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]


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
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)
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
(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


General Approach

Characterize the symptoms:

Low red blood cell count or low hemoglobin level

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

Low white blood cell count

❑ Abnormal bleeding
❑ 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
❑ Previous surgery
Infections e.g., HIV
Chronic kidney disease
Chronic lung disease


Medications - anticoagulants, thrombolytics
Examine the patient:

❑ Vital signs:

Blood pressure: ↓
Pulse rate: ↑ or ↓
Respiratory rate: ↑ or ↓
Oxygen saturation: ↓ (<90%)
Temperature: ↑ or ↓ in sepsis
❑ Skin:
Petechiae, ecchymosis
Active bleeding
❑ Central nervous system:
Altered sensorium
❑ Personality changes
❑ Lungs:
❑ Abdomen:
Abdominal distension
Abdominal tenderness
Order laboratory tests (Routine):

Serum electrolytes
BUN, creatinine
❑ 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
Low platelets
Click here for management
Coagulation factor deficiency
Consider fresh frozen plasma
Consider cryoprecipitate
Consider prothrombin complex concentrate

Low Hemoglobin Level

Low hemoglobin concentration:
❑ Hb (g/dL)❑ 14 - 17.4❑ 12.3 - 15.3
❑ HCT (%)❑ 42 - 50❑ 36 - 44
Review indications to transfuse:
Patient categoryThreshold (g/dL)
❑ Symptomatic patients e.g.,
chest pain,
orthostatic hypotension, CHF,
unresponsive to fluids
❑ Hemodynamically stable ICU
in-patients (adult and pediatric)
❑ 7 - 8[7]
❑ In-patient with preexisting
cardiovascular disease
❑ ≤ 8 or for symptoms[7]
Acute coronary syndromes❑ < 8[8], 8 - 10[9]
❑ All patients❑ Consider symptoms
+ Hb level before transfusing[7]
Actively bleeding?

❑ Frank bleeding

❑ Bleeding from trauma sites
❑ Intraoperative bleeding

❑ Occult bleeding

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


❑ 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
Treat underlying cause:

❑ Control bleeding

❑ Surgical, endoscopic, radiological interventions e.g., upper GI procedures


Managing Complications




  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.
  5. Carson JL, Brooks MM, Abbott JD, Chaitman B, Kelsey SF, Triulzi DJ; et al. (2013). "Liberal versus restrictive transfusion thresholds for patients with symptomatic coronary artery disease". Am Heart J. 165 (6): 964–971.e1. doi:10.1016/j.ahj.2013.03.001. PMC 3664840. PMID 23708168.
  6. Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads GG; et al. (2011). "Liberal or restrictive transfusion in high-risk patients after hip surgery". N Engl J Med. 365 (26): 2453–62. doi:10.1056/NEJMoa1012452. PMC 3268062. PMID 22168590.
  7. 7.0 7.1 7.2 Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK; et al. (2012). "Red blood cell transfusion: a clinical practice guideline from the AABB*". Ann Intern Med. 157 (1): 49–58. doi:10.7326/0003-4819-157-1-201206190-00429. PMID 22751760.
  8. Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H; et al. (2011). "ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC)". Eur Heart J. 32 (23): 2999–3054. doi:10.1093/eurheartj/ehr236. PMID 21873419.
  9. Cooper HA, Rao SV, Greenberg MD, Rumsey MP, McKenzie M, Alcorn KW; et al. (2011). "Conservative versus liberal red cell transfusion in acute myocardial infarction (the CRIT Randomized Pilot Study)". Am J Cardiol. 108 (8): 1108–11. doi:10.1016/j.amjcard.2011.06.014. PMID 21791325.

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