blood_transfusion
Table of Contents
blood product transfusions
see also:
- Western Health blood transfusion reaction form (docx) - intranet only
- as of 2023, the following recommendations have been introduced in Victoria to reduce the demand for group O RhD negative RBC
- Where the patient’s blood group is unknown:
- group O RhD positive RBCs to be issued for females > 50 years and males >18 years (or based on organisational definition of paediatrics)
- group O RhD negative RBCs to be issued for females of childbearing potential (≤50 years, including children) and males ≤18 years.
- Where the person’s age or sex cannot be determined, clinical judgement should prevail.
consent
Jehovah's Witnesses
- 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
- 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:
- these documents and more are available online at https://www.jw.org/en/medical-library/
indications for RBC transfusion in patients
- 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
usage of RBCs
- 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
- renal patients
- consider washed RBCs (less electrolytes)
- CMV neg
indications for fresh frozen plasma (FFP)
- 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
usage of FFP
- 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.
indications for platelet transfusion
- 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)
usage of platelets
- 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
indications for cryoprecipitate
- fibrinogen deficiency with clinical bleeding AND EITHER:
- invasive procedure, or
- trauma, or,
- DIC
usage of cryoprecipitate
- standard bag 10-40ml; apheresis 60ml;
blood / RBC transfusion reactions
immediate:
immediate simple febrile reactions:
- 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;
allergic reactions:
- 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).
haemolytic reactions:
- 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;
circulatory overload:
- 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;
bacterial contamination:
- 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;
biochemical derangements in massive transfusions:
- 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)
- ⇒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
air embolism:
- May tolerate 200ml air but 40ml can have serious results (see elsewhere);
transfusion related acute lung injury
- 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
delayed reactions:
sensitisation:
- Foreign Ags on donor cells, IgA, etc may → prod. of alloAbs which may complicate future transfusions or pregnancies;
delayed haemolytic transfusion reactions:
- 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;
donor blood-borne infection:
- 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
multiple microemboli:
- 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;
toxic substances in plastic leached out from plastic bag/tubing by blood:
- Phthalate plasticisers, although toxic in minnows - unknown human effects;
transfusional haemosiderosis:
- Repeated Tx over many yrs for chronic anaemias such as aplastic, may result in Fe overload;
thrombophlebitis:
- 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;
graft-vs-host reaction (TA-GVHD):
- 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)
references and other resources
blood_transfusion.txt · Last modified: 2023/03/14 05:44 by wh