Approach
• Obtain type/screen for any pt suspected of needing transfusion
• See Chapter 18 for use of transfusions in trauma
Definition
• FFP: Contains ALL coagulation factors
• Cryoprecipitate: Precipitate of thawed FFP (contains fibrinogen, vWF, VIII, XIII)
• Irradiated: Destroys donor T cells, preventing GVHD
• CMV-negative: For pregnant pts, transplant candidates, AIDS pts
• Leuko-reduced: ↓ # WBCs (which mediate febrile transfusion rxn, carry CMV), thus ↓ fever, ↓ CMV
Packed Red Blood Cell Transfusion (Ann Intern Med 2012)
Approach
• Indications: (1) Acute &/or ongoing blood loss, &/or chronic anemia in pt who is symptomatic or HD unstable (↑ HR, ↓ BP); (2) Hct <30 in pts w/ active CAD; (3) consider in pts w/ Hct <21 or <24 in postsurgical pts
Treatment
• (Adult) ↑ Hgb by 1 g/dL or Hct by 3%, for each 1 U PRBCs
• (Neonates) ↑ Hgb by 3 g/dL for 10–15 mL/kg of PRBCs
Pearls
• Give O negative blood to females, O positive to males in emergencies
• Large PRBC transfusions → hemodilution → bleeding
• Consider giving FFP &/or PLTs if e/o ↑ bleeding
• These transfusions also cause ↑ K, ↓ Ca
• Carefully consider need for transfusion; ↑ mortality in critically ill pts receiving PRBC transfusion (JAMA 2002;288:1499; JAMA 2004;292:1555)
• Tx underlying cause (ie, pts w/ acute blood loss 2/2 coagulopathy need FFP also)
Platelet Transfusion
Approach
• Indications: (1) PLTs <50000 w/ active bleeding/invasive procedures; (2) PLTs <10000; (3) PLTs <100000 + ophth or neuro procedure/surgery; (4) unstable nonbleeding (high-risk onc) pts w/ PLTs <20000
Treatment
• ↑ PLTs by 5000–10000 for each 1 U PLTs
Fresh Frozen Plasma Transfusions (Transfusion 2010;50(6):1227)
Approach
• Indications: (1) Coagulopathy; (2) reversal of coumadin/heparin; (3) TTP//HUS; (4) DIC
Treatment
• ↑ coagulation factors by 2% for each 1 U FFP
Cryoprecipitate Transfusions
Approach
• Indications: (1) Fibrinogen deficiency <1 g/L; (2) factor XIII deficiency; (3) hemophilia or vWB dz
Treatment
• Dose: 1 U/5–10 kg body weight to maintain fibrinogen >1 g/L
REVERSAL (Stroke 2007;38:2001)
Approach
• Indications: Pt w/ ↑ PT/PTT or on PLT inhibitor (eg, ASA, clopidogrel) AND (1) significant bleeding (eg, intra-abdominal, intracranial); or (2) need for invasive procedure or surgery
Treatment
• ↑ PT/INR
• Vit K: IV form preferred in emergency (risk of anaphylaxis, takes ≥4 h)
• FFP: 15 mL/kg (faster than Vit K, requires large volumes)
• Other: Prothrombin complex concentrate & recombinant factor VIIa (less volume but ↑ risk thromboembolism)
• ↑ PTT:
• Protamine: Dose depends on timing of last heparin dose
• PLT inhibitors (eg, ASA, clopidogrel):
• PLTs: Start w/ 6 U
TRANSFUSION COMPLICATIONS
Approach
• Always obtain consent if possible before giving a transfusion
• For any rxn, stop the transfusion, check bag, label, & send remaining products back to blood bank
• If febrile, obtain CBC, smear, direct Coombs, UA, gram stain, blood culture from pt & bag of blood
Definitions and Treatment
• Acute febrile hemolytic: Preformed Abs → donor hemolysis (usually ABO incompatibility)
• P/w fever, ↓ BP, renal failure w/i 24 h
• IVF, diuretics (↑ UOP), pressors
• Delayed hemolytic: Same as acute, but usually minor antigens (NOT ABO)
• Presents up to 1 wk later, failure of Hgb to rise appropriately; no spec tx necessary
• Febrile nonhemolytic: 2/2 antigens on WBC or PLT & cytokines in stored blood; a Dx of exclusion
• Fever, chills, rigors w/i 6 h transfusion
• Acetaminophen, r/o hemolysis/infection
• Allergic: Preformed Abs (typically IgA in pts w/ IgA deficiency) attack donor proteins
• P/w urticaria, bronchospasm, upper airway edema, ↓ BP, anaphylaxis
• Tx: See 1f
• Transfusion-related ALI (TRALI): Donor Abs bind recipient WBCs → pool in pulmonary capillaries → mediate ↑ vascular permeability → pulmonary edema
• Tx: Oxygen, NIPPV, mechanical ventilation prn, see 2b
• Transfusion-associated circulatory overload (TACO): 2/2 hypervolemia, leading to pulmonary edema → oxygen, furosemide