Principles of transfusion

Question 1

most common organ transplantation in the US is

Answer 1

blood transfusion

Question 2

Blood Bank

Answer 2

unit of clinical laboratory that stores, tests for compatibility and releases blood products

Question 3

Transfusion Medicine

Answer 3

Study and practice of effective and safe use of blood products

Question 4

Serologic

Answer 4

ABO (donor and recipient)
Rh (D) (donor and recipient)

Recipient antibody screen (for unexpected            alloantibodies - react with antigens from the same species)

Question 5

Preservatives and Storage Life: Summary

Answer 5

CPD - Citrate Phosphate Dextrose 21 days

CP2D - Citrate phosphate double dextrose 21 days

CPDA1- Citrate phosphate dextrose adenine 35 days

AS-1 Adenine Solution #1 42 days

AS-3 Adenine Solution #3 42 days

Question 6

Anticoagulant =

Answer 6

Citrate

Question 7

Preservatives =

Answer 7

Phosphate, Dextrose, Adenine

Question 8

Physical Characteristics

“Unit of Packed Cells (RBCs)”

Answer 8

Total volume:
200-250 mL CP2D or CPDA-1
275-325 mL AS-1 + CPD

Plasma volume:
30-50 mL CP2D & CPDA = 15-25% normal plasma volume
70-90 mL AS-1 = 40-50% normal plasma volume

Hematocrit (depends on blood donor hematocrit):
65-80% CPD2D or CPDA-1
50-65% AS-1

Total hemoglobin:
42.5-80 grams

Total Iron:
~147-278 mg; vast majority in hemoglobin

Question 9

Monitoring During a Transfusion

Answer 9

Before and During Transfusion: Visual and Clinical
The initial few minutes of transfusion are the most important observation period since hemolysis of as little as 10 mL red cells can give rise to clinical evidence of a reaction

Patients should be observed for 24 hours after completion of last transfusion (never happens in outpatient setting).

Question 10

what are we looking for when monitoring a transfusion?

Answer 10

Key symptoms to monitor include:
Pain at the infusion site
Sudden onset of lower back pain
Change in urine color (dark or red) urine
Dyspnea or shortness of breath
Sudden increase in patient anxiety
These suggest there may be acute hemolytic transfusion reaction

Question 11

Transfusion-Related Acute Lung Injury (TRALI)

Answer 11

Acutely increased permeability of the pulmonary microcirculation allows the massive
leakage of fluids and protein into the alveolar spaces and interstitium

Associated with the presence of leukocyte antibodies in the donor or recipient

Signs and symptoms
• Acute respiratory distress within 6 hours of administration
• Hypoxemia (oxygen saturation under 90% on room air)
• Bilateral pulmonary infiltrates on frontal chest x-ray

Question 12

Indications for Red Cell Transfusions General Guidelines

Answer 12

Treatment of a symptomatic O2-carrying deficient when patient’s condition and symptoms require acute replacement

Acute severe hypovolemia following massive hemorrhage with shock

Exchange transfusion (hemolytic disease of the newborn) or red cell exchange (sickle cell disease) requiring replacement RBCs

Question 13

when do we give blood?

Answer 13

7 grams or less of hemoglobin

Question 14

Goals RBC Transfusion

Answer 14

Severe hemorrhage/shock, replace RBCs sufficient to maintain vascular volume and provide sufficient oxygen-carrying capacity for oxygenation

Symptomatic anemia and surgical replacement

Question 15

Each unit in an adult theoretically raises hemoglobin how much?

Answer 15

1 g/dL or hematocrit 3%

Question 16

how much blood to give?

Answer 16

Old Rule

As a general rule, two or more units of RBCs are always ordered for any given patient”.
Replacement with 1 unit indicates
Clinical situation that doesn’t require transfusion
Can be handled by bone marrow production of rbcs

No longer true!

Question 17

Contraindications for RBC Transfusion

Answer 17

First of All Do No Harm
There should be a definite purpose for the transfusion

The theoretical benefits should outweigh the potential harm, both short-term and long-term.

Inappropriate Indications and Contraindications:
• Chronic, steady-state (asymptomatic anemia)
• Uncomplicated pain episodes
• Infection
• Minor surgery that does not require general anesthesia
• Aseptic necrosis of the hip or shoulder (unless indicated for surgery)
• Uncomplicated pregnancy

Question 18

Incompatible ABO blood group

Answer 18

O patients should not receive A, B or AB red cells

A patients should not receive B or AB red cells

B patients should not receive A or AB red cells

AB patients can receive any red cell product

Question 19

blood costs

Answer 19

Cost $225
Costs have doubled
Cost to transfuse have quadrupled

Question 20

Safety

Answer 20

Mistransfusion is the single most serious
Greater than HIV or HB or HC

Why?
Infection
Febrile and allergic reactions
Hemolytic
“Storage defects”

Question 21

Temporary immunodeficiency

Answer 21

Transfusion related immmunomodulation

Cellular
NK and helper/suppressor
Humoral

Question 22

Outcomes

Answer 22

7-10X increase in post op infections
Increase in Ca
Increase in mortality CABG

Question 23

Transfusion triggers

Answer 23

Who came up with the 10/30 rule? (1950s)
8.5 Hg is average ICU trigger
No evidence base!

7 g is the perfect trigger

Hg greater than 7-9 did not improve outcomes!
Even in ICU or MI’s
MI’s with TFX had poor Px

Question 24

Blood conservation

Answer 24

Epo (Erythropoietin) [can bring up hematocrit 1-2%]
Platelet gel [spun down, given back]
Cell savers
Normovolemic hemodilution [drain a unit of blood before surgery, give it back after- bloodless surgery]

Question 25

Blood as potentially toxic substance

Answer 25

Patients not bleeding or hypovolemic
Little to no benefit if Hgb > 7.0G/dl
Ref: Critical Care Clinics April 2004

Question 26

transfusion of choice

Answer 26

packed unit of leuko-reduced RBCs

Question 27

what does cryoprecipitate have in it

Answer 27

Factor 8, Anti-hemophilic factor

Question 28

Plasma Derivatives

Answer 28

Factor VIII Concentrates
Factor IX Concentrates
Other Recombinants

Question 29

Transfusions are inherently hazardous!

Answer 29

Bacterial contamination
Misidentifaction
TRALI

Question 30

Blood is a liquid transplant!

Answer 30

Changes in the immune system
Increased complications
Stepwise

Question 31

Transfusions progressively increase infection rates!

Answer 31

Each unit increases 50%

Standard practice to order two units

Question 32

Less is more for transfusions!

Answer 32

Improves patient outcomes

Saves blood

Question 33

Transfusion education is grossly inadequate!

Answer 33

No formal training
Unaware of transfusion guidelines
Little hospital oversight

Question 34

Transfusion rates in the US are higher than many countries!

Answer 34

Increasing in the US
15% higher than UK
44% higher than Canada

Question 35

Blood costs are on the rise!

Answer 35

Blood acquisition costs have doubled
They will continue to rise 10-15%

Blood costs are the tip of the iceberg for total costs!
Transfusing blood costs 5 times as much
Labor, supplies, adverse events

Question 36

Transfusions are risky business!

Answer 36

Medical legal liability
National patient safety goal #1
Medication and transfusion errors

Question 37

You break it you pay for it!

Answer 37

Medicare and commercial carriers
Don’t pay for bleeding complications
Hospital acquired infections 2-5 fold