Transfusion therapy resident survival guide

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.
• Transfusion of greater than 10 units of RBCs in 24 hours.

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, or when 50% of total blood volume is replaced within 3 hours. These situations often require the activation of massive transfusion protocols (MTP).

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 Infuse over 30 - 60 minutes
Fresh frozen plasma	❑ For bleeding patients due to multiple deficiencies of coagulation factors e.g., TTP/HUS, hepato-biliary diseases ❑ Warfarin-induced bleed (2nd choice)	1 unit = 200 - 250 ml of plasma 1 ml of plasma = 1 u coagulation factors 1 unit contains 220 u coagulation factors 'A dose of 10-20 mL/kg (4-6 units) = 20% ↑ of circulating coagulation factors Note - specific coagulation factor concentrates should be used to treat patients with hemophilia , Von Willebrand disease, and antithrombin III deficiency
Cryoprecipitate	❑ Bleeding patients with fibrinogen < 100 mg/dL ❑ Bleeding patients with Von Willebrand disease and factors VIII and XIII deficiencies Note - specific coagulation factor concentrates should be used to treat patients with hemophilia , Von Willebrand disease	1 unit = fibrinogen (150 mg), factor VIII (80-120 u), von Willebrand factor (40-70 u), and factor XIII (20-30 u) 1 dose = ↑ circulating fibrinogen concentration by 50-100 mg/dL
Irradiated cellular products	❑ Patients at risk of transfusion-associated graft-versus-host disease ❑ Stem cell transplant candidates ❑ HLA-matched platelet product recipients ❑ Patients on fludarabine ❑ Patients with congenital immunodeficiency
Cytomegalovirus-negative (red cells and platelets)	❑ Organ/stem cell transplant candidates or recipients ❑ Premature/low birth weight infants
Leuko-reduced	❑ Patients at risk for HLA alloimunization ❑ Chronically transfused patients e.g., patients on chemotherapy ❑ Patients for future organ transplants ❑ Patients with history of febrile non-hemolytic transfusion reactions

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 tooth extraction ❑ Prolonged bleeding from cuts

Obtain a detailed history: ❑ Review medical records ❑ Past medical history ❑ Previous blood transfusion ❑ Cardiovascular disease ❑ Hypertension ❑ Arryhthmias ❑ Trauma ❑ Previous surgery ❑ Infections e.g., HIV ❑ Malignancy ❑ Chronic kidney disease ❑ Chronic lung disease ❑ Malignancy ❑ Pregnancy ❑ Medications - anticoagulants, thrombolytics

Examine the patient: ❑ Vital signs: ❑ Blood pressure: ↓ ❑ Pulse rate: ↑ or ↓ ❑ Respiratory rate: ↑ or ↓ ❑ Oxygen saturation: ↓ (<90%) ❑ Temperature: ↑ or ↓ in sepsis ❑ Skin: ❑ Pallor ❑ Jaundice ❑ Petechiae, ecchymosis ❑ Active bleeding ❑ Central nervous system: ❑ Altered sensorium ❑ Personality changes ❑ Lungs: ❑ ❑ Abdomen: ❑ Abdominal distension ❑ Abdominal tenderness

Order laboratory tests (Routine): ❑ CBC ❑ Serum electrolytes ❑ BUN, creatinine ❑ PT/PTT ❑ Type and screen (when transfusion is unlikely) ❑ Type and crossmatch (if transfusion is certain) ❑ ABO antigens and antibodies ❑ Rhesus (D) antigen ❑ Antibodies to red cell antigens (antibody screen) Note - Send fresh samples whenever a second transfusion is required Other additional laboratory tests to determine etiology: ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑

Pre-transfusion preparation: 4 R's - right Blood, right Patient, right Time, right Place ❑ Intravenous access/sample collection ❑ Large-bore cannula ❑ Use bottle containing EDTA anticoagulant (purple color) ❑ Avoid using IV site for drugs ❑ Dextrose solution (cause hemolysis) ❑ Calcium-containing solutions (cause clotting of citrated blood) ❑ Precaution against errors ❑ Bleed only one patient at a time ❑ Ensure two independent patient identifiers ❑ Proper labelling of samples ❑ Record date and time of blood or blood component ❑ Bleeding patient ❑ Stop all anticoagulation - heparin, warfarin ❑ Reverse anticoagulants, if necessary ❑ Record vital signs ❑

Low hemoglobin level

Coagulopathy

Low platelets Click here for management

Coagulation factor deficiency

Consider fresh frozen plasma

Consider cryoprecipitate

Consider prothrombin complex concentrate

Refractory

Refractory

Refractory

Low Hemoglobin Level

Low hemoglobin concentration: Parameter Men Women ❑ Hb (g/dL) ❑ 14 - 17.4 ❑ 12.3 - 15.3 ❑ HCT (%) ❑ 42 - 50 ❑ 36 - 44

Review indications to transfuse: Patient category Threshold (g/dL) ❑ Symptomatic patients e.g., chest pain, orthostatic hypotension, CHF, tachycardia unresponsive to fluids ❑10 ❑ Hemodynamically stable ICU in-patients (adult and pediatric) ❑ 7 - 8 ❑ In-patient with preexisting cardiovascular disease ❑ ≤ 8 or for symptoms ❑ Acute coronary syndromes ❑ < 8, 8 - 10 ❑ All patients ❑ Consider symptoms + Hb level before transfusing

Actively bleeding? ❑ Frank bleeding ❑ Hematemesis ❑ Hematuria ❑ Bleeding from trauma sites ❑ Intraoperative bleeding ❑ Hematochezia ❑ Hemoptysis ❑ Occult bleeding

Yes

No

Asymtomatic

Symptomatic

Symptomatic

Asymptomatic

Treat

Transfuse packed red blood cells: ❑ In emergency situation ❑ Request for emergency group O-negative red cells ❑ Give adequate volume of crystalloids to maintain normal blood pressure ❑ Monitor urine output (>30 ml/hr) or 0.5 ml/kg/hr

Treat

Monitoring: ❑ Vital signs ❑ 15 minutes ❑ Then every 30 minutes ❑ Urine output ❑ Central venous pressure in major bleeding or cardiopulmonary disease ❑ PT, platelet count in liver disease ❑ Cardiac monitoring for ischemia ❑ Post-transfusion Hb level between 15 mins to 24 hours post transfusion

Manage complications: ❑ Early (< 24 hours) ❑ Acute hemolytic reaction ❑ Anaphylaxis ❑ Bacterial contamination ❑ Febrile non-hemolytic transfusion reaction ❑ Allergic reaction ❑ Transfusion-associated circulatory overload (TACO) ❑ Transfusion related acute lung injury (TRALI) ❑ Delayed (> 24 hours) ❑ Iron overload ❑ Transfusion-associated graft versus host disease ❑ Post-transfusion purpura ❑ Transfusion-associated microchimerism (TA-MC)

Treat underlying cause: ❑ Control bleeding ❑ Surgical, endoscopic, radiological interventions e.g., upper GI procedures ❑ ❑ ❑ ❑

Do's

• The decision to transfuse a patient should be based on the hemoglobin level, clinical status, presence of co-morbidities, and the patient's wish.
• Dextrose solutions, calcium-containing solutions, or drugs should not be administered via the same intravenous access used for transfusing blood and blood products.
• Monitor vital signs (temperature, pulse, blood pressure, respiratory rate, oxygen saturation) every 30 minutes.

Don'ts

• Clinical symptoms and signs such as fever, flushing, urticaria, hypotension, increasing anxiety/restlessness, pain at or near the site of the transfusion, respiratory distress in a patient receiving any blood or blood product should not be ignored.