Virginia Commonwealth Univeristy

Practicing Excellence in Transfusion Therapy

VCUHS Transfusion Guidelines

Blood samples

Revised March 2013

Blood product

Dose

Response

Utilization guidelines

Packed RBC

Adult dose  1 unit

Neonatal dose: 5-15ml/kg
  • 1 g/dl increase Hb
  • 3% increase in Hct
  • Hb < 8g/dl
  • Need to increase O2 carrying capacity
  • Blood loss > 30%

Platelets

Adult Dose: >3x10¹¹ pltsPool random donors (RDP)
v. single donor pheresis SD

Neonatal dose:  10 ml/kg

 

  • Increase in count
  • 30 – 60,000/mL/dose
  • Assay 10 min- 1 hr post transfusion Increase in count
  • Plt < 10 – 20,000/mL
  • Plt < 50,000/mL with bleeding or invasive procedure
  • Plt < 100,000 CNS surgery
  • Platelet dysfunction with bleeding

Plasma

Warfarin reversal

5 – 8 ml/kg

Factor replacement

Adult dose:  2-4 units

Neonatal dose:  10-15 ml/kg
    • Decrease in PT, INR
    • Replace coagulation factors
    •  

       

  • PT > 1.5 x the upper limit of normal or the midpoint of normal range; aPTT > 1.5 x the upper limit of normal with bleeding or invasive procedure
  • Factor deficiency ONLY if no concentrate available

Cryoprecipitate

Adults: 1 dose (received pre-pooled from blood supplier)

Neonatal dose:  1 unit/10kg

 

  • Increase in fibrinogen
  • Increase vWF  (von Willebrand’s factor)
  • Increase factor VIII
  • Increase factor XIII
  • Fibrinogen < 100mg/dL
  • Von Willebrand’s Disease if other safer products not available
  • Uremic platelet dysfunction with bleeding

 

Risk/unit by serology :   HBV 1: 208-488,000 HTLV I/II 1: 641,000
Risk/unit by Nucleic Acid Testing (NAT) and serology combined ~HCV 1:1,600,000     ~HIV 1:1,900,000, HBV, NAT: has not demonstrated a decreased risk from serologic testing as listed above.
Risk of West Nile Virus varies by year, location and season; testing by NAT
Risk of Chagas: dependent on geographic location, testing by ELISA and positives confirmed by RIPA.

CMV Seronegative Components

Reduce exposure to cytomegalovirus (CMV)
Donor serum screened for CMV antibodies
Determine patient CMV immune status – order CMV IgG antibody

Indications:

  1. CMV seronegative BMT & PBSC transplant candidates & recipients
  2. Infants<4 months of age
  3. Intrauterine transfusions
  4. Congenital immunodeficiencies
  5. CMV seronegative children receiving CMV seronegative solid organ transplants
  6. HIV positive patients who are also CMV seronegative
  7. Seronegative pregnant women

Alternative: = Leukoreduced components

Considered CMV “safe” equivalent

White cells which harbor CMV are removed

 

Sickledex Negative Red Cells

Prevent the transfusion of abnormal Hgb S

Indications:

  • Neonates < 4 months
  • Patients with sickle cell disease

Premedication: Acetaminophen / Benadryl Caution:
Premedication should be given only when indicated, not as a routine for all patients. Premedication may mask symptoms such as fever which is the first indication of an acute hemolytic transfusion reaction.

Informed Transfusion Consent:

  • Obtained by MD, DO, PA, NP; witnessed
  • Complete form: check “I do” vs. “I do not” consent
  • Required for RBC, Plasma, Cryo, Platelets
  • Permit adequate lead time for special donations:
  •         Autologous donations
    Patient selected donations (PSD) –    family/friends
  • Caution: consent form includes option “I do not consent” (Jehovah’s witnesses)

 

Transfusion Reactions

Clinical response for all reactions:  1. STOP TRANSFUSION / check pt. ID against bag / Keep IV open with 0.9% NaCl / document vital signs.  2.  Notify physician / Document decision process in medical record.  3.  Order transfusion reaction work up and notify Transfusion Medicine (TM).  4.  Send a pink/purple (EDTA) top tube and remaining unit with any attached tubing to TM. (For mild allergic reaction see below)

Reaction Type

Signs and Symptoms Etiology

Clinical Action

Allergic (mild)
Pruritis, hives- limited to small area antibodies to transfused plasma proteins Administer antihistamines. Resume Transfusion if improved. Notify TM; no samples neccessary. If no improvement in 30 minutes treat as moderate to severe. Do not use unit of blood.
Allergic (moderate to severe) Generalized hives, bronchospasm and dyspnea, abdominal pain, hypotension, nausea, anaphylaxis
  • Antibodies to plasma proteins usually IgE 
  • Can be IgA
Administer antihistamines, epinephrine, vasopressors and corticosteroids as needed. Do not use unit of blood.
Acute Hemolytic Temp>1˚C or 2˚F, chills, rigors, anxiety. Cytokines released from WBC

Mild: administer antipyretics as needed
Recurrent or severe reactions, require consultation with Transfusion Medicine attending physician.

*May occur after transfusion complete
Acute Hemolytic Hemoglobinemia / uria, fever, chills, anxiety, shock, flank pain, chest pain, unexplained bleeding, cardiac arrest

Intravascular hemolysis usually due to ABO incompatibility

  • check for patient ID clerical error
Treat shock with vasopressors; maintain airway; increase renal blood flow; administer fluids and maintain brisk diuresis; monitor for acute renal failure. If DIC is present, consider heparin. Administer blood products as needed after etiology is clear.
Septic

Rise of > 2°C or 3°F

Sudden hypotension or hypertension, shock
  • -Bacteria in donor bag
  • Risk greater for platelets vs. RBC; platelets now screened for pathogens by culture, but not all bacteria can be detected during the storage period
Send bag to transfusion medicine. Order blood culture on patient as needed.  Pressor support if necessary.  Broad spectrum antibiotics.
TRALI – Transfusion Related Acute Lung Injury Acute respiratory distress usually within 1 – 2 hours of transfusion. Non-cardiogenic pulmonary edema unresponsive to diuretics; diagnosis of exclusion. One of the leading causes of death due to transfusion reported to the F.D.A. Usually donor HLA/neutrophil specific antibodies from transfused plasma.  Recipient has corresponding antigens; get pulmonary neutrophil activation that results in extravasation of fluid into air spaces

Respiratory support!  Most will resolve within 24 – 96 hours.  Steroids, diuretics; no known benefit.

Leukoreduced Components

All blood products at VCUHS are prestorage leukoreduced.
Still needs a standard blood administration set.
Evidence based indications are listed below as a reference.

Reduces incidence:

  1. HLA alloimmunization / platelet refractoriness
  2. Febrile transfusion reactions, recurrent
  3. CMV transmission = ** CMV “safe” equivalent

Indications:

    • Hematologic malignancies
    • BM or PBSC transplant recipients / candidates
    • Patients w/ history of multiple febrile reactions
    • Chronically transfused patients (i.e. Sickle cell disease)
    • Patients receiving multiple rounds chemotherapy
    • Living liver donor
    • Patients on cardiac bypass
    • Patients undergoing cardiac transplant
    • Cardiac patients on LVAD or mechanical heart

Irradiated Components

Prevents transfusion assoc. Graft v. Host Disease (GVHD)
Fatal complication – need to prevent, no cure
Indicated for immunocompromised recipients
Prevents immunocompetent donor T-cell replication
Notify TM to flag patient – irradiated products
Required for cellular products, not plasma

Indications:

    • BM or PBSC transplant recipient
    • Hematologic malignancies
    • High dose chemotherapy &/or radiation therapy w/bone marrow suppression or receiving fludarabine
    • Congenital immunodeficiencies
    • HLA / crossmatched platelets
    • Patient selected donation (PSD)
    • Intrauterine transfusions
    • Infants who received intrauterine transfusions
    • Infants < 1 year

 

For more information, please call Transfusion Medicine at (804) 828-0256.