INDICATIONS FOR EMERGENT TRANSFUSIONS

Manjushree Matadial DO

Saint Joseph Hospital and Medical Center, April 27,2009

Red Blood Cells

• Indications• Hemoglobin less than 7.0 g/dl in the absence of

coronary disease or ischemia• Hemoglobin less than 7.0 g/dl during surgery

associated with major blood loss or impaired oxygen transport

• Hemoglobin less than 8.0 g/dl in patients with chronic transfusion regimen or during marrow suppressive therapy

Red Blood Cells

• Hemoglobin less than 10.0 g/dl in select populations ie. Neonates, coronary disease or cerebrovascular disease

• Age less than 40 with Hct = 24

• Age 40 – 60 with Hct = 27

• Age 60 – 70 with Hct = 30

Pathophysiology

• Consequences of Anemia• Increased cardiac output when Hgb < 7.0 g/dl

in acute situations

• Not the case in chronic anemia has been compensated

• Increased oxygen extraction systematically at the capillary level

Pathophysiology

• Decreased hemoglobin decreases the oxygen delivery and the oxygen extraction ratio increases which maintains a constant oxygen uptake into the tissues

• A hemoglobin below 3.0 g/dl increases the lactic acidosis

Blood Products

• Type and Screen• Determines the ABO and Rh status and the

presence of antibodies

• Takes anywhere from 5 mins – 30 mins

• Risk of adverse reaction is 1: 1000

• Type O red cells are mixed with the patient’s serum

Blood Products

• Type and Cross• Determines ABO and Rh status as wells as

adverse reactions to low incidence antigens—risk of reaction is 1 : 10,000

• Takes 60 mins• Type O red cells are mixed with the patient’s

serum and the donor red cells are then mixed with the patient’s serum to determine incompatibility

Transfusions

• Type specific crossmatch

• Type specific uncrossmatch

• Type O Rh(-) used emergently

Transfusions

• Donor• O

• A

• B

• AB

• Recipient

• O, A, B, AB

• A, AB

• B, AB

• AB

Blood Products

• Whole blood• Contains 510 ml

• PRBC’s• Prepared by centrifuging whole blood and removing

250 ml of plasma supernatant

• Each unit of PRBC contains 200 ml of erythrocytes and 50 – 100 ml of plasma and CPD solution

• The concentration of hemoglobin is 23-27 g/dl

• 10 ml/kg will increase HCT by 10%

Blood Products

• Leukocyte-Poor Red Cells• Used in transfusing patients that are febrile

• Patients with a history of non-hemolytic transfusion reactions (caused by antibodies to leukocytes in donor blood)

• Transplant recipients or candidates

• Patients requiring CMV (-) transfusions

Blood Products

• Washed Red Cells• These are packed cells washed with isotonic

saline to remove leukocytes and residual plasma

• The removal of plasma prevents allergic reactions caused by prior sensitization to plasma proteins in donor blood

• Is to be used in patients with hypersensitivity reactions

Blood Products

• CMV (-) Blood• CMV infects many tissues ie. Blood, kidney,

lung , liver and brain

• Following patients are susceptible to transfusion-transmitted CMV primary infections and disease therfore they should receive CMV (-) blood

Blood Products

• CMV (-) Blood

• Low birth weight neonates < 1200 grams

• CMV seronegative pregnant women

• CMV seronegative recipients of , or candidates for bone marrow or peripheral blood cell transplants

• CMV seronegative HIV (+) patients

Blood Products

• CMV seronegative recipients of, or candidates for solid organ transplants

• CMV PCR screening tool

• A large portion of CMV seronegative donors are CMV PCR positive

Blood Products

• Irradiated • Prevents graft versus host disease in the

immune compromised patients

• Gamma irradiation eliminates the ability of lymphocytes to proliferate and preventing them from mounting and immune response to the host tissue

Blood Products

• Bone marrow and stem cell transplant recipients

• Congenital T cell immunodeficiency syndromes: SCIDS, Wiskott-Aldrich, DiGeorge

• Intrauterine transfusion

• Neonatal exchannge transfusion

Blood Products

• Irradiated Cells• Premature neonates < 1200 grams

• Transfusions from blood relatives

• Patients with hematologic malignancies: ie.Hodgkin’s, Non-Hodgkin’s and acute leukemia and neuroblastoma

Platelet Therapy

• Indications for transfusions• Platelets < 10, 000 with no risk factor

• Active bleeding

• Bone marrow failure

• Platelets < 20, 000 with the following risk factors: febrile, bleeding, ICH, antibiotic therapy

Platelet Therapy

• Indications• Surgery with a high risk of bleeding or an

invasive procedure • Endoscopy with biopsy

• Lumbar puncture

• Surgical intervention

Platelet Therapy

• Indications• Platelet function defects ie CABG (maintain

the platelets > 50, 000)

• Bleeding/ massive transfusion (maintain the platelets > 100, 000 )

• Ie. DIC or CNS trauma

Platelet Transfusion

• Prepared by centrifuging fresh whole blood and suspending the supernatant pellet in a small volume

• 1 unit of whole blood has 50 – 100 billion platelets in 50 ml of plasma

• Stored up to 7 days• Effectiveness declines after 3 days• Transfused in (6-10 ) units at a time

Cyropprecipitate Useage

• Replaced in the following manner (5-10 ml/kg)• Replaces VIII (Hemophilia A), factor XIII,

fibrinogen, fibronectin, and vWF

• Used also in DIC and Trauma

Fresh Frozen Plasma

• Indications• Used in life threatening bleeding in patients on

coumadin

• Liver disease if bleeding with abnormal coagulation profile

• Acute DIC

• Following massive transfusions or CABG