George spoke with Jose DeJesus, MS, MLS, transfusion service manager for DCH Regional Medical Center in Tuscaloosa, Alabama. In the past year, Jose has managed three warfarin overdose patients with acute hemorrhage who were blood group AB. The worldwide prevalence of group AB is 5.6%, and despite special AB plasma donor programs, AB donor plasma is in chronic short supply. AB plasma is considered the “universal” donor because it lacks anti-A and anti-B antibodies, however AB recipients may only receive blood group AB plasma to avoid acute intravascular hemolysis. The anti-A or anti-B antibodies in group A, B, or O plasmas are the source of the hemolysis. The situation is rare, however Jose asks what he could do if another AB warfarin overdose patient came to the DCH emergency department and there was no AB plasma available.
Thanks for your question, Jose. I’ve looked at several references, and also checked withMargaret G. Fritsma, MA MT (ASCP) SBB, a transfusion service expert who is well acquainted with the AABB standards (and related by marriage). She recommends you do not substitute A, B, or O plasma, the possibility of hemolysis outweighs any possible hemostatic benefit. The best reference for managing warfarin overdose bleeding is Ansell J, Hirsh J, Hylek E, et al. Pharmacology and management of the vitamin K antagonists; American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest 2008;133:160S–198S. ACCP recommends, “In patients with serious bleeding and elevated INR, we recommend holding warfarin therapy and giving vitamin K (10 mg) by slow IV infusion supplemented with fresh frozen plasma, prothrombin complex concentrate (PCC), or recombinant factor VIIa, depending on the urgency of the situation.” They go on to say that “Although fresh-frozen plasma can be given in this situation, immediate and full correction can only be achieved by the use of factor concentrates because the amount of plasma required to fully correct the INR is considerable and may take hours to infuse.”
Based on the ACCP guidelines, and similar guidelines published by the American College of Physicians and the Anticoagulation Forum, it appears that in the absence of AB plasma, PCC (Proplex) or recombinant activated factor VIIa (NovoSeven) are the answer. Both are managed carefully, as they may eventually lead to thrombosis, conversely, they would not lead to transfusion-associated circulatory overload (TACO) associated with plasma. The use of NovoSeven to control bleeding is an off-label, but common approach. I hope this helps, and I especially hope you’ve already seen your lifetime share of group AB warfarin overdose patients.