Transfusion therapy resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]

Overview

Blood transfusion is the process of transferring blood or blood products obtained from one person (donor) into the circulatory system of another (recipient).

Massive blood transfusion refers to transfusing a large volume of blood to a patient, especially in trauma patients with uncontrollable hemorrhage. Several definitions used in the past include:

  • Transfusion of 20 units of red blood cells (RBCs) in 24 hours.[1]
  • Transfusion of greater than 10 units of RBCs in 24 hours.[2]

Currently, it is more practical to identify patients in need of massive transfusion when greater than four red blood cell units is needed in one hour and an ongoing need for transfusion is predicted,[3] or when 50% of total blood volume is replaced within 3 hours. These situations often require the activation of massive transfusion protocols (MTP).[4]

Blood Products and Indications for Use

Blood Products Indications Dose
Packed red blood cells (PRBC) Acute hemorrhage
❑ To ↑ O2-carrying capacity of blood in cases of end-organ ischemia
1 unit of PRBC = ↑ Hemoglobin (Hb) concentration by 1 g/dL
Transfuse slowly for the first 15 minutes
Complete transfusion within 4 hours.
Platelets (Plts) In patients with thrombocytopenia (plts < 150,000 cells/uL)
❑ For prophylaxis (to prevent bleeding)
❑ For treatment (during active bleeding)
Contraindications
TTP/HUS, HIT, HELLP syndrome
Click here for more information.
1 apheresis unit = 6 units of plts in 250 - 300 mls of plasma
1 dose of apheresis unit = ↑ plt count by 30,000 - 60,000/uL
Fresh frozen plasma
Cryoprecipitate
Immunoglobulins
Albumin
Irradiated
Cytomegalovirus-negative
Leuko-reduced

Management

General Approach

 
 
Characterize the symptoms:

Low red blood cell count or low hemoglobin level

❑ Difficulty concentrating
Difficulty sleeping
Dizziness
Easy fatigability
Headache
Pale skin
Rapid heart beat
Shortness of breath

Low white blood cell count

❑ Abnormal bleeding
Fever
Irritability
Neurasthenia
❑ Recurrent infections - canker sores, gingivitis, periodontitis

Low platelet count

❑ Blood in urine or stool
❑ Easy or excessive bruising
Heavy menstrual flow
❑ Prolonged bleeding during surgery
or after dental work
❑ Prolonged bleeding from cuts
 
 
 
 
 
 
 
 
 
 
Obtain a detailed history:

❑ Review medical records
❑ Past medical history

❑ Previous blood transfusion
❑ Cardiovascular disease
Trauma
❑ Previous Surgery
Infections e.g., HIV
Malignancy
Chronic kidney disease
Medications - anticoagulants, thrombolytics
-
 
 
 
 
 
 
 
 
 
 
Examine the patient:











 
 
 
 
 
 
 
 
 
 
 
Order laboratory tests:










 
 
 
 
 
 
 
 
 
 
 
Pre-transfusion preparation:










 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low hemoglobin level
 
Coagulopathy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low platelets
 
Coagulation factor deficiency
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Indications
 
Indications
 
Indications
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider fresh frozen plasma
 
Consider cryoprepitate
 
Consider prothrombin complex concentrate
 


Packed Red Blood Cells

 
 
 
 
 
 
 
 
 
 
Low hemoglobin concentration:




 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Review indications to transfuse:











 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Actively bleeding:

❑ Frank bleeding





❑ Occult bleeding





 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asymtomatic
 
Symptomatic:











 
Symptomatic:











 
Asymptomatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat
 
 
 
Transfuse packed red blood cells
 
 
 
Treat
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Monitoring:











 
Manage complications:











 
Treat underlying cause:











 

Managing Complications

Do's

Don'ts

References

  1. Wudel JH, Morris JA, Yates K, Wilson A, Bass SM (1991). "Massive transfusion: outcome in blunt trauma patients". J Trauma. 31 (1): 1–7. PMID 1986111.
  2. Malone DL, Hess JR, Fingerhut A (2006). "Massive transfusion practices around the globe and a suggestion for a common massive transfusion protocol". J Trauma. 60 (6 Suppl): S91–6. doi:10.1097/01.ta.0000199549.80731.e6. PMID 16763487.
  3. Moltzan CJ, Anderson DA, Callum J, Fremes S, Hume H, Mazer CD; et al. (2008). "The evidence for the use of recombinant factor VIIa in massive bleeding: development of a transfusion policy framework". Transfus Med. 18 (2): 112–20. doi:10.1111/j.1365-3148.2008.00846.x. PMID 18399845.
  4. Sihler KC, Napolitano LM (2009). "Massive transfusion: new insights". Chest. 136 (6): 1654–67. doi:10.1378/chest.09-0251. PMID 19995767.


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