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Toronto Notes 2019 Blood Products and Transfusions
Selection of Red Cells for Transfusion
• whenanticipatinganRBCtransfusion,thefollowingshouldbeordered:
■ group and screen: determines the blood group and Rh status of the recipient as well as the presence
of autoantibodies vs. major/minor blood group antigens in the patient’s serum
■ cross-match: involves mixing the recipient’s blood with potential donor blood and looking for
agglutination (takes 30-45 min)
• whenbloodisrequired,severaloptionsareavailable
■ 1st-line: fully crossmatched blood, electronic crossmatch is becoming more widely used (not always available in emergency situations)
■ 2nd-line: donor blood of the same group and Rh status as the recipient
■ 3rd-line: O- blood for females of reproductive age; O+ blood for all others
Hematology H53
Platelets
Table 37. Platelet Products
Product
Random Donor (Pooled) Single Donor Platelets HLA Matched Platelets
Indication
Thrombocytopenia with bleeding
Potential BMT recipients. Refractory to pooled platelets.
Refractory to pooled or single donor platelets, presence of HLA antibodies
Transfusion Requirements in Critical Care (TRICC)
NEJM 1999;340:409-417
Study: Multicentre, RCT.
Participants: 838 critically ill patients with euvolemia after initial treatment and hemoglobin less than 9 g/dL within 72 h of ICU admission. Intervention: Patients receiving a transfusion followed either (1) a restrictive strategy (RS; n=418) in which red cells were transfused if hemoglobin was less than 7.0 g/dL and then maintained at 7 to 9 g/dL) or (2) a liberal strategy (LS; n=420) in which transfusions occurred when the hemoglobin was less than 10.0 g/dL and then maintained at 10 to 12 g/dL.
Primary Outcome: Mortality at 30 d and severity of organ dysfunction.
Results: Mortality rates at 30 d were similar between groups. However, mortality rates were significantly lower with the RS among less acutely ill patients (8.7% and RS group and 16.1% in LS group; p=0.03) and among those <55 yr of age (5.7% RS and 13% LS; p=0.02), but did not differ in a subgroup with clinically significant cardiac disease.
Conclusion: A RS of red cell transfusion is at least as effective as, and possibly superior to, a LS transfusion in critically ill patients.
Liberal or Restrictive Transfusion in High-Risk Patients After Hip Surgery (FOCUS)
NEJM 2011;365:2453-2462
Study: Multicentre RCT.
Participants: 2,016 patients aged greater than 50 yr with a history of or risk factors for cardiovascular disease and hemoglobin (Hb) level below 10 g/dL after hip-fracture surgery.
Intervention: Patients were randomly assigned to a liberal transfusion strategy (a Hb threshold of 10 g/dL) or a restrictive transfusion strategy (anemia symptoms or at physician discretion for a Hb level less than 8 g/dL).
Primary Outcome: Mortality or inability to walk across a room without human assistance on a 60 day follow-up.
Results: Primary outcome rates were 35.2% in
the liberal transfusion strategy group and 34.7% in the restrictive transfusion strategy group. Rates of complications were similar in the two groups. Conclusion: A liberal transfusion strategy did
not reduce mortality rates or the inability to walk independently on 60 d follow-up compared to a restrictive transfusion strategy in elderly patients with high cardiovascular risk factors after hip surgery.
Group & Screen vs Cross-Matching:
G&S: ABO Group + Rh factor Cross-Matching: match recipient's serum with donor's packed RBC or antibodies
• storedat20-24oC
• randomdonorplateletsaretransfusedfromapoolof4units;thisshouldincreasetheplateletcountby
≥15 x 109/L
• singledonorplatelets(transfusedassingleunits)shouldincreasetheplateletcountby40-60x109/L
• ifanincreaseintheplateletcountisnotseenpost-transfusion:autoantibodies(i.e.ITP),alloantibodies,
consumption (bleeding, sepsis), or hypersplenism may be present
Table 38. Indications for Platelet Transfusion
Plt (x 109/L) <10
<20
<50
<100 Any
Indications
Non-immune thrombocytopenia
Procedures not associated with significant blood loss
Procedures associated with blood loss or major surgery (>500 mL EBL) Pre-neurosurgery or head trauma
Platelet dysfunction (or antiplatelet agents) and marked bleeding
Relative Contraindications of Platelet Transfusion
• TTP,HIT,post-transfusionpurpura,andHELLP
Coagulation Factors
Table 39. Coagulation Factor Products
Product
Frozen plasma (FP)
Cryoprecipitate (enriched fibrinogen, vWF, VIII, XIII)
Humate P or Wilate
Factor VIII concentrate Factor IX concentrate Recombinant factor VIIa
Prothrombin complex concentrate; PCC (Octaplex®, Beriplex®)
Activated prothrombin complex concentrate; aPCC (FEIBA)
Indication
Depletion of multiple coagulation factors (e.g. sepsis, DIC, dilution, TTP/HUS, liver disease), emergency reversal of life-threatening bleeding secondary to warfarin overdose
Hemophilia A (Factor VIII deficiency) – use in emergencies von Willebrand disease – use in emergencies Hypofibrinogenemia
von Willebrand disease Hemophilia A
Factor VIII deficiency (Hemophilia A) Factor IX deficiency (Hemophilia B)
Factor VII deficiency with bleeding/surgery, Hemophilia A or B with inhibitors, Glanzmann thrombasthenia
Reversal of warfarin therapy or vitamin K deficiency in bleeding patient or in patient requiring urgent (<6 h) surgical procedure, urgent non-specific “reversal” of direct Xa inhibitors
Hemophilia A or B with inhibitors, urgent non-specific “reversal” of direct thrombin inhibitors