Transfusion Medicine¶

R. Dixon Dorand

For emergent transfusions, call the blood bank (see directory)
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
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 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 pt on treatment

Platelets Transfusion¶

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

Fresh Frozen Plasma (FFP) and 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 (FFP will not fix an INR < 1.7)

Indications for transfusion - 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 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)

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.
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 pt 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 occurring within 6 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.
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