Military Blood Bank Experience with -80°C Frozen P latelets

Femke Noorman (PhD) Military Blood Bank The Netherlands 13 januari 2015

Exsanguinating Haemorrhage is the Major Cause of Death in Military Conflict Operations • Up to 60% mortality rate • Death occurs within 6 hours • Majority is preventable if Red Cells, Plasma and Platelets are available! Military Blood Supply 2

MilitaryBlood Blood Bank Military Bank

Commando DienstenCentra Central Military Hospital Health Division Ministry Ministry of Defence Support Command of Defence

The Netherlands The Netherlands 14 januari 2015

How to get the right amount, type, quality of blood products at the right time in remote areas?

3

Military Blood Bank

Central Military Hospital

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

Sanquin NLD Standard Blood Products

Platelets Plasma Red Cells

7 days +22 °C 2 years - 30 °C 35 days + 4 °C

MBB Frozen Blood Products

Platelets Plasma Red Cells

2 4 years 7 years 10 years

- 80 ºC (*) - 80 ºC (**) - 80 ºC (***)

* + 6 hrs at +22°C after thawing / mixing ** + 7 days at + 4°C after thawing *** + 14 days at +4°C after sterile thawing and wash ing 4

Military Blood Bank

Central Military Hospital

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

5

Military Blood Bank

Central Military Hospital

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

DMSO 5% ±14 ml Platelets

Thaw to +30°C

Connect to 1 unit DFP +30°C

6

Military Blood Bank

Central Military Hospital

Mix DTC-DFP DMSO (±0.7gr) ±14 ml Platelets AB Plasma ±300ml

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

Validation 2 yr vs 4 yr stored DTC QC parameter:

DTC 2yr

DTC 4yr

MBB PBB 2005-2014 2003-2014

Number of DTC tested

19

19

226

1108

Volume after thaw (mL)

312±9

314±7

308±21

313±14

Product content after thaw(10^11/unit)

3.1±0.3

3.0±0.3

2.9±0.5

3.0±0.6

Recovery (% of ATC)

68±5

69±4

68±11

69±12

Years of storage

2.3±0.2

4.2±0.3

1.7±0,9

0.6±0.4

Validation: published as abstract AABB 2014; full manuscript in preparation 7

Military Blood Bank

Central Military Hospital

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

MORPHOLOGY OF FROZEN PLATELETS Fresh Plt product

Frozen Plt product

Diameter 3.1 µm Length 5 µm

Kunicki score=114±10 DTC 2yr and 115±10 for DTC 4 yr. Validation 2yr vs 4 yr storage of frozen platelets: published as abstract AABB 2014; F.Noorman et al. full manuscript in preparation

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Military Blood Bank

Central Military Hospital

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

SIZE DTC: THROMBOLUX 1 day stored apheresis platelets

We have changed the settings of the thrombolux to calculate the percentage and size of platelets and microparticles (MP); Platelets 375-5000 nm radius, MP 50550nm )

Frozen-thawed platelets, large Plt and MP

Frozen platelets: Average diameter of platelets is 2.5 µm Average diameter of MP is 0.4 µm Average %Plt=73±13% (MP27%)

Frozen thawed platelets, small Plt and MP

Average Thrombolux score is 10±5 No sign difference 2 and 4 yr stored frozen platelets

Scale: radius in nm 9

Military Blood Bank

MP

PLT

Central Military Hospital

Validation 2yr vs 4 yr storage of frozen platelets: published as abstract AABB 2014; F.Noorman et al. full manuscript in preparation

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

Fresh Plt product

Frozen Plt product

(CD62P-/CD61+=gray) Average Pselectin+ (CD62P+/CD61+=black) expression is: Platelets 10±5%, Microparticles 2±1% Average percentage of platelets is 71±5% (MP 29%) No sign difference between 2 and 4yr stored frozen plt Validation 2yr vs 4 yr storage of frozen platelets: published as abstract AABB 2014; F.Noorman et al. full manuscript in preparation

10

Military Blood Bank

Central Military Hospital

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

Fresh Plt product

Frozen Plt product

(CD42b-/CD41a+=black) Average GP1b+ (CD42b+/CD41a+= gray) content after thaw is: Platelets 3.1±1 1011/unit; Microparticles 0.8±0.5 1011/unit No sign difference between 2 and 4 yr stored Validation 2yr vs 4 yr storage of frozen platelets: published as abstract AABB 2014; F.Noorman et al. full manuscript in preparation

11

Military Blood Bank

Central Military Hospital

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

plasma

supernatant

Frozen Plt product

Fresh Plt product

Nog plasma en ATC bij!

AnnV-/CD41a+=gray) Average content of particles with AnnV binding sites (AnnV+/CD41a+=black) is: Product Platelets Plt 1.2 ± 0.6 11/unit MP 0.6 ± 0.3 1011/unit Supernatant DTC: Plt 0.2 ± 0.2 11/unit MP 0.6 ± 0.2 1011/unit Plasma pre-resusp: Plt 0.02 ± 0.0111/unit MP 0.02±0.0111/unit No sign difference between 2 and 4yr stored frozen plt Validation 2yr vs 4 yr storage of frozen platelets: published as abstract AABB 2014; F.Noorman et al. full manuscript in preparation

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Military Blood Bank

Central Military Hospital

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

*Thromboelastography:

Coagulation

α= Clot Amplification

DTC

MA=Clot Strength

DFP R= Clotting Speed

ATC

TEG® citrated kaolin 2*1011Plt/L DFP: Green: fresh plt. (ATC); Pink: frozen platelets (DTC); White: plasma (DFP) 13

Military Blood Bank

Central Military Hospital

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

Phospholipids: Coagulation Coagulation time (sec) in phospholipid deficient plasma+FXa

1000

Sta-Procoag-Pospholipid test (PPL) coagulation analyser Destiny Max:

100

10

y = 10,327x-0,274 R² = 0,9963 1 0,00001

0,0001

0,001

0,01

0,1

1

DTC supernatant dilutionfactor with Omniplas (yellow triangle) (Omniplas= NLD FFP treated with Octaplas LG method) Validation 2yr vs 4 yr storage of frozen platelets: published as abstract AABB 2014; F.Noorman et al. full manuscript in preparation

14

Military Blood Bank

Central Military Hospital

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

TEG VS PPL, DFP and supernatant DTC Sample name all test N=19 (except PPL test)

TEG R (min)

TEG Angle (°)

TEG MA (mm)

PPL clotting time (sec) (N=)

Sup DTC2yr

4.5±0.8

78±2

31±4

12±1 (18)

Sup DTC4yr

4.7±0.7

75±5(*)

28±5(*)

12±1 (18)

DFP 2yr

8.2±1.1

65±7

28±4

52±6 (19)

DFP 4yr

8.1±0.9

65±7

25±5

50±8 (19)

SupDTC 2yr, diluted 250x with omniplas

8.7±1.1

59±4

28±2

46±3 (19)

Sup DTC 4yr, diluted 250x with omniplas

8.6±1.1

58±5

28±3

47±5 (19)

Validation 2yr vs 4 yr storage of frozen platelets: published as abstract AABB 2014; F.Noorman et al. full manuscript in preparation

15

Military Blood Bank

Central Military Hospital

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

Thromboelastography: Coagulation Sample name all test N=19 (except PPL test)

TEG R (min)

TEG Angle (°)

Delta TEG ° Angle -Angle DFP (°)

TEG MA (mm)

PPL clotting time (sec) (N=)

DTC 2yr undiluted

3.3±0.6

79±2

14±7

58±4

11±0 (10)

DTC 4yr undiluted

3.6±0.6

77±4(*)

12±5

57±6

11±1 (8)

DTC 2yr 5x diluted in DFP

4.2±0.5

77±3

12±9

39±4

ND

DTC 4yr 5x diluted in DFP

4.3±0.7

74±4(*)

10±6

39±6

ND

Sup DTC2yr

4.5±0.8

78±2

13±6

31±4

12±1 (18)

Sup DTC4yr

4.7±0.7

75±5(*)

10±5

28±5(*)

12±1 (18)

Validation 2yr vs 4 yr storage of frozen platelets: published as abstract AABB 2014; F.Noorman et al. full manuscript in preparation

16

Military Blood Bank

Central Military Hospital

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

CELL ANALYSER TYPE VS FLOWCYTOMETER TYPE N=19 all measurements Content in 1011/unit ND=not done

DTC 2yr

DTC 4 yr

Supernatant DTC 2yr

Supernatant DTC 4yr

Plasma used for 2yr DTC

Plasma used for 4yr DTC

CD41a+CD42b+ Plt fix

3.1±1.2

3.2±1.0

ND

ND

ND

ND

CD41a+CD42b+ MP fix

0.8±0.5

0.8±0.5

ND

ND

ND

ND

CD41a+AnnV+ Plt unfix

1.2±0.6

1.2±0.3

0.2±0.2

0.2±0.1

0.02±0.01

0.02±0.01

CD41a+AnnV+ MP unfix

0.6±0.3

0.6±0.2

0.6±0.3

0.6±0.2

0.02±0.01

0.02±0.01

Sysmex KX21 Plt

3.1±0.3

3.0±0.3

0.2±0.1

0.1±0.0

0.04±0.04

0.03±0.02

Sysmex XS1000i Plt

3.7±0.5

3.7±0.5

0.5±0.2

0.4±0.2

0.06±0.06

0.04±0.03

Validation 2yr vs 4 yr storage of frozen platelets: published as abstract AABB 2014; F.Noorman et al. full manuscript in preparation

17

Military Blood Bank

Central Military Hospital

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

STANDARD QC FROZEN PLATELETS QC parameter:

DTC 2yr

DTC 4yr

MBB PBB 2005-2014 2003-2014

Number of DTC tested

19

19

226

1108

Volume after thaw (mL)

312±9

314±7

308±21

313±14

Product content after thaw(10^11/unit)

3.1±0.3

3.0±0.3

2.9±0.5

3.0±0.6

Recovery (% of ATC)

68±5

69±4

68±11

69±12

Years of storage

2.3±0.2

4.2±0.3

1.7±0,9

0.6±0.4

Validation 2yr vs 4 yr storage of frozen platelets: published as abstract AABB 2014; F.Noorman et al. full manuscript in preparation

18

Military Blood Bank

Central Military Hospital

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

All NLD frozen blood products are in compliance with international regulations and guidelines

Transf. Apher. Sci.; 2006; 34; 289-298. 19

Military Blood Bank

Central Military Hospital

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

20

Military Blood Bank

Central Military Hospital

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

Bosnia 1996-2005

Pakistan 2005

Liberia 2003-04 Somalia 2010-15

Iraq 2003-04

Afghanistan 2003, 2005, 2006-15

MALI 2015: SF&SWE 21

Military Blood Bank

Central Military Hospital

Commando DienstenCentra Health Division Ministry of Defence

The Netherlands 14 januari 2015

MTF ISAF 2006-2012 supplied by NLD

Khandahar (KF): Helmand (HL): Mazar E Sharif (ME): Tarin Kowt (TK): 22

MilitaryBlood Blood Bank Military Bank

Backup CND/USA Backup UK Backup GER Total supply NLD

620 patients 46 patients 16 patients 346 patients

jun2006-may2011 dec2006-sep2007 nov2011-xxx20xx aug2006-nov2010

Commando DienstenCentra Central Military Hospital Health Division Ministry Ministry of Defence Support Command of Defence

The Netherlands The Netherlands 14 januari 2015

Military Blood Bank 23 100 90 80 70 60 50 40 30 20 10 0

DFP DTC

Central Military Hospital Products / month

Products / month

MT

Aug-06 Nov-06 Feb-07 May-07 Aug-07 Nov-07 Feb-08 May-08 Aug-08 Nov-08 Feb-09 May-09 Aug-09 Nov-09 Feb-10 May-10 Aug-10 Nov-10

Aug-06 Nov-06 Feb-07 May-07 Aug-07 Nov-07 Feb-08 May-08 Aug-08 Nov-08 Feb-09 May-09 Aug-09 Nov-09 Feb-10 May-10 Aug-10 Nov-10

Patients / month

non-MT 90 80 70 60 50 40 30 20 10 0

100 90 80 70 60 50 40 30 20 10 0 Aug-06 Nov-06 Feb-07 May-07 Aug-07 Nov-07 Feb-08 May-08 Aug-08 Nov-08 Feb-09 May-09 Aug-09 Nov-09 Feb-10 May-10 Aug-10 Nov-10

Aug-06 Nov-06 Feb-07 May-07 Aug-07 Nov-07 Feb-08 May-08 Aug-08 Nov-08 Feb-09 May-09 Aug-09 Nov-09 Feb-10 May-10 Aug-10 Nov-10

Products / month

20 18 16 14 12 10 8 6 4 2 0

DEC

EC

published as an abstract AABB 2012; F.Noorman et al. full manuscript in preparation

Commando DienstenCentra Health Division Ministry of Defence The Netherlands 14 januari 2015

Tarin Kowt ISAF 2006-2010 supplied by NLD

% of products shipped

100

24

80

transfused

41

delivered not transf/stratevac. pos. Crossmatch/ recall

51 68

60

79

to other MTF/returned MBB

40 52 20

expired (22°C/4°C)

29

thaw-wash failure

7

breakage-leakage freezer failure

0

MilitaryBlood Blood Bank Military Bank

EC DEC DFP (1741/720) (2454/1244) (1730/1155)

DTC (441/372)

transport failure published as an abstract AABB 2012; F.Noorman et al. full manuscript in preparation

Commando DienstenCentra Central Military Hospital Health Division Ministry Ministry of Defence Support Command of Defence

The Netherlands The Netherlands 14 januari 2015

Patient Type and DTC use Tarin Kowt Afghanistan Tarin Kowt 346 patients Aug’06-Nov’10 1964 RBC, 1155 DFP, 372 DTC 267 trauma, 59 no trauma; 20 different hospital.

• 220 no-MT-Trauma patients (1-9 RBC/24hr) • 47 MT-Trauma patients (>=10 RBC/24hr)

F.Noorman et al. Abstract AABB2012 Manuscript in preparation, Data will be verified with database as published by R.Hoencamp et al. 25

MilitaryBlood Blood Bank Military Bank

Commando DienstenCentra Central Military Hospital Health Division Ministry Ministry of Defence Support Command of Defence

The Netherlands The Netherlands 14 januari 2015

Survival and product use before and after introduction of 4:3:1 policy (Nov 2007) Trauma N=267

Nr of Perc patients surv.

MT