Sandbox/22

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 ❑ Family history of bleeding ❑ 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

Coagulation factor deficiency

Consider fresh frozen plasma

Consider cryoprecipitate

Consider prothrombin complex concentrate

Refractory

Refractory

Refractory

PRBCs

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 ❑ Hematuria ❑ Bleeding from trauma sites ❑ Intraoperative bleeding ❑ Hematochezia ❑ Hemoptysis ❑ Occult bleeding ❑

Yes

No

Asymtomatic

Symptomatic: ❑ ❑ ❑ ❑ ❑ ❑

Symptomatic: ❑ ❑ ❑ ❑

Asymptomatic

Treat

Transfuse packed red blood cells

Treat

Monitoring: ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑

Manage complications: ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑

Treat underlying cause: ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑