Transfusion Medicine

R. Dixon Dorand

Zoe Finer

For emergent transfusions, call the blood bank (615-322-2233)

  • RNs on 10T and 11N can follow transfusion protocols for pRBCs and plts – enter as a “Nursing Communication” or as part of the Hematology/Oncology Admission Order set.
  • At VUMC, all blood products are leukoreduced to reduce the risk of febrile nonhemolytic reactions. Other special processing of blood products (such as irradiation) will be decided by blood bank based on special considerations listed in order set. Examples include: stem cell transplant, hematologic malignancy, or thalassemia
  • Pts with frequent transfusions (e.g. sickle cell hemoglobinopathy) should have an “RBC Extended Phenotype” ordered (once) for minor RBC antigens to avoid immunization and antibody development to these proteins - You may ask the VUMC hematology lab to email you pictures of the peripheral smear

VA: Orders Tab – Blood Bank Orders – follow prompts to select appropriate product. Must order both the blood product AND the transfusion order (“Transfuse blood”) 

  • You need to specify all special processing such as irradiation
  • To order “Type & Screen” as a lab, you must go to Blood Bank Orders
  • Type & Screen and Transfusion results are under the Blood tab in Results

Red Blood Cell Transfusions

  • Volume 200-300 mL per unit prbc
  • In general, 1 unit of packed RBCs increases Hgb by 1g/dL and HCT by ~3%
  • Assessment of the post-transfusion Hgb can be performed 15 min following transfusion, but ideally 1 hour after completion

Indications

  • Hgb < 7 g/dL for most adults
  • Hgb < 7.5 g/dL pre cardiac surgery
  • Hgb < 8 g/dL or Hct <25: Bone marrow failure or receiving antineoplastic therapy
    • Also sometimes used in pts with pre-existing CAD, ACS, and pre-orthopedic surgery

Platelet Transfusions

  • Most likely blood product to be contaminated (unable to be frozen for storage) Indications for transfusion
    • <11 k/μL: all pts, reduce risk of spontaneous hemorrhage (use on BMT, Brittingham)
    • <50 k/μL: active bleeding, scheduled to undergo select invasive procedure
    • <100 k/μL: CNS hemorrhage, intrathecal catheter
      • This is also the threshold used for most neurosurgical procedures
  • Poor response is common
    • Nonimmune mediated causes: fever, infection, splenomegaly, DIC, meds, bleeding
    • Immune mediated causes: anti-HLA antibodies and anti-human plt antigens (try cross matched or HLA matched plts for this), drug induced antibodies, plasma protein antibodies

Fresh Frozen Plasma (FFP) and Cryoprecipitate (Cryo)

Cryoprecipitate: fibrinogen, factor VIII, VWF, Factor XIII, Fibronectin (typically 1u/10kg)

  • low fibrinogen (<100) with active bleeding
  • fibrinogen < 150 +massive hemorrhage, APML
  • Should not be used in hemophilia or vWD (there are better options such as concentrate or recominant factors)

FFP (typically dosed 10mL/kg to correct INR) 

  • Once thawed, must be used in 24 hrs (due to decline in labile coagulation factors)
  • Must be ABO compatible but not crossmatched or Rh typing
  • Only administer FFP if INR ≥1.7 (FFP will not fix an INR < 1.7, the average INR of a unit of plasma is 1.3-1.4)

Indications for transfusion

  • Bleeding
    • FFP If INR >1.6
    • Cryoprecipitate if fibrinogen <100.
  • DIC
    • Fibrinogen <100: Transfuse 5 – 10 units cryoprecipitate and repeat fibrinogen. If bleeding, consider raising transfusion threshold of cryoprecipitate to fibrinogen <150
    • Plasma exchange o Massive transfusion
  • Cirrhosis:
    • General concept: PT/INR, aPTT are unreliable markers for bleeding. Fibrinogen ≤100 – 120 or thromboelastography are better surrogates for bleeding risk
    • Transfuse fibrinogen ≤100 – 120 if the pt is actively bleeding or about to undergo a procedure or surgery other than paracentesis
    • Transfuse FFP based on hepatology team preference (generally few indications for FFP)

Massive Transfusion Protocol

In the setting of large blood loss or ongoing bleeds

  • Transfuse RBCs, FFP, and Platelets (typically 1:1:1 ratio in trauma scenarios). Transfusing large amounts of RBCs can dilute coagulation factors, which is the reason for the matched ratio.
  • At VUMC can order a “fastpack” which includes 2u prbc and 2u plasma
  • Complications to monitor for
    • Hypocalcemia, hypomagnesemia, (blood products have citrate as a preservative which binds to ca and affects mag levels) → replete with Ca gluconate and Magnesium Sulfate
    • Hyperkalemia – due to the breakdown of RBC in transfusion process
    • Hypothermia
    • Coagulopathy – due to the dilution of clotting factors discussed above.

Transfusion Premedication and Reactions

  • If you are concerned about a serious transfusion reaction, pause the transfusion and contact the blood bank ASAP
  • Order the transfusion reaction blood testing in Epic. You will send a CBC, the bag of blood products, and the completed form to the blood bank for analysis

Premedication

  • Only if history of severe reaction
    • Diphenhydramine 25-50mg IV
    • Acetaminophen 650 mg PO
    • Meperidine 25-50 mg IV (optional for chills)
    • Hydrocortisone 50 mg IV (optional, for severe reactions or reactions despite acetaminophen and diphenhydramine)

Reaction

Signs & Symptoms

Etiology

Clinical Action
Allergic (mild) Pruritus, hives limited to small area Antibodies to transfused plasma proteins Pause transfusion. Administer antihistamines. Resume transfusion if improved; NO samples necessary. If no improvement in 30 min treat as moderate to severe.
Allergic (moderate to severe) Generalized hives (>2/3 body surface), bronchospasm & dyspnea, abdominal pain, hypotension, nausea, anaphylaxis Antibodies to transfused plasma proteins usually IgE but can also be IgA. Possible allergen in blood product Administer antihistamines, epinephrine, vasopressors and corticosteroids as needed. Send product to blood bank. Evaluate for IgA deficiency → pt may need washed blood bloods from IgA deficient donor.
Febrile Non-Hemolytic Rise of temp >1°C, chills, rigors, anxiety, headache – during or up to 4 hours after typically. Cytokines released from residual white blood cells in the blood product Mild: administer antipyretics as needed
Acute Hemolytic Hemoglobinemia / uria, fever, chills, anxiety, shock, flank pain, chest pain, unexplained bleeding, cardiac arrest Intravascular hemolysis usually due to ABO incompatibility. Clinical emergency. Ensure correct product given to correct patient. Treat shock w/vasopressors; maintain airway; administer fluids and maintain brisk diuresis; monitor for AKI.. Reach out to blood bank to assist in evaluation. Administer blood products as needed after etiology is clear.
Delayed Hemolytic Asymptomatic or anemia, fever, jaundice, mailaise, hemoglobinuria and renal failure 3 days – 2 weeks after transfusion Newly formed alloantibody or increase in previously undetectable antibody leading to hemolysis of transfused RBCs
Septic Rise of temp > 2°C, sudden hypotension or hypertension, shock Micro-organism (i.e. bacteria) in donor bag (Greater risk in apheresis vs. RBC) Send bag/tubing to transfusion medicine. Order BCx. Broad spectrum abx Pressor support if necessary.
TRALI – Transfusion Related Acute Lung Injury Acute respiratory distress occurring within 6 hours of transfusion. Imaging typically shows Noncardiogenic pulmonary edema unresponsive to diuretics; Dx of exclusion. Usually donor HLA antibodies from transfused plasma. Recipient has corresponding antigens; causes neutrophil activation that results in extravasation of fluid into air spaces Respiratory support! Most will resolve within 24- 96 hours. Steroids, diuretics: no known benefit.
TACO - Transfusion Associated Circulatory Overload Cardiogenic pulmonary edema occurring within 6 hours from the end of transfusion. Elevated BNP is often observed. Can be seen with as little as one unit of blood. Increased oncotic and pulmonary capillary pressures (to a greater extent than crystalloid) resulting in pulmonary edema Diuretic therapy and supportive care. Typically preventable with decreasing transfusion rate
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