Group AB cryoprecipitate hospital practices

Author: Rob Romans 
Publication date: March 2019  

The primary target audience for this educational resource: Medical Laboratory Technologist (MLT) in the hospital laboratory, Prescribers of cryoprecipitates. 

What is the challenge? 

  • Unit of cryoprecipitate prepared by Canadian Blood ServicesGeneral population – approximately 3% of individuals in the general Canadian population are group AB
  • Canadian Blood Services’ whole blood donors – approximately 4% of Canadian Blood Services donors are group AB
  • Hospital demand –13.4% of all plasma units issued to hospitals by Canadian Blood Services are group AB (2016-2017 data).  
  • Manufacturing – When cryoprecipitate is prepared from a whole blood collection, only a red blood cell product can be manufactured from the same collection, plasma and platelet products cannot be manufactured.  

Managing the inventory of AB plasma for transfusion and AB cryoprecipitate, because of the numbers outlined above and the manufacturing process, remains a challenge. Demand for group AB plasma continues to grow and, at times, the demand is greater than the supply. As universal donors for plasma, group AB donors are consistently asked to donate. Further, as group AB red blood cells are not in high demand, the need for whole blood collections from AB donors to produce plasma and cryoprecipitate must be balanced with the need to minimize the discard and outdating of group AB red blood cells.  

Optimum use of group AB cryoprecipitate by hospitals could improve the inventory management and supply of group AB plasma for transfusion. As part of Canadian Blood Services’ efforts to better understand hospital practices and policies regarding the use of cryoprecipitate, and in particular group AB cryoprecipitate, the hospital liaison specialist team conducted a short survey of the top 100 individual hospitals that order cryoprecipitate. Some of these 100 hospitals are either part of a hospital corporation or a health region that have one common policy, thus 77 responses were expected. The survey was conducted in April 2017 and a total of 74 responses were received representing a high response rate of 96%. We thank all hospitals that participated and are pleased to share the collected responses below. We trust that sharing these hospital practices will serve as a source of guidance for all hospitals served by Canadian Blood Services, especially where only group AB cryoprecipitate is currently used.  

Background

The literature guiding the utilization of ABO group for cryoprecipitate is scarce. Article 10.7.6 of the Canadian Standards Association (CSA) blood and blood components standard Z902-15 (December 2015) states that “A policy shall be in place concerning ABO compatibility of cryoprecipitate components.” In version 4 of the Canadian Society for Transfusion Medicine (CSTM) Standards for Hospital Transfusion Services, published in April 2017 (shortly before distribution of our survey), article 5.4.3.2 states that “Adult recipients can be transfused with any ABO group of cryoprecipitate.10.7.6” Furthermore, in the same period, Canadian Blood Services issued Customer Letter 2017-14 to inform hospitals of changes to group AB cryoprecipitate production and Customer Letter 2017-18 to share results of this hospital survey on group AB cryoprecipitate. Finally, in August 2018, Canadian Blood Services updated its Circular of Information for the Use of Human Blood Components – Plasma Components which now states “for cryoprecipitate, recipients can be transfused with any ABO group, although neonates and minor children should be given ABO compatible units when possible, or as defined by your facility’s policies.” 

What have we learned from the 2017 hospital survey? 

  • Changes to hospital customer practices and policies regarding use of group AB cryoprecipitate could improve the supply of group AB plasma for transfusion.  
  • The majority of hospital customers surveyed treat patients with any blood group of cryoprecipitate whether the patient’s blood group is unknown (57%) or known (86%).  The largest pediatric hospital in Canada and a large Toronto hospital that operates a level III neonatal program are included in this group. 
  • Fibrinogen concentrate is used as a source of fibrinogen by 67% of hospitals that stock this product for patients with one or more of the following indications; congenital hypofibrinogenemia, large bleeds associated with cardiopulmonary bypass surgery, trauma, obstetrical cases, or other large bleeds.  

Survey responses

When a patient’s blood group is not known

When asked what their policy is for the provision of cryoprecipitate when the patient’s blood group is unknown (e.g. trauma or massive transfusion protocol patient), the majority of hospitals (57%, n= 42) responded that they prepare and issue any blood group cryoprecipitate, while few prepare and issue only group AB (13%, n = 10) or prepare and issue group AB cryoprecipitate for neonates only (12%, n = 9). Some hospitals responded “Other” (18%,  n = 13 ) amongst which nine (9) do not stock group AB cryoprecipitate.  

Following up on this question, the 10 hospitals that provide group AB cryoprecipitate when the patient’s group is not known were asked to provide the rationale for such practice. Four (4) responded that it was historic policy, three (3) responded that they would use another group if group AB cryoprecipitate was not available, one responded that they would use fibrinogen concentrate, one responded their policy is based on the Canadian Blood Services Circular of Information (COI) For the Use of Human Blood Components – Plasma Components. (Note; as indicated above, the COI has now been updated), and one responded that they wish to provide the best component for the patient.  

When a patient’s blood group is known

When asked if they are willing to use any blood group of cryoprecipitate for transfusion when the patient’s blood group is known, the majority of hospitals (n= 64) responded yes (that they are willing to use any blood group cryoprecipitate), while 10 hospitals responded no (that they are not willing to use any blood group cryoprecipitate).  

Following up on this question, the 10 hospitals that responded that they are not willing to use any blood group cryoprecipitate were asked to provide the rationale for such practice. Two (2) responded that it was historic policy, two (2) responded that treating physician’s approval would be required, one (1) responded that they only provide group specific cryoprecipitate, one (1) responded that they stock all ABO groups of cryoprecipitate and that they would give group specific, one (1) responded that it is best to give ABO identical/compatible whenever possible, one (1) responded that group A cryoprecipitate is the preferred substitution.

First choice of alternative if Canadian Blood Services is unable to fill an order for group AB cryoprecipitate

When asked what their first alternative would be if Canadian Blood Services was not able to supply group AB cryoprecipitate, the majority of hospitals (n = 54) responded that they would use another ABO of cryoprecipitate, three (3) responded that they would use fibrinogen concentrate, and 17 responded “other” of which the majority (13) responded that they do not stock group AB cryoprecipitate, three (3) responded that it was up to the ordering physician, and one (1) responded they would wait until group AB cryoprecipitate was available.  

Ordering fibrinogen concentrate: 

When asked if they order fibrinogen concentrate (RiaSTAP®) from Canadian Blood services, the majority of hospitals (54%) responded that they order fibrinogen concentrate from Canadian Blood Services.  

Types of patients treated with fibrinogen concentrate:  

When asked the groups of patients treated with RiaSTAP® ordered from Canadian Blood Services: 

  • 23% (9) only use it to treat patients with congenital hypofibrinogenemia.  
  • 67% (27) use it to treat patients for a combination of the following; congenital hypofibrinogenemia, cardiopulmonary bypass surgery, trauma, obstetrical bleeds, other large bleeds.  
  • 2.5% (1) used it to treat a patient with toxic shock syndrome.  
  • 2.5% (1) use it at the request of the ordering physician.  
  • 2.5% (1) have fibrinogen concentrate in stock at the hospital transfusion service but have not yet used it.