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.[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 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)
|
Irradiated cellular products | ❑ Patients at risk of transfusion-associated graft-versus-host disease
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Cytomegalovirus-negative (red cells and platelets) |
❑ Organ/stem cell transplant candidates or recipients ❑ Premature/low birth weight infants |
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Leuko-reduced | ❑ Patients at risk for HLA alloimunization
❑ Patients with history of febrile non-hemolytic transfusion reactions |
Management
General Approach
Characterize the symptoms: ❑ Low red blood cell count or low hemoglobin level
❑ Low white blood cell count
❑ Low platelet count
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Obtain a detailed history: ❑ Review medical records
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Examine the patient: ❑ Vital signs:
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Order laboratory tests (Routine): ❑ CBC
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
❑ Precaution against errors
❑ Bleeding patient
❑ 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:
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Review indications to transfuse:
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Actively bleeding? ❑ Frank bleeding
❑ Occult bleeding | |||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||
Asymtomatic | Symptomatic | Symptomatic | Asymptomatic | ||||||||||||||||||||||||||||||||||||||
Treat | Transfuse packed red blood cells: ❑ In emergency situation
❑ Monitor urine output (>30 ml/hr) or 0.5 ml/kg/hr | Treat | |||||||||||||||||||||||||||||||||||||||
Monitoring: ❑ Vital signs
❑ Urine output | Manage complications: ❑ Early (< 24 hours)
❑ Delayed (> 24 hours) | Treat underlying cause: ❑ Control bleeding
❑ | |||||||||||||||||||||||||||||||||||||||
Managing Complications
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
- Never ignore 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.
References
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Sihler KC, Napolitano LM (2009). "Massive transfusion: new insights". Chest. 136 (6): 1654–67. doi:10.1378/chest.09-0251. PMID 19995767.
- ↑ 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.
- ↑ 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.
- ↑ 7.0 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.
- ↑ 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.
- ↑ 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.