24 Transfusion Medicine

Blood Transfusion

Is the infusion of whole blood or of a blood

component
Indications for Blood Transfusion

O2
carrying
capacity

Leukocyte
function

Improve

Blood
volume

Physiologic Guidelines

Acute anemia
o
The lower limit of human tolerance to
hypovolemia is not established but at Hgb
of 7mg/dl or higher, oxygen delivery is
believed to be adequate
o
In healthy individuals, tissue oxygenation is
maintained and anemia is tolerated at
hematocrit as low as 18-25 CV%
o
The heart does not produce lactic acid until
Hct reaches 15-20% CV% and heart failure
does not usually occur until Hct reaches 10
CV%.

Chronic anemia
o
Cardiac output does not change until Hgb
falls below 7gm/dl
Significant symptoms do not appear until
o
there is a 50% reduction in red cell mass.
Practice Guidelines for Component Therapy,
American Society of Anesthesiology, 1996

Hemostasis

Blood Component Therapy

Patients are best treated by the administration of a

specific fraction of blood that they lack
Values of Blood Component Therapy

Patients who are treated with the specific

components that they lack will avoid risk of
sensitization to other blood components
Proper use of component therapy can result in

potential treatment of many patients with blood

obtained from one donor
Use of components can result in effective transfusion

therapy with reduced risk of volume overload

Packed Red Blood Cell

Separated from whole blood by centrifugation

1 unit PRBC raises Hgb by 1g/dl and Hct by 3% in an

average-sized adult

Restores or maintains oxygen-carrying capacity with

the least volume
How does one arrive at the decision to transfuse?
Information necessary to assess need for red cell transfusion
Hemoglobin, hematocrit
Evaluation of patients symptoms
Physiologic assessment of patients functional
capacity/co-existing or underlying medical conditions
Cause of the anemia
Factors that influence production of symptoms
Rapidity of onset of anemia
Severity of anemia
Age
Presence or absence of cardiac or pulmonary disease
Presence of co-morbid disorders liver, endocrine,
kidney

General Management Principles for Elective Transfusion in

Anemic Patients
Determine nature of anemia/cause

Determine which symptoms will be alleviated by

transfusion; consider alternative therapeutic
interventions when available

Avoid an empiric automatic transfusion threshold

(transfusion trigger)
Anticipate the need for autologous blood transfusion

Discuss all risks and benefits with patients

Administer transfusion on a unit by unit basis

Guidelines for (packed) RBC transfusion
1. Transfusion is indicated in symptomatic anemia
regardless of Hgb level:
Syncope
Tachycardia
Dyspnea
Angina
Postural hypotension
TIA
2. Transfusion is rarely indicated for Hgb >10g/dl and
almost always indicated for Hgb <6g/dl, especially if
acute in onset
3. For values between 6-10g/dl, the decision is based on
the presence of risk for complications of inadequate
oxygenation
Patient Groups at Risk from Intravascular Volume Depletion
Patients at risk for myocardial ischemia

Coronary artery disease

Valvular heart disease (for example,

hemodynamically-significant aortic stenosis

Congestive heart failure

Patients at risk for cerebral ischemia

History of transient ischemic attacks

Previous thrombotic stroke

Annals of Internal Medicine, 1992

4.

In situations of acute bleeding, suggested transfusion

threshold is 30-40% blood loss for otherwise healthy
patients as long as volume is maintained.
Practice Guidelines for Component Therapy,
American Society of Anesthesiology, 1996

rainwater@mymelody.com || 1st semester, AY 2011-2012

Whole Blood

Volume of 450-500ml including preservative,

Hct 35-45 CV%
Freshness cannot be precisely defined

o
Platelets and granulocytes no longer viable
within 24 hours
o
Factor V >80% level for at least 5 days
o
Factor VIII >80% level for 1-2 days
o
Factor XI falls rapidly to 20% within 1 wee
Factor II, VII, IX, X, fibrinogen are wello
maintained
*
For the above contents, pRBC, FFP, and
platelet concentration are superior to
fresh whole blood
Indications for Whole Blood

Actively bleeding patient who has lost over 25-30% of

blood volume

Massively-transfused patients meeting any of the

following criteria
o
Actively bleeding
Blood loss exceeding 1 blood volume in a
o
period of 2-3 hours
o
Prior transfusion with at least 5 u pRBC or
20ml/kg of pRBC in pediatric patients
o
Reasonable anticipation of transfusion of at
least 10 u RBC components or 40 ml/kg in
pediatric patients

Exchange transfusion
Autologous transfusion

Platelet Concentrate

Prepared in 2 ways:
Random donor platelet concentrate:
1.
Separated by centrifugation from whole
blood within 6 hours from extraction
2.
Platelet pheresis:
Blood drawn from donor passes through an
apheresis machine, which by centrifugation
separated the platelets and returns the
remainder of the blood to the donor

1 unit platelet pheresis =

6-8 bags of random donor platelet
Indications for Platelet Pheresis
When HLA-matched or crossmatched compatible

donors are needed for refractory patients

Reduce donor exposures

Limited number of donors

Platelet Lifespan and Kinetics
Circulates with a lifespan of 10.5 days

Residual mean lifespan of donated platelets is

approximately 4-5 days

Has a shelf-life of 3-5 days, stored at 20-24C under

constant agitation
Dose of Platelets: 1 unit/10gBW

Dose may increase to 1.5-2 bags/10kgBW in the

following:
o Splenomegaly
o Infection
o Fever
o DIC

Expected response: 5-10 x 10 /L/m BSA

Timing of repeat platelet count: 15 mins to 1 hour post-BT.
Excellent predictor of effective platelet transfusion.
Guidelines for Platelet Transfusion
1. A threshold of 10,000/ul is effective in preventing
morbidity and mortality from bleeding in stable
oncology patients undergoing chemotherapy
2. Platelet count <10,000-20,000/uL in the presence of
marrow failure and absence of clinical bleeding
3. A platelet count >50,000/ul is desirable prior to
invasive procedure and in the immediate postprocedure period
4. Platelet counts closer to 100,000/ul may be prudent
for patients at high risk of intracranial hemorrhage
such as those with leukostasis or when undergoing
neurosurgical or ocular procedures
Bethesda Handbook of Clinical Hematology, 2005

5.

6.

7.

8.

9.

Prophylactic platelet transfusion is ineffective and

rarely indicated when thrombocytopenia is due to
increased platelet destruction
Prophylactic platelet transfusion is rarely indicated
surgical patients with thrombocytopenia due to
decreased production when platelet count is more
than 100,000 and is usually indicated when the count
is below 50,000. For intermediate counts, decision to
transfuse is based on the risk of bleeding.
Surgical and obstetric patients with microvascular
bleeding usually require transfusion if platelet count
is <50,000 and rarely require it if >100,000.
Vaginal deliveries or operative procedures ordinarily
associated with insignificant blood loss may be
undertaken in patients with platelet count <50,000.
Platelet transfusion may be indicated despite an
apparently adequate platelet count if there is known
dysfunction or microvascular bleeding.
Practice Guidelines for Component Therapy,
American Society of Anesthesiology, 1996

Fresh Frozen Plasma

Separated from whole blood within 8 hours or

collected by apheresis

Rapidly frozen by -18C, shelf-life of 1 year

After thawing, must be transfused within 24 hours

(AABB standards) and within 6 hours (FDA)
Guidelines for FFP Transfusion
1. Urgent reversal of warfarin therapy
(dose: 5-8 ml/kg BW)
2. Correction of known deficiencies for which specific
concentrated are unavailable
3. For correction of microvascular bleeding in the
presence of elevated PT or PTT (1.5 times normal)
4. For correction of microvascular bleeding secondary to
coagulation factor deficiency in patients transfused
with more than 1 blood volume and when PT and PTT
cannot be obtained in a timely fashion
5. FFP should be given in doses calculated to reach a
minimum of 30% of plasma factor concentration
(usually achieved with administration of 10-15 ml/kg)
6. FFP is contraindicated for augmentation of plasma
volume or albumin concentration
Practice Guidelines for Component Therapy,
American Society of Anesthesiology, 1996

rainwater@mymelody.com || 1st semester, AY 2011-2012

Cryoprecipitate

Portion of plasma that is rich in certain clotting factors

80-120 u F8
o
40-70% vWF
o
o
20-30% F9
150-250 mgs fibrinogen
o
o
55 mgs fibronectin

Removed from plasma by freezing and then slowly

thawing the plasma
Once thawed, cryoprecipitate cannot be refrozen and

may be kept at temperatures of 20C-24C for no

longer than 6 hours
Indications for Cryoprecipitate

Treatment of bleeding patients with

hypofibrinogenemia

Treatment of bleeding in von Willebrands disease or

Hemophilia A

Treatment of refractory bleeding in uremia

Preparation of surgical adhesive/fibrin glue

*
Therapeutic dose: 1u/6kg BW or 8-10 units in an adult
Granulocyte Transfusions

Collected through apheresis

Indications are not well-defined

Consider in patients with:

o
Absolute neutrophil count <500
Fever
o
Identified responsible organism
o
No decrease in fever after 48 hours of
o
antibiotic therapy
*
Should not be initiated for at least 96 hours after
onset of clinical signs and symptoms of infection
Consider giving for at least 7 days

WBC count monitored daily

Problems:
o
Highly antigenic
Cost
o

Use of newer-generation antibiotics and colonystimulating factors have reduced its use
Washed pRBC

Washing with sterile NSS to remove >98% of plasma

proteins, electrolytes (K), and Abs

Removes most plasma, platelets and leucocytes

Leucocyte-Reduced Blood Products

Indications:
For the prevention of the following:
1. Febrile, non-hemolytic transfusion reactions
2. HLA alloimmunization
3. Platelet refractoriness
4. CMV infection
Preparations
1. Washing
2. Centrifuging
3. Freezing
4. Leucocyte filters:

Cumbersome
Collection filters
Bedside filters

Leukocyte reduction filters

Reduces number of leukocytes in platelets and red

cell components

Reduces risk of HLA alloimmunization and

transmission of CMV infection

Reduces incidence of febrile, non-hemolytic

transfusion reaction
Limitation: Cost

More complex administration

Irradiation (RBC, platelets, WBCs)

Gamma irradiation to inactivate viable lymphocyte

proliferation within the component
For prevention of transfusion-associated GVHD

NOT indicated for prevention of febrile non

hemolytic transfusion reaction
Reasons for strict indications for BT
Limited supply

Finite shelf life

Risk of adverse transfusion reactions

The decision to transfuse, like any other form of

therapy, should be based on risks, benefits, and
alternatives.
Guides to therapy are provided but cant substitute
for clinical judgment.

Indications for Washed pRBC

For prevention of allergic reactions (patients with

recurrent allergic reactions not responsive to
pre-medications)

IgA-deficient patients when IgA-deficient component

is not available

Recipients at risk for hyperkalemia; newborns and

intrauterine transfusions

For PNH
Bethesda Handbook of Clinical Hematology, 2005

rainwater@mymelody.com || 1st semester, AY 2011-2012