CLS 306 (BB) - Lecture 9: Transfusion Therapy

• Anemia: Hb ≤ 7.0 g/dL (anemia)

• Thrombocytopenia: PLT < 50,000/µL pre-surgical; <10,000/µL therapeutic non-bleeding

• Coag deficiency/Acute hemorrhage: FFP → INR > 1.5; Cryo → Fibrinogen < 80-100 mg/dL

Transfusion triggers (3)

• Female: Hb 12-16 g/dL; HCT 36-48%

• Male: Hb 13-18 g/dL; HCT 39-54%

Hemoglobin and hematocrit reference intervals

• Bleeding time: 8 min

• Thrombin time: 17-23 s

• Prothrombin time: 11-13 s

• Partial thromboplastin time: 25-35 s

Reference intervals for bleeding time, thrombin time (TT), prothrombin time (PT), partial thromboplastin time (PTT)

• Irradiation of product

• Age of blood product

• Removal of WBCs

• Removal of plasma

• Rare donor

• Ag negative RBCs

• Special screen/Disease tested donor (CMV, sickle cell)

Special attributes to consider when appropriate for transfusion therapy (7)

• Routine/ASAP

• Emergency

• Refusal

Transfusion Statuses (3)

• Therapeutic (oncology, coagulation deficiency, neonate)

• Surgery (Surgical Blood Order Schedule, Type and Screen, Autologous)

Types of Routine/ASAP transfusion therapy (2)

• STAT (Latin: Statim)

• Massive Transfusion Protocol (MTP)

Types of emergency transfusion therapy (2)

Routine

(Transfusion status) not needed until hours alter or the next day; there is an anticipation that the patient needs or will need blood; not actively bleeding (therapeutic transfusion)

ASAP

(Transfusion status) Needed within the next few hours, e.g., patient going to surgery, patient has low Hb, etc.); there is an anticipation that the patient needs or will need blood; not actively bleeding (therapeutic transfusion)

• RBCs - correct anemia by O2 carrying capacity

• Plasma - maintain coag, blood volume, osmotic pressure

• Platelet - correct thrombocytopenia, maintain clotting

Treatment objective for routine transfusion therapy (3)

STAT (Statim)

(Transfusion status) usually patient has active/uncontrolled bleeding, e.g., surgery, trauma, overdose anticoag, stomach ulcer; treatment: stop the bleeding

• Adult: 1-2 minutes

• Babies/children: seconds

Time for arterial bleed to lead to death (2)

• % Blood volume: 8%

• Signs and symptoms: None

500 mL blood loss (% blood volume, sign/symptom)

• 16-20%

• Tachycardia (110-120), exercise tachypnea, postural hypotension

1000-1500 mL blood loss (%blood volume, sign/symptom)

• 20-30%

• Tachycardia at rest (120), hypotention (90 mm systolic), sweating, air hunger, anxiety, restlessness

1500-2000 mL blood loss (%blood volume, signs/symptoms)

• 40%

• Severe hypotension (60 mm systolic)

2000 mL blood loss (%blood volume, signs/symptoms)

• 50%

• Severe hypotention, pale, cold, ashen, drowsy, unconsious

> 2000 mL blood loss (%blood volume, signs/symptoms)

• LTOWB

• Plasmas: FFP, thawed plasma, liquid plasma

• Can use A plasma on unknown blood type pt

• Cold Stored Platelets

Emergency Primary Treatment Options (4)

• Maintain Oxygen Carrying Capacity

• Coag. scheme and clot mechanisms

• Balance osmotic pressure

• Maintain body temp / or close

Emergency Transfusion Objectives (4)

RBC:Plsm:PLT = 1:1:1

Massive Tranfusion Protocol maintains a ratio of…

• 6 RBCs, 6 FFP, 1 PLTPH

• 6 LTOWB, then 13 unit component packet

Different versions of MTPs (2)

• 10±2 pt (5L)

• 3 MTP (~12 WB)

• 10 WB units

The human body contains about (——) of blood, which is equivalent to (——) MTPs; (——) is considered a full body blood volume exchange

• Christian science

• Jehova’s Witnesses (court may intervene with minors)

Populations that are known to refuse blood transfusions (2)

Blood fractions

• Hb based substitute

• Interferon/Interleukins

• Albumin, globulins, clotting factors

• Wound healing factor

Acceptable transfusion specimens for Jehovah’s witnesses

1. Give erythropoietin

2. Give vitamin K (→ clot)

3. Use harmonic scalpel (→cauterize)

4. Intraoperative blood salvage system

5. Artificial hemoglobin

Techniques that can be used for bloodless medicine (5)

1. Perfluorocarbons (PFCs)

2. Hemoglobin-based products

Artificial blood types (2)

• Adverse effects + toxicity

• Inefficient oxygen delivery

• Retains PFC in liver

• Cannot mimic platelets + coag

Issues with Artificial Blood (4)

• Febrile Rxns

• HLA antibody alloimmunization

LR Blood can reduce… (2)

• Prevents GVHD

• Donors can be random or family members

• Decreases RBC integrity → K+ anf Hb leach into unit

Things to consider when using irradiated blood products (3)

• Uses cesium 137

• Minimum dose of 25 GY with nothing less than 15 Gy

• Irradiator indicator to confirm

• 28 day expiration

• QC = mapping radiation field field for correct dose

Irradiation Characteristics (requirements (3), expiration, QC)

• Infusion centers + nursing homes + long-term care

• Therapeutic transfusions to correct anemia

• Crossmatched blood transported to facility

• Transfusion RN intiates transfusion

Scheduled Out-of-Hospital Transfusion (4)

• 170 micron filter for every unit

• ≤ 4 hours total

• Only use normal saline

Blood / Blood Comp. Administration (3)

• RN / physician / anesthesiologist check pt wrist band and MRN

• Family members may verify

Non Conscious PT Identification (2)

• RN watches pt for first 15 minutes

• If adverse reaction within first 15 min, stop IMMEDIATELY

• Blood Bank begins Transfusion Reaction Investigation Process

• Blood Bank Med. Director review results

Transfusion Intervention (4)

• RN watch for 15 min

• If rxn → stop transfusion immediately

• BB perform transfusion reaction investigation process/test

• BB medical director evaluates and concludes pt treatment requirement

Transfusion reaction procedure (4)

Hospital Transfusion Committee (Safety/Quality Committee)

Peer review for the appropriateness of all blood/blood component transfusions

• Hb ≤ 7.0 g/dL

• PLT ≤ 10,000/µL

Transfusion Criteria + Triggers (2)