blood product transfusions

see also:

• blood_groups
• haematology
• massive blood transfusions
• anaemia
• the blood donor who collapses
• USC 2008 conference video - strategies and evidence for managing the patient requiring massive transfusion for acute hemorrhage - subscription required
• Western Health pretransfusion testing procedure (docx)
• Western Health blood transfusion reaction form (docx) - intranet only
• Western Health Blood Products resource page

• Residual risk estimates for Transfusion-transmitted infections - Australian Red Cross Blood Service

• early involvement of the hospital's Haematology team should be sought if likely to need blood products
• most carry a Medical Directive that clearly states the person’s view on the non-use of blood products
  • BUT the existence of a medical directive does not automatically mean the patient carrying it will refuse treatment.
  • clinicians have an obligation to be satisfied that the patient is fully informed prior to the patient making a decision to refuse treatment
  • inability to consent:
    • if the patient is unconscious or not competent to make an informed decision the staff should make every effort to notify next of kin or other representatives to discuss treatment options
    • only an agent under the Medical Treatment Act or a guardian under the Guardianship and Administration Act can refuse medical treatment
    • other persons responsible can merely withhold consent to treatment, they cannot refuse treatment
  • Jehovah’s Witnesses have set up a number of Hospital Liaison Committees with representatives who are available to advise or assist in individual cases - there is a 24hr emergency contact number
  • refusal should be documented as per hospital's Refusal of Treatment procedure
  • children:
    • Section 24 of the Human Tissue Act 1982 enacts that a medical practitioner who gives a child a blood transfusion against the express wishes of the parent is not committing a criminal offence.
    • the blood transfusion must be treatment for a condition the child has and without the transfusion the child is likely to die.
  • where there is a dispute or disagreement, contact the Office of the Public Advocate
    • see OPA and Jehovah's Witnesses and blood products (pdf)
• most will usually NOT accept:
  • whole blood transfusions
  • transfusion of major blood components - red blood cells, platelets, plasma and white blood cells
  • preoperative autologous blood collection and storage for later re-infusion
• on an individual basis, may accept:
  • blood fractions such as albumin, clotting factors, etc
  • autotransfusion (intra/postop blood salvage & re-infusion)
  • heart bypass –when primed with non-blood products
  • haemofiltration/haemodilution
  • haemodialysis -when no blood prime is used
  • renal dialysis
• see the following documents distributed by JW in 2019 to assist doctors in management to avoid transfusions:
  • critically ill patients (pdf)
  • GIT bleeding patients (pdf)
  • obstetric and gynae patients (pdf)
  • surgical patients (pdf)
  • these documents and more are available online at https://www.jw.org/en/medical-library/

• consider:
  • signs and symptoms of hypoxia
  • ongoing blood loss
  • risk to the patient of the anaemia
  • risk to the patient of the transfusion
  • level of anaemia:
    • Hb < 70 g/L (although if asymptomatic and specific therapy available may consider no transfusion)
    • Hb 70-100 g/L AND EITHER:
      • likely to have blood loss in surgery, or,
      • signs or symptoms of impaired oxygen transport, or
      • anaemia-related symptoms in a patient on a chronic transfusion regime, or,
      • during marrow suppressive therapy
    • NB. Hb > 100 g/L unlikely to need blood transfusion unless significant acute blood loss

• Transfusion Medicine - RBC packs
• complete transfusion bag within 4 hours of commencement of that bag
• 1 unit of RBCs ~240ml and will raise Hb level in an adult by ~10g/L (paediatric unit is ~50ml)
• NB. see your hospital's policy and procedure for the administration of blood products - the following is only a guide!
• administer through a new IV blood giving set incorporating a 170-200 micron filter (large particle filter which only removes aggregates and other large particles)
• usually give over 2-4hrs but faster if acute bleeding
• start transfusion within 30 minutes of removing blood from fridge, otherwise, return blood to fridge
• use a blood warmer if massive transfusion
• transfuse one unit at a time
• avoid transfusing overnight unless an emergency
• check patient vital signs (pulse rate, respiration rate, blood pressure and temperature) at the start of transfusion AND at least after 15 minutes, at the end of the transfusion
• special requirements:
  • irradiated RBC's:
    • to reduce Transfusion Associated Graft-Versus Host Disease (TA-GVHD) thus examples of when to use irradiated RBCs are:
      • infants under 3 months age
      • patients treated with ECMO or LVAD
      • immunocompromised patients (eg. transplant recipients, malignancies, haem/onc patients)
      • intrauterine and exchange transfusions
      • directed donations
    • timing of irradiation is important for neonatal and paediatric patients.
    • irradiation reduces the storage-life of red cells and whole blood
      • Packs irradiated within 14 days of collection expire 28 days after collection.
      • Packs irradiated more than 14 days after collection expire either 5 days after irradiation OR at original expiry of pack, whichever comes first.
    • in patients where hyperkalaemia is a concern, red cells should be transfused within 24 hours of irradiation eg:
      • Examples include large volume neonatal transfusion such as exchange transfusion, ECMO or rapid large volume transfusion
    • RCH guideline
  • renal patients
    • consider washed RBCs (less electrolytes)
  • CMV neg

• patients on warfarin with life-threatening bleeding - see Mx of excessive INR or bleeding on warfarin Rx for guidelines
• acute DIC in presence of bleeding and abnormal coagulation (not for chronic DIC)
• patients with impaired liver function in presence of bleeding and abnormal coagulation

• standard bag of FFP = 300ml; paediatric bag = 74ml; cryo depleted > 160ml; apheresis > 500ml
• dose: 10-20ml/kg given as fast as tolerated and within 4 hours of commencement of infusion.

• bone marrow failure:
  • no risk factors ⇒ administer if platelet count less than or equal to 10×10⁹/L
  • risk factors such as fever, antibiotics, etc ⇒ administer if platelet count less than or equal to 20×10⁹/L
• surgery in patients with thrombocytopenia:
  • aim to maintain platelets > 50×10⁹/L
  • high risk of bleeding surgery (eg. neuro/ocular), aim to maintain platelet count > 100×10⁹/L
  • maybe appropriate in other patients with thrombocytopenia
• platelet function disorders:
  • administer based on clinical features as platelet count unreliable marker
• massive blood transfusion or haemorrhage:
  • patients whose bleeding is caused by thrombocytopenia
  • may be appropriate when platelet count < 50×10⁹/L (< 100×10⁹/L if diffuse micro vascular bleeding)

• most platelets arrive as a single pooled unit suspended in T-sol and reduced plasma
• DO NOT refrigerate - platelets are stored for up to five days at 20 - 24°C with gentle agitation on a platelet shaker.
• volume: pooled > 160ml; apheresis 100-400ml; apheresis paeds 40-60ml
• give 1 bag as fast as is tolerated (but not faster than 5mls/minute for first 15 minutes unless acute bleeding) and complete within 4 hours of start
• Transfusion Medicine - platelets

• fibrinogen deficiency with clinical bleeding AND EITHER:
  • invasive procedure, or
  • trauma, or,
  • DIC

• standard bag 10-40ml; apheresis 60ml;

• most often due to presence of WBC Abs formed by recipient as a result of previous transfusions or pregnancies, (rarely now due to Gram -ve endotoxin in blood or apparatus) usually not severe & last only few hrs;
• occur in 3-4% of blood transfusions
• Always Ix as fever is sign of haemolytic reactions as well!
• Rx: panadol;

• Urticaria usually due to sensitising Abs in recipient reacting with exogenous Ag such as milk or egg protein in donor serum - esp. if recipient atopic. Rx antihistamine;
• Generalised anaphylaxis rare (1 in 20,000 units transfused) due to this cause;
• Immediate HS reactions may be severe due to donor proteins such as IgA which recipient either lacks or has different IgA subclass.
• In addition, allergic reactions may occur if donor has Hx of striking HS & thus has much Ab, therefore of recipient comes in contact with that Ag, a HS reaction may occur but only via donor Ab (ie. passive transfer of a HS state).

• occur in 1 in 40,000 units transfused and result in death in 1 in 100,000 units transfused
• intravascular haemolysis:
  • Usually due to rapid destruction of donor RBCs - usually due to incompatible ABO gps mainly result from labelling errors rather than technical error in failing to detect incompat.
  • Soon after Tx begins → heat/pain along transfused vein → facial flushing, rigors, fever, severe loin pains, constriction feeling in chest, hypotension/shock/death may follow;If severe, Hbaemia, Hburia, decr. [haptoglobin], methaemalbuminaemia appears; DIC;
  • Jaundice may take several hrs to develop;
  • Oliguria due to intense renal vasoconstriction & acute renal failure may develop;
• extravascular haemolysis in MP system (esp. spleen):
  • Usually due to other blood gp incompatibilities (Rh, etc) & is slower & less dramatic with milder symptoms although Hbaemia may occur to same degree but renal failure/death rare.
  • May also result from faulty storage of blood (freezing or heating), over-long storage or bacterial contamination;

• XS or too rapid administration may → CCF/APO esp. heart dis/severe anaemia;
• Thus if susceptible then limit to 2 units packed cells/24hrs each unit <4hrs Tx time;
• Consider exchange transfusion or intraperitoneal (irradiated) Tx if severe anaemia;

• Esp. Pseudomonas & coliforms (cold-growing Gram -ves);
• After brief latent period, → profound shock, fever, abdo. pain → death in hrs!
• Thus don't use blood kept @ room temp > 4hrs;

• hyperkalaemia esp. old cells or irradiated cells, or if renal impairment & potentiated by citrate induced hypocalcaemia;
• increased ammonia levels ⇒ hepatic encephalopathy;
• increased citrate
  • ⇒ coagulopathy (may also be due to dilutional effect as blood has coag. defects)
  • ⇒hypocalcaemia
  • ⇒metabolic alkalosis and hypokalaemia if large volume of citrated cells
• hypothermia; XS 2,3 DPG → shifts Hb-O2 curve;
• coagulopathy due to dilutional effect and lack of platelets and clotting factors in packed red cells

• May tolerate 200ml air but 40ml can have serious results (see elsewhere);

• may be caused by transfusing any plasma-containing blood product
• it is caused by the interaction between the recipient's leukocytes and preexisting donor antileukocyte antibodies
• this results in complement activation and increased pulmonary vascular permeability
• complicates 0.1-0.2% of all transfusions

• Foreign Ags on donor cells, IgA, etc may → prod. of alloAbs which may complicate future transfusions or pregnancies;

• In pts. sensitised by previous preg/Tx, alloAb titre may be undetectable & thus apparent compatible blood when transfused may restimulate Ab production → sudden destruction of donor cells usually within 3-7 days → jaundice or failure of Hb to rise as expected or falls;
• May then find the irregular Ab when re-Xmatch or if Direct Coombs test pts blood;

• EB virus
• CMV probably the most common;
• Hep A/B/C/D/E
  • ⇒ screen all for HBsAg as 50% will develop hepatitis if +ve;
  • risk of hep C is ~1 per 3000-4000 units transfused
  • risk of hep B is ~1 per 50,000 units transfused
• HIV screened blood risk ~1 per 150,000 units transfused
• Malaria
• Syphilis now rare as survives poorly in storage & many recipients on penicillin;
• Brucellosis
• Toxoplasma
• Filariasis
• Trypanosoma
• Kala-azar

• Significant pulmonary microemboli may occur in seriously ill pts due to aggregated platelets/WBCs as well as other particulate matter in Tx such as particles of:
  • rubber bungs, glass, cellulose fibres;

• Phthalate plasticisers, although toxic in minnows - unknown human effects;

• Repeated Tx over many yrs for chronic anaemias such as aplastic, may result in Fe overload;

• esp. if: > 12hrs Tx (different units though)
• rubber tubing not plastic;
• adminis. autoclave glucose soln → decr. pH, esp. if post-Tx → ?lyse RBCs;
• indwelling catheters > 8hrs;

• now reduced to 0.15% of transfusions due to improved preventive measures
• TA-GVHD occurs when donor lymphocytes from transfused blood engraft in the recipient and cause disease.
• typically TA-GVHD occurs 10-14 days post transfusion with clinical features of fever, skin rash, hepatitis, diarrhoea and pancytopenia.
• it is fatal in more than 90% of cases.
• at risk patients:
  • immuno-compromised
  • receiving transfusion from a relative (directed donation)
  • reported rarely in patients with a 'normal' immune system.
• prevent by giving irradiated cells to at risk patients (leukocyte depletion using current technology is inadequate for this purpose)

• Emedicine - blood transfusion reactions
• Aust. Transfusion Medicine website for clinicians
• Australian Rh Anti-D administration guidelines