LITERATURE
- 2024 CHEST Guidelines for Transfusion in the ICU Red Blood Cell Transfusion in Critically Ill Adults – CHEST
| RBCs | Platelets | Plasma (aka: FFP) | Cryoprecipitate | |
| Major Indications | 1. Hgb <7 g/dL (No end-organ ischemia or coronary disease)2. Hgb <8 g/dL (cardiovascular or cerebrovascular disease)2. Symptomatic Anemia3. RBC exchange (e.g.: Sickle Cell crisis) **Single unit RBC transfusions should be the standard for non-bleeding, hospitalized patients. Additional units should only be given after reassessment of the patient and their Hgb value** | 1. Prophylaxis against bleeding: Platelet count <10,000/mL2. Known coagulopathy: <20,000/mL3. Bedside or low-risk procedure (paracentesis, central line placement): <30,000/mL4. High-risk procedure (IR or OR, thoracentesis, LP), surgery or active hemorrhage:<50,000/mL4. Neurosurgical/Opthomologyprocedure: <100,000/mL5. Active bleeding in patients with decreased or functionally abnormal platelets (e.g. uremia, ASA, clopidogrel) | 1. Bleeding with prolonged PT/PTT (e.g.: INR >2)2. Procedural prophylaxis when INR >23. Intracranial bleeding or neurosurgery: when INR >1.54. Plasma exchange (e.g.: TTP) **Note: INR of plasma = 1.6-1.8** | Contains Factor VIII, Factor XIII, fibrinogen, fibronectin, vWF 1. Bleeding with fibrinogen <100 mg/dL2. Bleeding with dysfibrinogenemia (post-cardiopulmonary bypass, use of asparaginase) **Suggestion: Use early in bleeding patients with liver disease** |
| Volume | 1unit: ~ 350mL | 1unit: ~ 300mL | 1 unit: 200-250mL Recommended dose = 10-15 mL/kg(In typical adult: ~4 units) 4 units: ~ 800-1000mL | 1 pool= 5-6 units (50-60mL)1 adult dose = 2 pools = 10-12 units **In adults, dosed in pools, not units** |
| Expected Increase per Unit | 1 g/dL | 30,000/mL | 1 unit = 2.5% of factors4 units = 10% of factors t1/2= 4-6hrs | Fibrinogen increase 45-85 |
| Adverse Effects | 1. Hypothermia2.Hyperkalemia/hypokalemia3. Hypocalcemia4. Transfusion reactions | 1. Transfusion reactions (~1 in 30)2. Infection3. Allergic reactions | 1. Transfusion reactions2. Volume overload |
PRE-TRANSFUSION ORDERS
Type: Defines/confirms ABO type and “Rh” (D-antigen) positive/negative status
- Required before transfusion of any non-emergent blood product
Screen: Rules in/out RBC alloantibodies by screening against 2-3 standardized cells
- Depending on number and complexity of antibodies identified, may result in significant delay in identification of compatible RBCs
- Must be completed before release of non-emergent RBC units
- Order if transfusion possible, but not eminent
- Must be repeated every 3 days for inpatients
Crossmatch: Establishes compatibility between patient’s (recipient’s) serum and specific unit(s) to be transfused
- Order if transfusion anticipated within 4 hours
- May be time-consuming if RBC alloantibodies are present, and can result in delays (hours-days) finding compatible products
SPECIAL NEEDS AND INDICATIONS
Leukocyte Reduced (LR):
- Reduces WBC content of blood product approx. 10-50 times depending on product
- For prevention of febrile non-hemolytic transfusion reactions (FNHTR), HLA alloimmunization, transmission of CMV (rate of CMV transmission equivalent, potentially less than, “CMV Negative” products)
- Indicated patient populations:
- Prior FNHTR
- Hematological malignancies
- Hemoglobinopathies requiring transfusion support
- Patients requiring CMV reduced-risk products:
- Premature, low birthweight neonates
- Intrauterine transfusions
- CMV-seronegative pregnant women
- CMV-seronegative recipients of, or candidates for, bone marrow or stem cell transplants
- CMV-seronegative recipients of, or candidates for, heart, lung or kidney transplants
- CMV-seronegative, HIV-infected patients
Irradiated:
- For prevention of transfusion-associated graft-versus-host disease (TA-GVHD), a nearly 100% fatal transfusion complication
- Will not prevent transmission of any infectious disease
- Indicated patient populations:
- Bone marrow and stem cell transplant recipients
- Patients with congenital T-cell immunodeficiency syndromes (SCIDs, Wiskott-Aldrich, DiGeorge’s)
- Premature, low birthweight neonates
- Intrauterine transfusions
- Hematological malignancies
- Recipients of transfusions from blood relatives
- Recipients of fludarabine (purine nucleoside analog) or alemtuzumab (Campath, an anti-CD52 monoclonal antibody)
- Not indicated in: HIV/AIDS, non-hematological malignancies, solid organ transplant recipients, other immunosuppression
CMV-Negative:
- CMV-negative by serological testing only, more accurately described as “CMV-Reduced Risk“ as products may still have detectable CMV by PCR
- For prevention of transfusion-transmitted CMV disease in at-risk patients
- CMV infection rates equivalent between LR and CMV-seronegative products (Blood 1995;86:3598-3603)
- Indicated patient populations: see LR section above
Washed (RBCs or platelets only):
- Removes almost all plasma from products, significant reduction in free K+ from RBC units
- Results in loss of RBCs, and loss of, and decreased survival/function of, platelets
- Indicated patient populations:
- Repeated severe allergic transfusion reactions
- Prior anaphylactic transfusion reaction
- IgA deficiency with anti-IgA antibodies
- Neonates and pediatric cardiac surgery patients
- Can be considered for patients with profound hyperkalemia (contact Blood Bank MD to discuss)
| APPROXIMATE RISKS PER UNIT TRANSFUSED | |
| · Febrile or Allergic Reaction | 1:100 |
| · Transfusion Associated Circulatory Overload | 1:400 |
| · Bacterial Contamination (platelet units) | 1:2,000 |
| · Transfusion Related Acute Lung Injury | 1:5,000 |
| · Mistransfusion | 1:19,000 |
| · Anaphylaxis | 1:20,000-50,000 |
| · Sepsis | 1:75,000 |
| · Hepatitis B virus transmission | 1:250,000 |
| · Hepatitis C virus transmission | 1:2,000,000 |
| · HIV transmission | > 1:2,000,000 |