Blood transfusion BloodSafe

Module
Criteria for transfusion - Focus on reversible causes instead of
transfusing straight away after a low Hb e.g. iron deficiency
Informed consent:
Engage patient
Obtain their trust
MORE important than running through the list of everything
Factors taken into account when considering a transfusion:
Signs/symptoms of anaemia - chest pain, dyspnoea (particularly on
exertion), dizziness
Volume of blood loss - rate and volume must be estimated
Cause of bleeding - acute or chronic? Likelihood of ongoing
bleeding? Potential for uncontrolled bleeding?
Cause of anaemia - particularly important to identify treatable
causes eg. iron deficiency or other haematinics - this way
appropriate therapy can be instituted possibly instead of a
transfusion
Cardiac dysfunction - red cell transfusion may be associated with
reduced mortality or increased risk of adverse events dependent
upon degree of anaemia and the nature of cardiac condition
Atherosclerotic disease - critical arterial stenosis e.g. in ACS may
modify threshold for use of red cells
Bone marrow suppression - 2o to disease or treatment may affect
pts ability to replace lost red cells and may be the cause of the
patients anaemia
Other relevant factors
Risk vs Benefit
Should only be giving blood when the potential benefit outweighs
the potential hazards
There is not really much evidence regarding effect of transfusing
patients at different Hb levels - current guidelines based on
available evidence and consensus expert opinion
RBC transfusion shouldnt be dictated by Hb concentration alone,
but based upon comprehensive assessment of pts clinical status
Where indicated transfusion of single unit RBCs followed by
reassessment

Hb concentration < 70 g/L

In this situation, red cell transfusion may be associated
with reduced mortality and is likely to be appropriate.
However transfusion may not be required in wellcompensated patients or where specific therapy is available to
treat the cause of the anaemia e.g. iron replacement.
The one group of patients in whom red cell transfusion is
likely to be appropriate at the higher Hb level of < 80 g/L are
those with acute coronary syndrome (ACS).
Hb concentration 70-100 g/L
At this Hb range, transfusion of red cells is not associated
with reduction in mortality. The decision to transfuse (with a
single unit followed by reassessment) should be based upon
the need to relieve clinical signs and symptoms of anaemia
and the patient's response to previous transfusions. In
patients who are elderly or who have respiratory or
cerebrovascular disease there is no evidence to warrant use
of a different approach.
In patients who have an acute coronary syndrome (ACS)
and a Hb concentration of 80-100 g/L the effect of red cell
transfusion on mortality is uncertain and may be associated
with an increased risk of recurrence of myocardial infarction.
Similarly, in the postoperative patient, in the absence of acute
myocardial or cerebrovascularischaemia, transfusion may be
inappropriate where the Hb level is > 80 g/L. Decision to
transfuse should be made with caution carefully considering
the risks and benefits.
In the critically ill patient group, where the most evidence
is available, the consensus is that transfusion is generally not
indicated when the patient's Hb is > 90 g/L. There are no
studies using this Hb level in the general medical or
postoperative patient cohort.
Hb concentration > 100 g/L
At this Hb level, red cell transfusion is likely to be
unnecessary and is usually inappropriate as the risks
outweigh the benefits.
In patients with acute coronary syndrome, transfusion has
been associated with increased mortality.
In the critically ill patient group the expert consensus is
that transfusion is generally unnecessary when the Hb level is
> 90 g/L.

Documentation
Indication

Explanation of procedure
Explanation of risks
Explanation of alternatives

Dosage
Generally for an average sized adult, one unit of blood will
increase Hb by approx. 10g/L
But in the end depends on pack volume (~250mL), pts
weight and hydration status

Causes of anaemia
Haematinic deficiency Fe, B12, folate (B9)
Bleeding
2o medication
ruptured vessels
surgery
Blood loss minimisation
Preoperative
Optimise pre-op Hb eg correction of iron deficiency
Timely cessation of anti-haemostatic agents
Intraoperative
Minimise tissue trauma
Careful vessel ligation and use of electro-cautery
Prompt attention to surgical bleeding
Topical thrombogenic measures eg fibrin sealant
Use of fibrinolytic drugs
Use of regional anaesthesia
Intraoperative cell salvage
Acute normovolemic haemo-dilution (ANH)
Pre and postop
Minimise pt blood sampling
Iron replacement - Clinical tip
Following therapeutic doses of oral iron, reticulocytosis should occur
within 72 hours, and haemoglobin should rise by 1 g/L per day
(about 20 g/L every 3 weeks), but this varies from patient to patient.

It is reasonable to replenish iron stores by continuing treatment for

3-6 months (2-3 months in children) beyond normalisation of
haemoglobin.

Risks and frequency

High >1:100; minor allergic reaction (urticarial), fever
Moderate 1:100 1:1,000; fluid overload, cardiac failure
Low 1:1000 1:10,000; delayed haemolytic reaction, TRALI
Very low 1:10,000 1:100,000; non-fatal acute haemolytic reaction
(wrong blood)
Minimal 1:100,000 1:1,000,000; fatal acute haemolytic reaction
(wrong blood)
Negligible <1:1,000,000; HIV, HCV, HTLV, malaria, syphilis

Implementing the decision

When the decision to transfuse has been made there are a number of
steps that need to be followed. These include:
Ensuring the patient's informed consent has been obtained and
documented in the patient's medical record
Determining any special requirements for this patient (e.g.
irradiated, CMV seronegative)
Ensuring there is a current blood specimen available for
crossmatching
Determining the appropriate time for transfusion based on the
urgency or availability of resources
Ordering blood product from the transfusion service provider
Documenting (including the reason for transfusion) and prescribing
the transfusion in the patient's medical record
Communicating with the patient's nurse.
Special requirements
Irradiation
Prevents transfusion-associated GVHD
CMV negative blood
CMV is typically carried by leucocytes and can be fatal in
specific patient populations neonates, pregnant patients
Haematology-oncology patients
Immunosuppressed pts eg transplant recipients
Leucodepletion
Removes >99% of the leucocytes

Reduces risk of specific types of transfusion reactions and

transmission of CMV
In Aus and NZ, ALL red cells and platelets are
leucodepleted during donor collection process
Washed red cells
Removes unwanted plasma proteins which may be the
cause of allergic reactions
Also removes any white cells and platelets
Indicated in pts with: reactions to transfused plasma
protein, severe allergic reactions of unknown cause, severe
reactions despite leucocyte depletion

Timing
Urgent give as rapidly as pts circulatory system will tolerate
Non-urgent 2 hours for adults, but always within 4 hours of being
removed from the fridge
*consider slow rate in pts at risk of circulatory overload (max 4 hours)
*may have another rule of within 4 hours of commencement, say in
neonates who require a slower rate of transfusion
Administration
All the checks right patient, right product, right pack
Special intravenous blood line, which can be primed with the blood
or N/S (NOT hartmans, ringer lactate or dextrose)
Monitor closely for 15 minutes pay special attention to the
development of any rash, SOB, wheezing, tachycardia, hypotension
increase in temperature (~1 degree is significant) and compare to
baseline measurements, or generalised oozing (may reflect ongoing
DIC)
Transfusionreactiontypes
Themostcommonadverseeventsrelatedtotransfusionarefebrileandallergicreactions.
Howeverthemostsignificantacutereactionsinclude:1,2

severefebrile(nonhaemolytic)transfusionreactions

allergyandanaphylaxis(includingIgA/antiIgAreactions)

acutehaemolytictransfusionreactions

transfusionassociatedcirculatoryoverload(TACO)

transfusionrelatedacutelunginjury(TRALI)
transfusiontransmittedinfection(TTI)includingsepsisfrombacterialcontaminationof
bloodcomponents.

TransfusionreactionsSignsandsymptoms
Adversetransfusioneventscanbelifethreatening.Itisimportanttoquicklyrecognise,
respondtoandreportanypossibleevents.Signsandsymptomsofimmediateadverse
reactionsinclude:1,2

fever(e.g.1Cabovebaseline,ifbaseline37C)

chills

urticarialrashUrticarialrashasignofanallergicreactioninvolvingraisedanditchy
areasofskin.Alsoknownashives.

tachycardia,hypotension(shock)

dyspnoea,wheezing

rigors,chills

nausea,vomiting

backorchestpain

haemoglobinuria,oliguria

painalongtheIVsite

uncontrolledbleedingorgeneralisedoozingfromIVsitesorwounds(DIC)
anxiety,feelinggenerallyunwellorasenseofimpendingdoom.
Whattodoiftransfusionreactionissuspected
STOP transfusion immeadiately
Act
Check vital signs
Emergency treatment if necessary
Maintain IV access (dont flush existing line use a new IV
line if required)
Check the right pack has been given to the right patient
Notify medical officer and transfusion service provider