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Transfusion Medicine

R. Dixon Dorand

Overview

For emergent transfusions:

Call the blood bank (VUMC: 615-322-2233; VA: 67025, supervisor at 67029).

For non-emergent transfusions:

VUMC:

  • 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 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
  • Patients 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 a 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 Transfusion

  • 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 <9-10 g/dL – Acute coronary syndrome
  • Hgb <8 g/dL or Hct <25 – Bone marrow failure or receiving antineoplastic therapy
  • Also sometimes used in pts with pre-existing CAD
  • Hgb <7 g/dL or Hct <21 – ICU, GI Bleeding, Oncology patient on treatment

Platelet Transfusion

Indications:

  • <11 k/µL – all patients, 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

Fresh Frozen Plasma (FFP) & Cryoprecipitate (Cryo)

Cryoprecipitate

  • FFP enriched for von Willebrand factor, factor VIII, factor XIII, and fibrinogen

FFP

  • 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 (the INR of FFP is ~1.7, so FFP will not fix an INR < 1.7)

Indications:

  • Bleeding:
    • FFP If INR >1.7
    • 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
    • For elevated INR, consider FFP transfusion. Thresholds for doing this vary by attending
  • 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 patient 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)

Transfusion Premedication & 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.
Febrile Non-Hemolytic Rise of temp >1°C, chills, rigors, anxiety. 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; Recheck for patient ID or clinical error.

This is an emergency.

 Treat shock w/vasopressors; maintain airway; administer fluids and maintain brisk diuresis; monitor for AKI.. Administer blood products as needed after etiology is clear.
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 usually
within 1-2 hours
of transfusion.
Non-cardiogenic
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.
Last update: 2022-06-25 02:05:01