Page 30 - Journal of Special Operations Medicine - Fall 2014

FLyP is a “universal” product that can be used for casu- to nine hypotensive, tachycardic patients resulted in an
alties of any blood type. It is made by pooling A, AB, and improvement in INR from 2.6 at baseline to 1.6 on ar-
B plasma from at least 10 donors. The French hemo- rival at the ED. In summary, combat casualties often
112
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vigilance system monitors adverse effects of blood com- have a coagulopathy; coagulopathy increases mortality,
ponent therapy, including FLyP; this system has reported and plasma administration reduces the coagulopathy.
no transmission of viral infections from the use of FLyP
since it started tracking the use of this product in 1994. Lyophilized plasma has been found to be as effective as
115
To date, more than 1000 units have been administered thawed plasma in a swine model of hemorrhagic shock
with no documented adverse effects resulting from this and TBI. Both plasma products reduced the brain le-
product. 102,116 Martinaud et al. reported that 87 casual- sion size and cerebral edema compared with resuscita-
ties received the French DP product at a Role 3 facility in tion with NS. 121,122 Preliminary animal models have also
Kabul from February 2010 to February 2011. These 87 suggested that reconstituting DP with less diluent to cre-
casualties (70% of whom were Afghan) received a mean ate a hyperosmolar product may confer logistical and
of 3.5 units of DP per transfusion episode without ma- physiological benefits. 123
jor adverse events. In the published commentary that
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accompanied this report, Schreiber remarked that these There is increasing recognition of the need to provide
results should be interpreted with caution because of resuscitation that both replaces plasma factors that help
missing data and the reported 10% mortality in this case to reestablish homeostatic conditions (as neither crystal-
series, but noted that the report is an important addition loids nor colloids do) and does not cause a fluid over-
to the literature in that it is the first large-scale report of load for patients prior to surgical control of bleeding.
DP use in an injured patient cohort. Hypotensive resuscitation with DP is the resuscitation
option that holds the most promise for use in prehos-
The German DP product (LyoPlas) is a quarantined, sin- pital settings for casualties in shock when whole blood,
gle-donor product. When stored at room temperatures RBCs, and thawed or liquid plasma are not available.
for 24 months, the individual coagulation factors retain This option is, however, not yet available to most US
75% to 100% of their activity. LyoPlas also enables combat medics in the absence of an FDA-approved DP
rapid treatment of coagulopathies without the need for product. Currently, the German LyoPlas product is
103
complex logistics or thawing. Over 230,000 units have being used by Germany, the Netherlands, the United
been transfused to date with no reports of major ad- Kingdom, Norway, Sweden, and Israel. The French
verse complications to include viral transmission. The FLyP product is being used by the French and by se-
frequency of transfusion reactions approximates that lected US military units. Studies examining the im-
112
of FFP. LyoPlas is type specific; type AB can be used pact of prehospital resuscitation with plasma compared
117
if the recipient’s blood type is unknown. The Israeli with colloids and crystalloids are needed. These studies
103
Defense Force (IDF) has implemented a program to pro- should also examine the impact of prehospital plasma
vide DP at the point of injury. The IDF program selected resuscitation on surrogate outcome measures such as
the German LyoPlas product, and it has now been used markers for coagulopathy and shock that could be more
at the point of injury. 102 readily explored in smaller studies. European manufac-
turers of DP products are reluctant to undertake the ex-
No studies were found in this review that demonstrate a pensive studies needed to allow them to enter the US
survival advantage from using plasma in the absence of market, emphasizing the need for US manufactured
124
RBCs in the prehospital environment. However, hemor- and FDA-approved DP product. One means to expedite
rhage is the leading cause of preventable deaths in com- this would be the establishment of a military use panel
bat casualties. When severe tissue injury is combined within the FDA to study medications and blood prod-
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with systemic hypoperfusion, an endogenous coagulo- ucts of unique value to the military and to consider them
pathy ensues quickly. Trauma-related coagulopathy is using methodology that recognizes the circumstances
119
associated with a 3- to 6-fold increase in mortality. 71,72 unique to the treatment of casualties in a deployed com-
Coagulopathy has been documented in 38% of combat bat setting. Such a panel might also provide a military
casualties who require transfusion. Trauma-associated USP approval for FLyP and/or LyoPlas.
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coagulopathy has also been found to be common in stud-
ies of trauma patients with a predominantly blunt mech- Blood Component Resuscitation Protocols
anism of injury and is associated with an increase in early The success of in-hospital blood product administration
deaths. Plasma is the standard of care for treating the in improving the survival of trauma patients is unques-
120
coagulopathy of trauma, while the use of crystalloids, tioned, and blood product transfusions are the standard
colloids, or RBCs alone superimposes a dilutional coagu- of care in both military and civilian trauma care. Use
lopathy to the endogenous coagulopathy of trauma. The of blood products is an advanced lifesaving interven-
prehospital administration of 2 units of thawed plasma tion that, until recently, was thought to be beyond the

22 Journal of Special Operations Medicine Volume 14, Edition 3/Fall 2014