Undergraduate lecture

1. Blood Transfusion Guidelines
in Clinical Practice

2. Introduction
 Blood Transfusion is not without hazards
 You should weigh the risk against benefit
 Use of right products to the right patient at
the right time

3. Principles of Clinical Transfusion
Practices
 Avoid blood transfusion
 Prevention and early diagnosis and treatment of
Anemia & underlying condition
 Use of alternative to transfusion.
-eg. IV fluids
 Good anesthetic and surgical management,to
minimized blood loss.

4. – Prescribing should bePrescribing should be
based onbased on national guidelinesnational guidelines
on the clinical useon the clinical use ofof
blood taking individualblood taking individual
patientpatient needs intoneeds into
account.account.
– Hb level should not beHb level should not be
the solethe sole deciding Factordeciding Factor
Clinical evaluation isClinical evaluation is
importantimportant

5. – Consent form to be obtained from the
patient before transfusion.
– The clinician should record the reason for
transfusion clearly.
– A trained person should monitor the
transfused patient and if any adverse
effects occur respond immediately.

6. TO TRANSFUSE BLOODTO TRANSFUSE BLOOD
WHENWHEN
NECESSARYNECESSARY

7. • The lowest threshold for transfusion of
components are:
– Hb level of 6-7g/dl.
– FFP threshold PT & PTT 1.5 times the upper
limit of the normal range.
Consider: Clinical judgment
Triggers of ComponentTriggers of Component
TransfusionTransfusion

8. – Platelet threshold of:
-10 000/µl- 20 000/µl for prophylactic
transfusion
– 20 000/µl for BMA and Biopsy
– 50 000/µl for surgery, massive
transfusion, Liver cirrhosis.
100 000/µl for surgery to brain or eye.
American Society of clinical Oncology guidline,1996&2001.American Society of clinical Oncology guidline,1996&2001.
Williamson LM. Transfusion Trigger in the UK. Vox sangWilliamson LM. Transfusion Trigger in the UK. Vox sang
2002.2002.
AABB Technical Manual 14AABB Technical Manual 14thth
ed, 2002.ed, 2002.

9. Haemoglobin
(Hb) trigger
for transfusion
Indications NB: Hb should not be the sole deciding
factor for transfusion.
< 7 g/dL
•If there are signs or symptoms of impaired oxygen
transport
•Lower thresholds may be acceptable in patients without
symptoms and/or where specific therapy is available e.g.
sickle cell disease or iron deficiency anemia
< 7 – 8
g/dL
•Preoperative and for surgery associated with major blood
loss.
< 9 g/dL
•In a patient on chronic transfusion regimen or during
marrow suppressive therapy.
< 10 g/dL •Not likely to be appropriate unless there are specific
indications.
• Acute blood loss >30-40% of total blood volume.
Guidelines for blood component therapy

10. Platelet Count
trigger for
transfusion
Indications
< 10 x 109
/L •As prophylaxis in bone marrow failure.
< 20 x 109
/L
•Bone marrow failure in presence of additional risk factors: fever,
antibiotics, evidence of systemic haemostatic failure.
< 50 x 109
/L
•Massive haemorrhage or transfusion.
•In patients undergoing surgery or invasive procedures.
•Diffuse microvascular bleeding-DIC
< 100 x 109
/L
•Brain or eye surgery.
Any Bleeding Patient
•Appropriate when thrombocytopenia is considered a major contributory
factor.
Any platelet count
•In inherited or acquired qualitative platelete function disorders, depending
on clinical features & setting.

11. FFP trigger for
transfusion Indications
PT & PTT are more
than 1.5 times the
upper limit of normal
range
•Multiple coagulation deficiencies associated with acute DIC.
•Inherited deficiencies of coagulation inhibitors in patients undergoing
high-risk procedures where a specific factor concentrate is unavailable.
•Thrombotic thrombocytopenia purpura (plasma exchange is preferred)
•Replacement of single factor deficiencies where a specific or combined
factor concentrates is unavailable.
•Immediate reversal of warfarin effect in the presence or potentially life-
threatening bleeding when used in addition to Vitamin K & / or Factor
Concentrate (Prothrombin concentrate)
•The presence of bleeding and abnormal coagulation parameters following
massive transfusion or cardiac bypass surgery or in patients with liver
disease
Cryoprecipitate
trigger for
transfusion
Indications
Fibrinogen< 1gm/L •Congenital or acquired fibrinogen deficiency including DIC.
•Hemophilia A, von Willebrand disease (if the concentrate is not available).
•Factor XIII deficiency.

12. Guidelines for
routine blood
leucodepletion
1. transfusion dependent patients
2. Bone marrow transplant candidates – either autologous /
peripheral blood stem cell transplants (PBSCT) or allogeneic bone
marrow transplants
3. may be for Patients undergoing intensive chemotherapy regimens
4. Previous repeated febrile reactions to red blood cells
Guidelines for
blood Irradiation
(to prevent
TAGVHD)
1.One week prior to stem cell collection, and for 12 months post
autografting or allografting.
2.Aplastic anaemia within 6 months of ATG treatment
3.Products obtained from close relatives or HLA matched donors.
4.Immunodeficiency patients: congenital or acquired

13. Chronic AnemiaChronic Anemia
AsymptomaticAsymptomatic
• Treat with
pharmacologic agents
based on the specific
diagnosis (e.g., Vit B12,
folic acid,recombinant
erythropoietin, iron).
SymptomaticSymptomatic
• Transfuse to minimize
symptoms and risks
associated with anemia.
• Transfusion is usually
required when
Hemoglobin is at 6 g/dL.

14. Hb incrementHb increment
• A dose of one unit of
compatible Red Blood Cells
will increase the hemoglobin
level in an average sized adult
who is not bleeding or
hemolyzing by approximately
1 g/dL or Hct by 3%.

15. Severe Thalassemia
• Transfuse to help
prevent symptomatic
anemia and suppress
endogenous
erythropoiesis by
maintaining hemoglobin
at 9.5-10.5 g/dL.

16. • Simple transfusion – give blood
• Erythrocytapheresis – use apheresis to
maximize blood exchange
Transfusion in Sickle CellTransfusion in Sickle Cell

17. • In severely anemic patients, simple
transfusions should be used.
Common causes of acute anemia:
• acute splenic sequestration
• transient red cell aplasia
• Hyperhemolysis (infection, acute chest
syndrome, malaria).
• If the patient is stable and the reticulocyte
count high, transfusions can (and should) be
deferred.
Transfusion in Sickle CellTransfusion in Sickle Cell

18. • In general, patients should be
transfused if there is sufficient
physiological derangement to result in
heart failure, dyspnea, hypotension, or
marked fatigue.
• Tends to occur during an acute illness or
when hemoglobin falls under 5 g/dL.
Transfusion in Sickle CellTransfusion in Sickle Cell

19. • Exchange transfusion offers many benefits
and is our first choice
• Phenotypically matched, leukodepleted packed
cells are the blood product of choice.
• A posttransfusion hematocrit of 30 to 36
percent or less is recommended.
• Avoid hyperviscosity, which is dangerous to
sickle cell patients.
Transfusion in Sickle Cell
(exchange transfusion)

20. Exchange transfusion:
1. Bleed one unit (500 ml), infuse 500 ml of
saline
2. Bleed a second unit and infuse two units.
3. Repeat. If the patient has a large blood
mass, do it again.
Transfusion in Sickle Cell
(exchange transfusion)

21. • Transfusions usually fall into two
categories:
 episodic, acute transfusions to stabilize or
reverse complications.
 long-term, prophylactic transfusions to
prevent future complications.
Transfusion in Sickle Cell
(exchange transfusion)

22. • episodic, acute transfusions to stabilize or
reverse complications.
 Limited studies have shown that aggressive
transfusion (get Hgb S < 30%) may help in
sudden severe illness.
 May be useful before general anesthesia.
Vichinsky et al., NEJM 1995
Transfusion in Sickle CellTransfusion in Sickle Cell
(exchange transfusion)(exchange transfusion)

23. Platelet RefractorinessPlatelet Refractoriness
• Platelet Refractoriness is the failure to
achieve the desired level of
blood platelets in a patient following
a platelet transfusion.

27. Transfusion Therapy in Special
Conditions

28. Surgical Blood Order Schedule;
Type and Screen
• Patients can be better served by performing
only a type and antibody screen.
• If the antibody screen is positive,
-antibody identification must be completed
and compatible units found.
• If the antibody screen is negative,
-ABO- and Rh type specific blood may be
released after an immediate spin crossmatch

29. Autologous Transfusion
• Autologous (self) transfusion is the
donation of blood by the intended
recipient.
• The patient’s own blood is the safest
blood possible, reducing the possibility
of transfusion reaction or transmission
of infectious disease.

30. Emergency Transfusion
• Group O RBCs are selected for patients for
whom transfusion cannot wait until the ABO
and Rh type of the patient can be determined.

31. Emergency Transfusion
• Group O–negative RBC units should be used,
especially if the patient is a female of
childbearing potential.

32. Emergency Transfusion
• A male patient or an older female
patient can be switched from Rh-
negative to Rh-positive RBCs if few O-
negative units are available and massive
transfusion is required.

33. Neonatal and Pediatric Transfusion
• Premature infants frequently require
transfusion of small amounts of RBCs to
replace blood drawn for laboratory
tests.

34. Aliquoted units
• Less than 7 days old, unless infused
slowly
• O-negative or compatible with mother
and infant
• CMV-negative or leukocyte-reduced
• Hemoglobin S–negative for hypoxic
newborns
• Dose
• 10 mL/kg over 2–3 hours

36. Important Points to Remember
• Transfusion therapy is used primarily to
treat two conditions:
• inadequate oxygen-carrying capacity
because of anemia or blood loss
• insufficient coagulation proteins to
provide adequate hemostasis.

37. Important Points to Remember
• A unit of whole blood or packed RBCs in
an adult should increase :
• The hematocrit level 3 percent
• hemoglobin level 1.0–1.5 g/dL.
• RBCs are indicated for increasing the
RBC mass in patients who require
increased oxygen-carrying capacity.

38. Important Points to Remember
• Platelet transfusions are indicated for
patients who are bleeding because of
thrombocytopenia.
• platelets are indicated prophylactically
for patients who have platelet counts
under 5000–10,000/L.

39. Important Points to Remember
• Each unit of platelets should increase
the platelet count
• 5000–10,000/L in the typical 70-kg human;
• Each should contain at least 5.5 10x10
platelets.
• A plateletpheresis product is prepared
from one donor and must contain a
minimum of 3 10x11 platelets

40. Important Points to Remember
• FFP contains all coagulation factors .
• indicated for patients with multiple
coagulation deficiencies that occur in
– liver failure, DIC, vitamin K deficiency,
warfarin overdose, and massive transfusion.

41. Important Points to Remember
• Massive transfusion is defined as the
replacement of one or more blood
volume(s) within 24 hours, or about 10
units of blood in an adult.
• Emergency transfusion warrants group
O RBCs when patient type is not yet
known.