View source for Transfusion therapy resident survival guide

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{{CMG}}; {{AE}}  {{AO}}

==Overview==
[[Blood transfusion]] is the process of transferring [[blood]] or [[blood product]]s 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 cell]]s (RBCs) in 24 hours.<ref name="pmid1986111">{{cite journal| author=Wudel JH, Morris JA, Yates K, Wilson A, Bass SM| title=Massive transfusion: outcome in blunt trauma patients. | journal=J Trauma | year= 1991 | volume= 31 | issue= 1 | pages= 1-7 | pmid=1986111 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1986111  }} </ref>
* Transfusion of greater than 10 units  of RBCs in 24 hours.<ref name="pmid16763487">{{cite journal| author=Malone DL, Hess JR, Fingerhut A| title=Massive transfusion practices around the globe and a suggestion for a common massive transfusion protocol. | journal=J Trauma | year= 2006 | volume= 60 | issue= 6 Suppl | pages= S91-6 | pmid=16763487 | doi=10.1097/01.ta.0000199549.80731.e6 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16763487  }} </ref>
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,<ref name="pmid18399845">{{cite journal| author=Moltzan CJ, Anderson DA, Callum J, Fremes S, Hume H, Mazer CD et al.| title=The evidence for the use of recombinant factor VIIa in massive bleeding: development of a transfusion policy framework. | journal=Transfus Med | year= 2008 | volume= 18 | issue= 2 | pages= 112-20 | pmid=18399845 | doi=10.1111/j.1365-3148.2008.00846.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18399845  }} </ref> or when 50% of [[blood volume|total blood volume]] is replaced within 3 hours.  These situations often require the activation of massive transfusion protocols (MTP).<ref name="pmid19995767">{{cite journal| author=Sihler KC, Napolitano LM| title=Massive transfusion: new insights. | journal=Chest | year= 2009 | volume= 136 | issue= 6 | pages= 1654-67 | pmid=19995767 | doi=10.1378/chest.09-0251 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19995767  }} </ref>

===Blood Products and Indications for Use===

{| Class="wikitable"
!Blood Products
!Indications
!Dose
|-
|[[red blood cell|Packed red blood cells]] (PRBC)
|❑ [[Bleeding|Acute hemorrhage]] <br>❑ To ↑ O<sub>2</sub>-carrying capacity of blood in cases of end-organ [[ischemia]]
| 1 unit of PRBC = ↑ [[Hemoglobin]] (Hb) concentration by 1 g/dL<br>Transfuse slowly for the first 15 minutes<br>'''Complete transfusion within 4 hours'''.
|-
|[[Platelets]] (Plts)
|In patients with [[thrombocytopenia]] (plts < 150,000 cells/uL)<br>❑ For prophylaxis (to prevent [[bleeding]]) <br>❑ For treatment (during active bleeding)<br> '''Contraindications'''<br>❑ [[Thrombotic thrombocytopenic purpura|TTP]]/[[Hemolytic-uremic syndrome|HUS]], [[Heparin-induced thrombocytopenia|HIT]], [[HELLP syndrome]]<br>Click [[Thrombocytopenia resident survival guide#Indications for Platelet Transfusion in Thrombocytopenia|here]] for more information.
|1 [[apheresis]] unit = 6 units of plts in 250 - 300 mls of plasma<br>1 dose of [[apheresis]] unit = ↑ plt count by 30,000 - 60,000/uL
|-
|[[Fresh frozen plasma]]
|❑ For bleeding patients due to multiple deficiencies of [[Coagulation#Coagulation Factors|coagulation factors]] <br>e.g.,  [[Thrombotic thrombocytopenic purpura|TTP]]/[[Hemolytic-uremic syndrome|HUS]], [[hepato-biliary diseases]] <br>❑ [[Warfarin]]-induced bleed (2nd choice)
|1 unit = 200 - 250 ml of plasma<br>1 ml of plasma = 1 u coagulation factors<br>1 unit contains 220 u coagulation factors<br>'A dose of 10-20 mL/kg (4-6 units) = 20% ↑ of circulating coagulation factors<br>'''Note''' - specific coagulation factor concentrates should be used to treat <br>patients with [[hemophilia]] , [[Von Willebrand disease]], and [[antithrombin III deficiency]]
|-
|[[Cryoprecipitate]]
|❑ Bleeding patients with [[fibrinogen]] < 100 mg/dL<br>❑ Bleeding patients with [[Von Willebrand disease]] and factors [[Hemophilia A|VIII]] and [[Factor XIII deficiency|XIII]] deficiencies<br> '''Note''' - specific coagulation factor concentrates should be used to treat <br>patients with [[hemophilia]] , [[Von Willebrand disease]]
|1 unit = fibrinogen (150 mg), factor VIII (80-120 u), von Willebrand factor (40-70 u),<br> and factor XIII (20-30 u)
<br>1 dose = ↑ circulating [[fibrinogen]] concentration by 50-100 mg/dL
|-
|[[Antibody|Immunoglobulins]]
|
|
|-
|[[Albumin]]
|
|
|-
|Irradiated
|
|
|-
|[[Cytomegalovirus]]-negative
|
|
|-
|[[Leukoreduction|Leuko-reduced]]
|❑ Patients at risk for [[Alloimmunity|HLA alloimunization]]
:❑ Chronically transfused patients e.g., patients on chemotherapy<br>
:❑ Patients for future organ transplants<br>
❑ Patients with history of [[Transfusion reaction#Types of transfusion reactions|febrile non-hemolytic transfusion reactions]]
|
|}

==Management==
===General Approach===
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left;"> '''Characterize the symptoms:''' <br> 
❑ '''Low red blood cell count or low hemoglobin level'''<br>
:❑ Difficulty concentrating <br>
:❑ [[Insomnia|Difficulty sleeping]] <br>
:❑ [[Dizziness]]<br>
:❑ [[Fatigue|Easy fatigability]]<br>
:❑ [[Headache]] <br>
:❑ [[Pallor|Pale skin]]<br>
:❑ [[Tachycardia|Rapid heart beat]]<br>
:❑ [[Shortness of breath]] <br>
❑ '''Low white blood cell count'''<br>
:❑ Abnormal bleeding <br>
:❑ [[Fever]]
:❑ [[Irritability]] <br>
:❑ [[Neurasthenia]]<br>
:❑ Recurrent infections - [[Aphthous ulcer|canker sores]], [[gingivitis]], [[periodontitis]]

❑ '''Low platelet count''' <br>
:❑ Blood in urine or stool <br>
:❑ Easy or excessive bruising<br>
:❑ [[Menorrhagia|Heavy menstrual flow]] <br>
:❑ Prolonged bleeding during surgery<br>or after dental work<br>
:❑ Prolonged bleeding from cuts
</div>}}
{{familytree | | | |!| | |}}
{{familytree | | | B01 | | B01=<div style="float: left; text-align: left;"> '''Obtain a detailed history:''' <br>
❑ Review medical records<br>
❑ Past medical history <br>
:❑ Previous [[blood transfusion]] <br>
:❑ Cardiovascular disease <br>
:❑ [[Trauma]] <br>
:❑ Previous [[Surgery]] <br>
:❑ [[Infection]]s e.g., [[HIV]] <br>
:❑ [[Malignancy]] <br>
:❑ [[Chronic kidney disease]]<br>
❑ [[Medications]] - [[anticoagulants]], [[thrombolytics]]</div> - }}
{{familytree | | | |!| | |}}
{{familytree | | | W01 | | |W01=<div style="float: left; text-align: left;">'''Examine the patient:''' <br> 
❑  <br>
❑  <br>
❑  <br>
❑ <br>
❑ <br>
❑  <br>
❑  <br>
❑  <br>
❑  <br>
❑ <br>
❑ </div>}}
{{familytree | | | |!| | |}}
{{familytree | | | C01 | | |C01= <div style="float: left; text-align: left;">'''Order laboratory tests:''' <br>
❑  <br>
❑  <br>
❑  <br>
❑ <br>
❑ <br>
❑  <br>
❑  <br>
❑  <br>
❑  <br>
❑ </div>}}
{{familytree | | | |!| | |}}
{{familytree | | | D01 | | |D01=<div style="float: left; text-align: left;">'''Pre-transfusion preparation:''' <br>
❑  <br>
❑  <br>
❑  <br>
❑ <br>
❑ <br>
❑  <br>
❑  <br>
❑  <br>
❑  <br>
❑ </div>}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | E01 | | E02 | | |E01=Low hemoglobin level|E02=Coagulopathy}}
{{familytree | | | |,|-|^|-|.| | |}}
{{familytree | | | F01 | | F02 | | F01=Low platelets|F02=Coagulation factor deficiency}}
{{familytree | | | |,|-|-|-|+|-|-|-|.| | |}}
{{familytree | | | G01 | | G02 | | G03 | |G01=Indications|G02=Indications|G03=Indications}}
{{familytree | | | |!| | | |!| | | |!| | |}}
{{familytree | | | H01 | | H02 | | H03 | |H01=Consider fresh frozen plasma|H02=Consider cryoprepitate|H03=Consider prothrombin complex concentrate}}
{{familytree/end}}



===Packed Red Blood Cells===

{{familytree/start}}
{{familytree | | | | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left;">'''Low hemoglobin concentration:''' <br> 
❑  <br>
❑  <br>
❑ <br>
❑ </div>}}
{{familytree | | | | | | | | | | | |!| | | |}}
{{familytree | | | | | | | | | | | B01 | |B01=<div style="float: left; text-align: left;">'''Review indications to transfuse:''' <br> 
❑  <br>
❑  <br>
❑  <br>
❑ <br>
❑ <br>
❑  <br>
❑  <br>
❑  <br>
❑  <br>
❑ <br>
❑ </div>}}
{{familytree | | | | | | | | | | | |!| | | |}}
{{familytree | | | | | | | | | | | C01 | |C01=<div style="float: left; text-align: left;">'''Actively bleeding:''' <br> 
❑ Frank bleeding  <br>
:❑  <br>
:❑  <br>
:❑ <br>
:❑ <br>
❑ Occult bleeding  <br>
:❑  <br>
:❑  <br>
:❑  <br>
:❑ <br>
:❑ </div>}}
{{familytree | | | | | | | | |,|-|-|^|-|-|.| | |}}
{{familytree | | | | | | | | D01 | | | | D02 | |D01='''Yes'''|D02='''No'''}}
{{familytree | | | | | |,|-|-|^|.| | | |,|^|-|-|.| |}}
{{familytree | | | | | E01 | | E02 | | E03 | | E04 | |E01='''Asymtomatic'''|E02=<div style="float: left; text-align: left;">'''Symptomatic:''' <br> 
❑  <br>
❑  <br>
❑  <br>
❑ <br>
❑ <br>
❑  <br>
❑  <br>
❑  <br>
❑  <br>
❑ <br>
❑ </div>|E03=<div style="float: left; text-align: left;">'''Symptomatic:''' <br> 
❑  <br>
❑  <br>
❑  <br>
❑ <br>
❑ <br>
❑  <br>
❑  <br>
❑  <br>
❑  <br>
❑ <br>
❑ </div>|E04='''Asymptomatic'''}}
{{familytree | | | | | |!| | | |`|-|v|-|'| | | |!| | |}}
{{familytree | | | | | F01 | | | | F02 | | | | F03 | |F01=Treat|F02=Transfuse packed red blood cells|F03=Treat}}
{{familytree | | | | | | | |,|-|-|-|+|-|-|-|.| | |}}
{{familytree | | | | | | | H01 | | H02 | | H03 | |H01=<div style="float: left; text-align: left;">'''Monitoring:''' <br> 
❑  <br>
❑  <br>
❑  <br>
❑ <br>
❑ <br>
❑  <br>
❑  <br>
❑  <br>
❑  <br>
❑ <br>
❑ </div>|H02=<div style="float: left; text-align: left;">'''Manage complications:''' <br> 
❑  <br>
❑  <br>
❑  <br>
❑ <br>
❑ <br>
❑  <br>
❑  <br>
❑  <br>
❑  <br>
❑ <br>
❑ </div>|H03=<div style="float: left; text-align: left;">'''Treat underlying cause:''' <br> 
❑  <br>
❑  <br>
❑  <br>
❑ <br>
❑ <br>
❑  <br>
❑  <br>
❑  <br>
❑  <br>
❑ <br>
❑ </div>}}
{{familytree/end}}

===Managing Complications===

==Do's==

==Don'ts==


==References==
{{Reflist|2}}

[[Category:Projects]]
[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Primary care]]
[[Category:Resident survival guide]]
[[Category:Signs and symptoms]]
[[Category:Up-To-Date]]

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