Comprehensive Transfusion Therapy

Transfusion Therapy

When to Transfuse

• Know what is Normal: Establish baseline hematology values.
• Lab Results: Confirm the need for transfusion with lab tests.
• Blood Order: Verify the presence of a blood order/request.
• Special Needs: Determine if there are any unique requirements.
• Patient Symptomatic: Usually determined by clinical staff.
• Benefits vs Risks: Clinician's evaluation.

Normal Hematology Values

• Values may vary depending on the normal population surrounding the individual lab
• Hgb
  • Female: 12 - 16 \frac{g}{dL}
  • Male: 13 - 18 \frac{g}{dL}
• Hct
  • Female: 36\% - 48\%
  • Male: 39\% - 54\%
• Platelet Count: 150,000 - 450,000 / µL

Normal Coagulation Values

• Bleeding Time: Approximately 8 minutes.
• Thrombin Time (TT): 17 - 23 seconds.
• Prothrombin Time (PT): 11 - 13 seconds.
• Partial Thromboplastin Time (PTT): 25 - 35 seconds.
• Coag Factors: Normal limits.
• Other Coag Tests: Fibrin Split Products, Antithrombin III, etc.

Transfusion Triggers

• Anemia: Low Hgb / Hct (Low RBCs)
  • Hgb: ≤ 7.0 \frac{g}{dL} / 21.0\%, as opposed to 10 \frac{g}{dL}
• Thrombocytopenia: Low Platelet Count
  • < 50,000/µL for pre-surgical patient
  • < 10,000/µL for therapeutic non-bleeding
• Coagulopathy / Coagulation Deficiencies or Acute Hemorrhaging; could include Platelet therapy, too
  • FFP - INR* > 1.5 (*International Normalized Ratio (Prothrombin Time Test calculation))
  • Cryo - Fibrinogen < 80-100 mg/dL

Special Attributes to Consider

• Irradiation of Product
• Age of blood product
• Removal of WBCs
• Removal of plasma
• Rare donor
• Ag negative RBCs
• Special screen / Disease tested donor, e.g., CMV, Sickle Cell

Patient Common Signs & Symptoms

• Anemia
  • Hyperventilation
  • Dyspnea
  • Tachycardia
  • Tiredness
  • Pale skin color
• Thrombocytopenia
  • Oozing blood in orifices, e.g., nose, ears, mouth
  • Petechiae or ecchymosis
• Coagulopathy / Coagulation Deficiencies or Acute Hemorrhaging
  • May be similar to thrombocytopenia

Patient Benefits vs Risks

• Benefits
  • Correction of patient signs & symptoms
  • Normal balance of elements to maintain standard of life
• Risks
  • Transfusion-associated diseases, e.g., hepatitis, AIDS, etc.
  • Transfusion adverse reactions
  • Morbidity & Mortality evaluation

Transfusion Therapy - Definitions

• Transfusion Therapy is the transfusion of blood & other blood components

Transfusion Statuses

1. Routine / ASAP (As Soon As Possible)
   • Therapeutic
     • Oncology
     • Coagulation Deficiencies (non-bleeding)
     • Neonate
   • Surgery
     • SBOS - Surgical Blood Order Schedule
     • TS / T&S - Type & Screen
     • Autologous
2. Emergency
   • STAT (L: Statim)
   • Massive Transfusion Protocol (MTP)
3. Refusal

Transfusion Therapy - Routine Details

• Category: Routine or ASAP (As Soon As Possible)
• Definition:
  • Routine - not needed until hours later or the next day)
  • ASAP - needed within the next few hours, e.g., patient going to surgery, patient has low Hgb, etc)
• Common Scenario: There is an anticipation that the patient needs or will need blood; not actively bleeding; aka, therapeutic transfusion
• Treatment: Usually give blood when ready (i.e., when all testing is complete, everything is compatible, etc.)
• Treatment Objective:
  • RBCs - corrects anemia via maintaining oxygen-carrying capacity to all the vital organs, e.g., heart, brain, liver, etc.
  • Plasma - Maintains coagulation scheme; corrects coagulopathy, blood volume, and osmotic pressure
  • Platelets - corrects thrombocytopenia & maintains clotting mechanism

Transfusion Therapy - Emergency

• Category: STAT (L: Statim) - Immediately / without delay
• Common Scenario: Usually patient has active / uncontrolled bleeding, e.g., surgery, trauma, overdose of anticoag prescription med, stomach ulcerations, etc.
• Arterial bleed (to death) / exsanguination:
  • Adult - as little as 1-2 minutes
  • Babies / children - seconds
• Immediate Treatment: STOP the bleeding

Blood Loss

Transfusion Therapy - Emergency - Old vs Current Practices

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