only to trauma patients and transfused at the discretion of the trauma surgeon on call. Thawed plasma was returned to the blood bank if unused within three days. Data on waste, cost, and blood product utilization were compared to data from the previous two years. The cost of plasma for the center was $46/unit, according to blood bank invoices.
During the study period, 5.84% (16/274) of the emergency release thawed plasma was transfused to patients in the trauma bay. The remaining 258 units were returned to the blood bank with 34 (12.41%) units wasted prior to administration. Overall, there was a significantly higher overall waste rate for the hospital during the protocol year compared to the previous two years (6.74% vs. 3.20% vs. 3.86%, p<0.001). Similarly, costs associated with plasma loss during the protocol year were significantly higher than the two previous years ($3496 vs. $2070 vs. $2116, p=0.020). Among patients requiring massive transfusion, the number of red blood cells required decreased significantly (14 vs. 6.4 units, p<0.02). No differences were noted in the number of units of plasma or platelets required.
Hannigan et al offer important insight in the use of immediate release thawed plasma at a rural trauma center. While there was a significant increase in the amount of plasma wasted by the hospital as a whole, absolute loss of units of plasma was low. Further, although the authors demonstrated an increase in costs, these were relatively negligible compared to the overall cost of administering a rural trauma center (estimated $2,333,113 annually). Overall, the study offers evidence to that rural trauma centers may support the availability of thawed plasma with minimal increase in expense.