Transfusion Medicine

Transfusion Medicine – R. Dixon Dorand

VUMC: search “Blood” and select General Blood Administration – follow prompts

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.
  • Nurses will NOT check post-transfusion levels unless you specify to do so; this is only needed in specific scenarios (e.g. “platelet refractoriness”)
  • 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

Remember:

  • You must send Type and Screen & consent the patient
  • To consent at VUMC, use Medex. To consent at the VA, use iMedConsent 
  • On Brittingham or BMT, all blood products must be irradiated. This will happen at VUMC if you select the right indication for blood; at the VA you must still specify this.

 

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

 

Indications for Platelets

  • <11 k/µL – all patients, reduce risk of spontaneous hemorrhage (use on BMT, Brittingham)
  • <20 k/µL – patients receiving induction chemotherapy with a fever
  • <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 (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 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. If DIC present, consider heparin. 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.