Somehow you are in the physics "plasma" listing, as opposed to the medical blood "plasmas".

Well clearly this is an issue with this website, because all my tags are specifically medical... Thanks for the input!

Probably, the only proved indication with evidence is "plasma exchange" in Thrombotic Thrombocitopenic Purpura (microangiopatic anemia with low levels of ADAMTS13). Also it is indicated to restore blood volume in neonatal hematic exchange in hemolytical born disease, if total blood is not avaible.

There are another non so clear indications (ambigous) as: bleeding and altered coagulation tests, like occur in cardiac or transplant surgery, massive transfusion (heavy bleeding) or patients under oral anticoagulation (but with anti K vitamin ones, as warfarin).

But, in most of those situations Concentrates of Complex Prothrombin are better and safer options, and "classical" coagulation tests are not idoneous neither validated for this use.

A Question: What platelet tests are available other then an actual count to trigger transfusion? It seems the current platelet funtion tests are not as helpful.

Some reseacher had studied the possible use of PFA-100 close to the patients at surgery room or emergency department, also at Transfusion Service.

The PFA-100 is a easy, quick and non-expensive system for analysing platelet function. You use citrated whole blood, before centrifuged for coagulation test, and some have used also EDTA samples. Blood sample (a very small volume) is aspirated at high shear rates through disposable cartridges containing an aperture within a membrane coated with either collagen and epinephrine (CEPI) or collagen and ADP (CADP). These agonists induce platelet adhesion, activation and aggregation leading to rapid occlusion of the aperture and cessation of blood flow termed the closure time (CT). At beggining was used for Von Willebrand Disease type I screening; after it has used to monitorized antiagregant or AINES effect instead the clasycal IVY Test.

Some authors affirm that PFA-100 has a high negative predictive value: if the PFA-100 gives a normal result then with some exceptions primary haemostasis is intact [Exceptions: SPD, Primary Secretion Defects, mild Type 1 VWD] and so may obviate further screening of platelet function.

I agree that the main indication for the transfusion of plasma is to correct deficiencies of clotting factors, when the PT or aPTT, expressed as a ratio is> 1.5. But there are other clinical conditions that may require plasma transfusion regardless of the values ​​of the PT or PTT. In these cases, also if the PT and aPTT can not be obtained within a reasonable period, or are not altered, plasma can be transfused in an attempt to stop or prevent the bleeding. I refer for example to the case of surgery or invasive procedures in patients with liver disease, patients undergoing massive transfusion, or massive blood diluition etc.

I am terrible sorry, but actually there is no evidence for these sentences.

First, those coagulation test do not preclude bleeding risks: there are only developed and validated as test to monitor the anticoagulation effect of two groups of drugs: aPTT for heparin and INR for anti K vitamins (warfarin or acenocumarol)

Second, plasma transfusion does not normalize those coagulation test in more than 95% of cases. Also, there is a hughe variation in coagulation factor concentration between plasma units, depending blood group, origin or inactivation process.

I agree with José, coagulation tests such as INR, TP and aPTT are not predictive of the risk of bleeding. Therefore, how could they be the appropriate trigger for a treatment against bleeding (plasma transfusions)? And José is also right, all the current data shows that plasma transfusions do not correct mild coagulopathies.

But then, José, do you ever prescribe plasma (apart for plasmapheresis or massive transfusions)? And if you do use plasma, how do you decide when to give it?

I am aware that coagulation tests do not preclude bleeding risks, even more so in an emergency. For these reasons I consider valid the suggestion of the panel of The Evidence-based practice guidelines for plasma transfusion (Transfusion. 2010 Jun, 50 (6) :1227-39 . Epub 2010 Mar 19) that suggested plasma be transfused to patients requiring massive transfusion, regardless of the coagulation tests. If there are more recent suggestions I'm very interested to know.

Indeed, in massive transfusion protocols, it is probably the right thing to give plasma without waiting for coagulation test results. But plasma is mostly given to non-massively bleeding patients... How do you treat these patients?

The majority (> 90%) of non-massively bleeding injured patients do not need of plasma. However the hypotermia contributes significantly at the consumption of coagulation factors and platelets in blunt trauma patients. In addition a few patients may have a coagulopathy as a result of drugs or acquired diseases, and need of immediate diagnosis and treatment.

Thank very much to all you for this very interesting and need debate.

Personally, I think we are actually in Stone Age plasma transfusion speaking!!

Let me explain. During decades all us have assumed ancestral blood use and costume without evidence. We have not forget that coagulation and anticoagulation is a dinamic living process.

At XXI Century we still need:

- Standarized and homogenous plasma products. Actually PFIAM must be forbidden.

- Point care test to diagnose and monitor coagulation- Probably, with ROTEM or TEG we are close-, but we also need for platelets -PFA 100 is a good beginning-

- Of course, don`t forget another bleeding sources

You asked me, how I manage? Last friday night, I was on guard and I received a call asking for massive transfusion packe (platelets, FVIIs, etc) from emergency operating room after transfused 4 RCC. It was a women with recidive amigdalar cancer who developed important bleeding after parathiroidectomy (??). But she with has normal platelets counts, a slight aTTP prolongation and INR of 1,1.....But also she had creatinin near 2 mg/d and calcium level under 5, and prophilactic 40 mg enoxaparin sc was administered at 21:00 (several hours before)... We stopped the bleeding and finish the operation with calcium ev, protamin ev, heating and a small amount of PCC.

We are not controlating all variables

Dear Oliver, I am terrible sorry, but I did not answer your questions: do you ever prescribe plasma (apart for plasmapheresis or massive transfusions)? And if you do use plasma, how do you decide when to give it?

- At my previous hospital, I use plasma to restore total blood for haematic exchange in Rh incompatible Born Hemolytic Disease

- Also in microangiopathies anaemias, also without plasma exchange, I used plasma transfusion before beginnig PE, and in various patients with recurrent TPP or congential ADAMTS13 deficit we also promote prophylactic quarentined plasma

- Actually, in patients under anti k vitamin treatment I prefer CPP

- And in cirrotic or hepatic insufficiency with active bleeding and altered coagulation tests, I accept plasma administration.

I hope these answers help you.

Thanks for these answers. It is also what I would do!

Nevertherless, how safe is plasma infusion in cirrotic or DIC/coagulophaty?

Most of them can not tolerate rapid volumen increase and also their osmotic balance would be worsenned, also diluting albumin concentration and seric calcium level! In our clinic experience, small amount of PCC (with or without plasma) is safe and effective.