BLOOD PRODUCT TRANSFUSIONS by Nick Mark MD ONE onepagericu.

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DEFINITIONS: Whole blood TRANSFUSION REACTIONS:
The goal of transfusion is to provide minimum O2 carrying AB+ (stored at 4°C up to 35 days)
capacity (RBCs) & sufficient platelets and clotting factors to
Rh positive
EXP 2021-01-01 23:30 ~450 ml + 60 ml citrate REACTION EXPLANATION MANAGEMENT
permit hemostasis. The goal is not correcting to “normal.” A9999 20 123456 K
Good at achieving hemostasis

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Most common immune reaction to transfusion. Prevention: APAP + H2 blockers,
Although RBC transfusions increase CaO2 they might not (contains all factors) but limited Febrile Non-
Occurs within 4 hours of transfusion due to accumulated consider leukoreduced units
normalize DO2 due to less efficient unloading of O2 in availability (autologous, military) Hemolytic
inflammatory cytokines in the banked donor blood. May Treatment: stop infusion, APAP,
transfused blood (2,3-BPG is degraded in storage). Transfusion recur; 25% of patients who had FNHTR once had another meperidine. R/o other causes.
Reaction (FNHTR) reaction subsequently. Notify blood bank.
Type and screen – determines blood type and detects
antibodies in recipient (e.g., indirect Coombs test) AB+ AB+ AB+ Occurs during or shortly after transfusion. A true emergency
Treatment with anti-CD38 antibodies (daratumumab, Rh positive Rh positive Rh positive Occurs due to mismatch of donor antigens (often ABO/Rh) & Prevention: carefully check units
EXP 2021-01-01 23:30 Acute Hemolytic
isatuximab) can cause a false positive on screen for minor
EXP 2021-01-01 23:30 EXP 2021-01-01 23:30
recipient antibodies leading to hemolysis & agglutination. Treatment: Stop transfusion,
A9999 20 123456 K
Transfusion

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antigens for up to six months (notify blood bank). S/sx: Fever, flank pain, dark urine, DIC, hypoTN, renal failure. notify blood bank, test for
Reaction (AHTR) Hemolysis on labs (↓haptoglobin, ↑LDH, etc) hemolysis & DIC, aggressive IV
Crossmatch – involves testing patient blood and specific
hydration (goal UOP > 100/hr).
donor units for compatibility. Crossmatch takes ~45 min.
RBCs Pooled Platelet FFP Occurs 24 hours to 30 days after transfusion due to mismatch Treatment: Notify blood bank,
In emergencies crossmatch can be skipped. (stored at 4°C (stored at RT up (frozen -25 °C Delayed Hemolytic
of minor antigens (often false negative crossmatch). 2nd repeat testing (DAT, type &
In extreme emergencies non-type specific blood can be up to 42 days) to 5 days) up to 3 yrs) Transfusion

IMMUNE MEDIATED
exposure can be faster, more severe. May have drop in Hct, screen, etc)
used (e.g., O- RBCs in women, O- or O+ RBCs in men). ~350 ml ~300 ml ~225 ml Reaction (DHTR) fever, minor hemolysis.
↑ Hb ~1 gm/dl* ↑ Plt by ~5-7k* (*in 70 kg pt)
Usually anaphylactoid (not IgE mediated). Prevention: washed (or IgA
EVIDENCE BASED TRANSFUSION THRESHOLDS:
v1.0 (2021-07-10) CC BY-SA 3.0

S/sx urticaria, maculopapular rash, pruritis, fv & hypoTN deficient) RBCs.Check for IgA
•Restrictive transfusion strategies (Hb > 7) are comparable/superior to Allergic reaction Occurs minutes to hours after transfusion, due to antibodies deficiency if recurrent anaphylaxis
liberal strategies in most settings including GI bleed, septic shock, against proteins on plts, leukocytes, or in plasma, including Tx: epi, H2 blockers, steroids
AB+
Rh positive cardiac surgery, TBI, and in most ICU patients. IgA (in recipients w/ IgA deficiency)
0.9% Sodium
EXP 2021-01-01 23:30
Chloride • Massive transfusion protocols (MTP) (e.g., trauma pts or massive GI
A9999 20 123456 K Injection USP Occurs 7-10 days after transfusion, due to anti-platelet Treatment: IVIG, plasmapheresis
bleed) target hemodynamic stability not a specific Hb. Among patients
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1000mL
L o re m ip s u m d o lo r s it a m e t,

Post Transfusion antibodies in donor blood. Causes purpura & severe

receiving MTP, balanced ratio (e.g., 1 RBC : 1 FFP : 1 Plt unit) is superior
c o n s e c te tu r a d ip is c in g e lit, s e d d o

e iu s m o d te m p o r in c id id u n t u t la b o re

Purpura (PTP)
e t d o lo re m a g n a a liq u a . U t e n im a d

thrombocytopenia, may be life-threatening.

m in im ve n ia m , q u is n o s tru d

e x e rc ita tio n u lla m c o la b o ris n is i u t

• Platelet transfusion thresholds are disease dependent: For most

a liq u ip e x e a c o m m o d o c o n s e q u a t.
D u is a u te iru re d o lo r in re p re h e n d e rit

More common in women (85%) & Caucasians.

in vo lu p ta te ve lit e s s e c illu m d o lo re e u
f u g ia t n u lla p a ria tu r. E x c e p te u r s in t
o c c a e c a t c u p id a ta t n o n p ro id e n t, s u n t

diseases 10k is adequate, if bleeding or needing surgery 50k may be

in c u lp a q u i o f f ic ia d e s e ru n t m o llit

a n im id e s t la b o ru m .

required. Limited evidence for higher targets (e.g., 100k for CNS bleed) Transfusion
Leading cause of transfusion related death (15% mortality). Treatment: ventilatory support
TRALI resembles ARDS, onset is 4-6 hours after transfusion. may be required (use LPV), use
SPECIAL BLOOD PRODUCT TYPES: Related Acute Lung
Most common following platelet transfusion from multi- platelets from male donors for
•Leukocyte reduced RBC: decreases incidence of febrile rxns & Injury (TRALI) parous female donors (due to anti-HLA or anti-HNA Ab) future transfusions.
Each unit
Y-tubing prevents allo-immunization. Also makes blood CMV-safe
contains: combines •Gamma-irradiated RBC: reduces incidence of GVHD during Occurs 8-10 days post transfusion, donor leukocytes attack Prevention: use irradiated and
Transfusion
·Blood type immunosuppressed recipient. leukocyte reduced blood in
blood & transfusions; important in very immunosuppressed patients Associated Graft
·Expiration crystalloid •Volume Reduced RBC: each unit comes in ~100 ml (instead of ~350 Versus Host Disease
Sx include: fever, cutaneous eruptions, diarrhea, liver immunosuppressed recipients
abnormalities. May progresses to pancytopenia due to Treatment: no effective treatment
·Product # ml), can reduce the incidence of febrile rxns because there are fewer (TA-GVHD)
marrow aplasia. High mortality.
·Barcodes Filter & drip plasma proteins; can also be used in volume overloaded patients
All must be chamber (though giving diuretic is probably better) Transfusion Occurs between 0-6 hrs after transfusion. Volume overload Prevention: minimum # of units,
NON-IMMUNE MEDIATED

verified! removes •Washed RBC: plasma is replaced with crystalloid; this should be done Associated Cardiac from transfusions, particularly in patients with CHF. Presents volume reduced units, diuresis
blood clots only if there was a previous allergic reaction or in IgA deficient Overload (TACO) as dyspnea potentially progressing to severe hypoxemia. Treatment: diuresis

Rate of transfusion depends
on severity of illness. In stable
patients, slower infusions (e.g.
over 2 hrs) permits earlier
stopping. In unstable patients
consider using a rapid infuser.
patients (if no IgA deficient donors) Hypocalcemia Citrate in RBCs binds to serum calcium. Blood products Treatment: Replete calcium and
•Single donor (apheresis) platelets: a full unit of platelets obtained Hyperkalemia contain potassium from lysed cells. monitor for hyperkalemia.
from a single donor via apheresis (in contrast to pooled platelets
typically combining 5 donors). Single donor limits antigen exposure Due to low temp of transfused products. iatrogenic Prevention/Tx: Use a blood
Hypothermia hypothermia exacerbates coagulopathy & ↑bleeding warmer for massive transfusions
STRATEGIES IN PEOPLE WHO DECLINE TRANSFUSION
People taking ACEi may develop hypotension due to inability Does not require intervention.
• Discuss specific reasons/concerns, understand what tx is acceptable Hypotension to break down bradykinin in transfused blood Rule out infection/hemolysis
• Correct coagulopathy (consider amicar, TXA, other products)
150 • Stop and minimize blood loss: hormonally suppress menstruation, Infection occurs due to untested organisms (rare), false negatives on testing (very rare), or bacterial contamination.
autotransfuse with cell-saver (OR) or hemothorax/chest tube (ICU)
Bacterial Platelets (stored at RT) are more likely to cause infections with skin flora (GPCs). RBCs (stored at 4C),
IINFECTION

• Minimize iatrogenic blood loss (fewer labs, less frequently, drawn in

pediatric tubes); no "routine" labs; every test should be thoughtful contamination are more likely to be contaminated with GNRs. Can lead to sepsis.

and drawn in pediatric tubes to minimize volume lost Untested Organisms NOT tested include: Malaria, Borrellia (Lyme disease), Trypanosoma (Chagas disease),
• Optimize hematopoesis (IV iron infusion, folate supplementation, organisms Babesiosis, & vCJD (varies by country)
EPO administration)
• Consider blood substitute (poly-heme) False negative Extremely rare: HIV 1 in 2,000,000,000, HBV 1 in 100,000,000, HCV 1 in 2,000,000, HTLV 1 in 650,000