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Updated: Dec 28 2021

Transfusion

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https://upload.medbullets.com/topic/121678/images/trali.jpg
  • Snapshot
  • introduction
    • RBCs, platelets, and coagulation factors (fresh frozen plasma [FFP], cryoprecipitate, factor concentrate) can be transfused
    • Donated blood is separated into various components
      • whole blood is centrifuged into RBCs and platelet-rich plasma
      • platelet-rich plasma is further separated into platelets and plasma
      • FFP is plasma frozen within 8 hours (in the United States)
      • cryoprecipitate is FFP precipitate when thawed at low temperatures
      • platelets can be selectively removed while returning rest of blood to donor via apheresis
    • Blood products can be irradiated
      • prevents proliferation of donor T-cells in recipients
      • used for immunocompromised patients, first-degree relatives, HLA-matched products and intrauterine transfusions
    • Blood products can be leukodepleted via filtration to attain CMV-negativity
      • leukocytes contain CMV
      • used for potential transplant recipients, neonates, AIDS patients, seronegative pregnant women
  • Packed Red Blood Cells (pRBCs)
    • Goal of pRBC transfusion is to increase oxygen carrying capacity
    • 1 unit of pRBC should increase Hb by 1 g/dL or Hct by 3-4%
    • Indications
      • Hb < 7 g/dL
        • may increase based on presence of symptoms
        • goal Hb between 7 and 10 g/dL during active bleeding
      • higher Hb threshold (Hb < 10 g/dL) for patients with
        • uncontrolled bleeding
        • cardiovascular disease (coronary artery disease, diabetes)
          • growing evidence that restrictive threshold of < 7 g/dL is okay
        • pulmonary disease (COPD)
      • dilution of sickled Hb in sickle cell disease patients
      • clinicical suspicion of blood loss - CBC will not demonstrate anemia in acute trauma
    • "Type and Screen" (T&S) vs. "Type and Cross" (T&C)
      • T&S determines blood group, Rh status, presence of major/minor autoantibodies
      • T&C determines possible agglutination by mixing recipient and donor blood
    • pRBC options in order of preference
      • after T&S: crossmatched blood (not always available in emergencies)
      • after T&C: donor blood of same group / Rh as recipient
      • O negative blood for all females of reproductive age; O positive for all others
  • Platelets (PLTs)
    • Goal of PLT transfusion is to decrease risk of bleeding
    • One unit of apheresis derived PLTs should increase PLT by ~50,000/uL
    • Indications
      • PLT < 10,000/uL for bleeding prophylaxis
        • threshold increases to < 20,000/uL in presence of comorbidities including coagulopathy (e.g., sepsis, DIC), fever, or active bleeding
      • higher levels needed for therapeutic purposes
        • < 50,000/uL for procedures a/w major blood loss, major surgery, or acute hemorrhage
        • < 100,000/uL for procedures involving CNS or eye
      • patients with platelet dysfunction (or on antiplatelet agents) and active hemorrhage need PLT transfusion within normal range
    • Relative contraindications
      • thrombotic thrombocytopenic purpura
      • heparin-induced thrombocytopenia
      • post-transfusion purpura
      • HELLP syndrome a/w preeclampsia
  • Fresh Frozen Plasma (FFP)
    • Goal of FFP transfusion is to decrease risk of bleeding due to coagulation factor deficiency
    • Initial dosing at 10 mL/kg should raise factor levels by ~25%
      • PT and/or PTT are checked 15 to 30 minutes after transfusion to adjust dose as needed
    • Indications
      • PT/PTT > 1.5x midpoint of normal in patients with following conditions, particularly if surgery is indicated and cannot be postponed:
        • liver disease and active bleeding
        • use of vitamin K antagonists (e.g. warfarin)
        • sepsis, DIC, TTP/HUS
        • dilutionary coagulopathy from massive transfusion protocol
      • replacement of coagulatory factors in absence of specific concentrates
  • Cryoprecipitate
    • Goal of cryoprecipitate transfusion is to replace fibrinogen
    • Contains fibrinogen, vWF, fVIII, fXIII, and fibronectin
    • 1 unit of cryoprecipitate should increase fibrinogen level by 7-8 mg/dL
      • 1 unit of FFP has equivalent of 2 units of cryoprecipitate, but at cost of higher volume
    • Indications
      • fibrinogen < 80-100 mg/dL in massive hemorrhage
      • replacement of fVIII or vWF when fVIII concentrate or Humate (vWF/fVIII concentrate) is unavailable for fVIII deficiency and for von Willebrand disease
  • Complications
    • Most common adverse reactions to blood transfusion
      • febrile nonhemolytic transfusion reaction
        • pathogenesis
          • secondary to generated and accumulated cytokines in stored blood components
            • cytokines include
              • interleukin (IL)-1, -6, -8 and tumor necrosis factor (TNF)-α
            • leukocytes are the source of cytokines
        • clinical presentation
          • fever and chills 1-6 hours after transfusion
          • note this is a benign condition
        • management
          • stop the transfusion
          • antipyretics to control fever
          • evaluate for other causes of fever
        • prevention
          • pre-storage leukoreduction
      • transfusion related acute lung injury (TRALI)
        • presentation
          • shortness of breath roughly 30 minutes after transfusion
        • pathophysiology
          • antibodies in donor blood against recipient leukocytes
        • evaluation
          • pulmonary edema seen on chest radiograph
        • treatment
          • resolves spontaneously
      • transfusion-associated circulatory overload (TACO)
        • pathogenesis
          • rapid or large volume transfusions that overwhelm the cardiovascular symptom
        • presentation
          • hypertension, dyspnea, edema, and jugular venous distension
        • treatment
          • supportive therapy +/- diuretics
    • Most serious adverse reactions to blood transfusion
      • acute hemolytic reaction
        • e.g. due to ABO incompatibility
        • presents with fever/chills
        • classic triad of fever, back pain, and red/pink urine rarely seen
        • stop transfusion and obtain sample for direct Coombs test
      • dilutional pancytopenia
        • infusions of RBCs/fluids dilutes blood cells through plasma expansion and results in pancytopenia
      • bacterial contamination of blood
    • Other effects
      • minor blood group incompatibility
        • e.g. due to Kell, Duffy, Lewis, or Kidd
        • presents with jaudice and indirect bilirubinemia several days after transfusion
        • patient otherwise asymptomatic
      • citrate toxicity
        • citrate is an anticoagulant used in blood products
          • chelates calcium and magnesium
          • normally rapidly metabolized by liver
        • may cause hypocalcemia and hypomagnesemia leading to paresthesias, cramping, hyperreflexia, etc
          • treat with IV calcium gluconate/chloride
          • may also need magnesium
          • of note, serum calcium may be normal as it is the ionized calcium that is low
      • hyperkalemia
        • RBCs leak K+ during storage
      • coagulopathy
        • may require transfusion of FFP and platelets
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