Updated: 12/28/2021

Transfusion

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  • 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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(M2.HE.17.4684) A 55-year-old man with known coronary artery disease presents to the ED with epigastric pain, worsening fatigue, and melena. He takes aspirin and rosuvastatin, but took ibuprofen over the past two weeks for lower back pain. He denies nausea, vomiting, hematemesis, chest pain, fever, and weight loss. Sitting blood pressure is 100/70 mmHg and pulse is 90/min, but standing blood pressure is 85/60 mmHg and pulse is 110/min. Airway is patent. His hands feel cold and clammy. Abdominal exam confirms epigastric pain, but no rebound tenderness or hyperpercussion. Despite 2 liters of lactated Ringer's, the blood pressure and pulse have not changed. What hemoglobin (Hb) threshold should be considered if packed red blood cell (pRBC) transfusion is ordered in this patient?

QID: 107352
1

threshold does not matter

0%

(0/3)

2

< 10

33%

(1/3)

3

< 9

0%

(0/3)

4

< 8

0%

(0/3)

5

< 7

67%

(2/3)

M 7 D

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(M2.HE.17.4828) A 29-year-old man presents to the emergency department after experiencing a motor vehicle accident. The patient was the front seat passenger in a head on collision. The patient is responsive only to painful stimuli. His temperature is 99.5°F (37.5°C), blood pressure is 90/60 mmHg, pulse is 150/min, respirations are 17/min, and oxygen saturation is 95% on room air. The patient is started on IV fluids and is given blood products. A FAST exam reveals no signs of intra-abdominal bleeding. A chest radiograph is ordered as seen in Figure A. A pelvic binder is placed and fluid and blood resuscitation is continued. Fifteen minutes later his temperature is 99.5°F (37.5°C), blood pressure is 110/70 mmHg, pulse is 100/min, respirations are 13/min, and oxygen saturation is 97% on room air. The patient is now able to respond to questions. The patient's lab values are ordered and are as below:

Serum:
Na+: 137 mEq/L
Cl-: 102 mEq/L
K+: 4.2 mEq/L
HCO3-: 24 mEq/L
BUN: 20 mg/dL
Glucose: 110 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 9.6 mg/dL
AST: 12 U/L
ALT: 14 U/L

Hemoglobin: 11 g/dL
Hematocrit: 30%
Leukocyte count: 6,500 cells/mm^3 with normal differential
Platelet count: 255,000/mm^3

The patient suddenly becomes short of breath. A chest radiograph is ordered as seen in Figure B. A FAST exam is repeated and is within normal limits. Repeat lab values are ordered as below:

Hemoglobin: 13 g/dL
Hematocrit: 36%
Leukocyte count: 6,000 cells/mm^3 with normal differential
Platelet count: 250,000/mm^3

Which of the following best describes the most likely diagnosis?

QID: 109458
FIGURES:
1

Trauma to lung tissue and capillaries

33%

(15/46)

2

Decreased left ventricular contractility

4%

(2/46)

3

Pericardial fluid accumulation

7%

(3/46)

4

Antibody binding of red blood cell antigens

26%

(12/46)

5

Antibody binding of leukocytes

26%

(12/46)

M 5 C

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(M2.HE.17.4869) A 23-year-old man is brought to the emergency department by ambulance. The patient was found unconscious in his bedroom after a suicide attempt. The patient had cut his wrists using a kitchen knife. The patient is unresponsive and pale. His temperature is 96°F (35.6°C), blood pressure is 70/35 mmHg, pulse is 190/min, respirations are 19/min, and oxygen saturation is 92% on room air. Pressure is applied to his bilateral wrist lacerations. His Glasgow Coma Scale (GCS) is 7. A full trauma assessment is performed and reveals no other injuries. IV fluids are started as well as a rapid transfusion sequence. Norepinephrine is administered. Repeat vitals demonstrate that his blood pressure is 100/65 mmHg and pulse is 100/min. The patient is responsive and seems mildly confused. Resuscitation is continued and the patient's GCS improves to 15. Thirty minutes later, the patient's GCS is 11. His temperature is 103°F (39.4°C), blood pressure is 90/60 mmHg, pulse is 122/min, respirations are 22/min, and oxygen saturation is 99% on room air. The patient complains of flank pain. Laboratory values are ordered and demonstrate the following:

Hemoglobin: 9 g/dL
Hematocrit: 27%
Leukocyte count: 10,500 cells/mm^3 with normal differential
Haptoglobin: 11 mg/dL
Platelet count: 198,000/mm^3

Serum:
Na+: 139 mEq/L
Cl-: 101 mEq/L
K+: 4.4 mEq/L
HCO3-: 23 mEq/L
BUN: 27 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.5 mg/dL
Ca2+: 10.0 mg/dL
Bilirubin: 3.2 mg/dL
AST: 22 U/L
ALT: 15 U/L

Which of the following describes the most likely diagnosis?

QID: 109546
1

Non-cardiogenic acute lung injury

0%

(0/52)

2

Decreased IgA levels

10%

(5/52)

3

Major blood group incompatibility

69%

(36/52)

4

Minor blood group incompatibility

6%

(3/52)

5

Recipient antibody reaction against foreign leukocytes

15%

(8/52)

M 6 D

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(M2.HE.15.29) A general surgery intern is paged to the bedside of a 59-year-old male who underwent a successful sigmoidectomy for treatment of recurrent diverticulitis. The patient's nurse just recorded a temperature of 38.7 C, and relates that the patient is complaining of chills. The surgery was completed 8 hours ago and was complicated by extensive bleeding, with an estimated blood loss of 1,700 mL. Post-operative anemia was diagnosed after a hemoglobin of 5.9 g/dL was found; 2 units of packed red blood cells were ordered, and the transfusion was initiated 90 minutes ago. The patient's vital signs are as follows: T 38.7 C, HR 88, BP 138/77, RR 18, SpO2 98%. Physical examination does not show any abnormalities. After immediately stopping the transfusion, which of the following is the best management of this patient's condition?

QID: 104914
1

Hydrate with 1 L bolus of normal saline followed by maintenance fluids at 125 cc/hr

19%

(5/26)

2

Monitor patient and administer acetaminophen

42%

(11/26)

3

Prescribe diphenhydramine

23%

(6/26)

4

Start supplemental oxygen by nasal cannula

8%

(2/26)

5

Initiate broad spectrum antibiotics

4%

(1/26)

M 7 E

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