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Clinician's Pocket Reference > Chapter 10. Blood Component Therapy >
Apheresis
Apheresis procedures are used to collect single-donor platelets (plateletpheresis) or WBC
(leukapheresis); the remaining components are returned to the donor. Therapeutic apheresis is the
separation and removal of a particular component to achieve a therapeutic effect (eg,
erythrocytapheresis to treat polycythemia).
Emergency Transfusions
Non-cross-matched blood is rarely transfused because most blood banks can do a complete cross-match
within 1 h. In cases of massive, exsanguinating hemorrhage, type-specific blood (ABO- and Rh-matched
only), usually available in 10 min, can be used. If even this delay is too long, type O, Rh-negative PRBC
can be used as a last resort. When possible, it is generally preferable to support BP with colloid or
crystalloid until properly cross-matched blood is available.
Blood Groups
Table 10–1 gives information on the major blood groups and their relative occurrences. Type O– is the
"universal donor," and AB+ is the "universal recipient."
O+ 1 in 3 O (+/–)
O– 1 in 15 O (–)
A+ 1 in 3 A (+/–) or O (+/–)
A– 1 in 16 A (–) or O (–)
B+ 1 in 12 B (+/–) or O (+/–)
Type (ABO/Rh) Occurrences Can Usually Receivea Blood From
B– 1 in 67 B (–) or O (–)
AB+ 1 in 29 AB, A, B, or O (all + or –)
AB– 1 in 167 AB, A, B, or O (all –)
a
First choice is always the identical blood type; other acceptable combinations are shown. An attempt is
also made to match Rh status of donor and recipient; Rh– can usually be given to an Rh+ recipient safely.
75%)
1 unit should raise HCT
3%
Universal Pedi-Packs 250–300 mL divided into Transfusion of infants
3 bags
Contains red cells, some
white cells, some plasma
and platelets
Leukocyte-Poor Most WBC removed by Potential renal transplant patients
(Leukocyte-Reduced) filtration to make it less Previous febrile transfusion reactions
Red Cells antigenic Patients requiring multiple transfusions
6
<5 x 10 WBC, few (leukemia, etc)
platelets, minimal plasma
1 unit = 200–250 mL
Product Description Common Indications
Washed RBCs Like leukocyte-poor red As for leukocyte-poor red cells, but very
cells, but WBC almost expensive and much more purified
completely removed
<5 x 108 WBC, no plasma
1 unit = 300 mL
Granulocytes, 1 unit = 220 mL See Apheresis
Pheresis
RBC = red blood cells; WBC = white blood cells; HCT = hematocrit; GI = gastrointestinal; ITP =
idiopathic thrombocytopenic purpura; TTP = thrombotic thrombocytopenic purpura; HLA =
histocompatibility locus antigen; PT = prothrombin time; PTT = partial thromboplastin time.
Red Cell Transfusions
Acute Blood Loss:
Healthy persons can usually tolerate up to 30% blood loss without transfusion. Patients may manifest
tachycardia and mild hypotension without evidence of hypovolemic shock. Start volume replacement (IV
fluids, etc).
• Hgb > 10 g/dL, transfusion rarely indicated.
• Hgb 7–10 g/dL, transfusion based on clinical symptoms, unless patient has severe medical
problems (eg, CAD, severe COPD).
• Hgb < 7 g/dL, transfusion usually needed.
"Allowable Blood Loss":
Often used to guide acute transfusion in the operating room. Losses less than allowable are usually
managed with IV fluid replacement.
Weight in kg x 0.08 = Total blood volume
Total volume x 0.3 = Allowable blood loss (assumes normal Hbg)
Example: A 70-kg adult
Estimated allowable blood loss = 70 x 0.08 = 5.6L or (5600 mL) x 0.3 = 1680 mL
Chronic Anemia:
Common in certain chronic conditions, such as renal failure, rarely managed with blood transfusion;
typically managed with pharmacologic therapy (eg, erythropoietin). However, transfusion is generally
indicated if Hgb < 6 g/dL or in the face of symptoms due to low hemoglobin.
RBC Transfusion Formula:
As a guide, 1 unit of PRBC raises the HCT 3% (Hgb, 1 g/dL) in the average adult. To roughly determine
the volume of whole blood or PRBC needed to raise the HCT to a known amount, use the following
formula:
where total blood volume is 70 mL/kg in adults, 80 mL/kg in children. The HCT of PRBC is
approximately 70%, and that of whole blood is approximately 40%.
White Cell Transfusions
• The use of white cell transfusions is rarely indicated because genetically engineered myeloid
growth factors such as GM-CSF (see Chapter 22) are used instead.
• Indicated for patients being treated for overwhelming sepsis and severe neutropenia (< 500 PMN/
L)
Platelet Transfusions
Indications are in Table 10–2.
Platelet Transfusion Formula:
Platelets are often transfused at a dose of 1 unit/10 kg of body weight. After administration of 1 unit of
multiple-donor platelets, the count should rise 5000–8000/mm3 within 1 h of transfusion and 4500 mm3
within 24 h. Under normal circumstances, stored platelets that are transfused survive in vivo 6–8 d after
infusion. Clinical factors (eg, DIC, alloimmunization) can significantly shorten this time. To standardize
the corrected platelet count to an individual patient, use the corrected count increment (CCI). Measure the
platelet count immediately before and 1 h after platelet infusion. If the correction is less than expected, do
a work-up to determine the possible cause (eg, antibodies, splenomegaly). Many institutions use platelet
pheresis units. One platelet pheresis unit has enough platelets to raise the count 6000–8000/mm3. Using a
single unit has the advantage of exposing the patient to only one donor versus possibly six to eight
donors. This practice limits exposure to different HLA antigens, reducing the risk of antiplatelet antibody
production, and also reduces the risk of infection transmission.
Blood Bank Products
Table 10–2 shows products used in blood component therapy and gives recommendations for use of these
products.
Transfusion Procedures
1. Draw a clot tube (red top), and sign the lab slips to verify that the sample came from the
correct patient. Identify the patient by referring to the ID bracelet and asking the patient to state,
if able, his or her name. Place the patient's name, hospital number, date, and your signature on
the tube label. Prestamped labels are not accepted by most blood banks.
2. Obtain the patient's informed consent by discussing the reasons for the transfusion and the
potential risks and benefits of it. Follow hospital procedure regarding the need for the patient to
sign a specific consent form. At most hospitals, chart documentation is usually all that is
necessary.
3. When the blood products become available, ensure good venous access for the transfusion
(18-gauge needle or larger is preferred for adults).
4. Verify the information on the request slip and blood bag with another person, such as a nurse,
and with the patient's ID bracelet. Many hospitals have defined protocols for this procedure;
check your institutional guidelines.
5. Mix blood products to be transfused with isotonic (0.9%) NS only. Using hypotonic products
such as D5W can result in hemolysis of the blood in the tubing. Lactated Ringer solution should
not be used because the calcium can chelate the anticoagulant citrate.
6. Infuse red cells through a special filter. Specific leukocyte reduction filters can be used in
highly specific circumstances (history of febrile transfusion reactions, need to reduce potential
CMV transmission, need to reduce risk of alloimmunization to WBC antigens).
7. When transfusing large volumes of PRBC (> 10 units), monitor coagulation, Mg2+, Ca2+, and
lactate levels. It also usually is necessary to transfuse platelets and FFP. Calcium replacement is
sometimes needed because the preservative used in the blood is a calcium binder, and
hypocalcemia can occur after large amounts of blood are transfused. For massive transfusions
(usually > 50 mL/min in adults and 15 mL/min in children), warm the blood to prevent
hypothermia and cardiac arrhythmia.
Transfusion Reactions
1. Acute intravascular hemolysis (1/240,000–760,000 units transfused) More than 85% of
adverse hemolytic reactions involving the transfusion of RBC result from clerical error. Usually
caused by ABO-incompatible transfusion. Can result in renal failure.
2. Nonhemolytic febrile reaction (~2–3/100 units transfused) Usually mild, fever, chills, rigors,
mild dyspnea. Due to a reaction to donor white cells (HLA) and more common in patients who
have received multiple transfusions or delivered several children.
3. Mild allergic reaction (~1/100 units transfused) Urticaria or pruritus can be caused by
sensitization to plasma proteins in transfusion product.
4. Anaphylactic reaction (1/150,000 units transfused) Acute hypotension, hives, abdominal
pain and respiratory distress; seen mostly in IgA-deficient recipients.
5. Sepsis (< 1/500,000 RBC units transfused, 1/12,000 platelet units transfused) Usually caused
by transfusion of a bacterially infected transfusion product, with platelet transfusions having the
greatest risk. Escherichia coli, Pseudomonas, Serratia, Salmonella, and Yersinia are the more
commonly implicated bacteria.
6. Acute lung injury (1/10,000 units transfused) Fever, chills, and life-threatening respiratory
failure; probably induced by antibodies from donor against recipient white cells.
7. Volume overload (1/100 units transfused) Usually due to excess volume infusion; can
exacerbate CHF.
Detection of Transfusion Reaction
1. Spin an HCT to look for a pink plasma layer (indicates hemolysis).
2. Order serum for free Hgb and haptoglobin (haptoglobin decreases with a reaction) and urine
for hemosiderin levels. Obtain a stat CBC to determine the presence of schistocytes, suggesting
a transfusion reaction.
3. If acute hemolysis is suspected, request a DIC screen (PT, PTT, fibrinogen, and fibrin
degradation products).
Treatment of Transfusion Reactions
1. Stop the blood product immediately, and notify the blood bank.
2. Keep the IV line open with NS, and monitor the patient's vital signs and urine output
carefully.
3. Save the blood bag, and have the lab verify the T&C. Verify that the proper patient received
the proper transfusion. Redraw blood samples for the blood bank.
4. Treat the patient using the following guidelines and clinical judgment:
○ Nonhemolytic febrile reaction: Use antipyretics and continue transfusion
monitoring. Use leukocyte-washed transfusion products in the future.
○ Mild allergic reaction: After giving diphenhydramine (25–50 mg IM/PO/IV)
resume the transfusion only if the patient improves promptly.
○ Anaphylactic reaction: Terminate transfusion, monitor closely, give
antihistamines (diphenhydramine 25–50 mg IM/PO/IV), corticosteroids
(methylprednisolone 125 mg IV, 2 mg/kg pediatric IV), epinephrine (1:1000 0.3–
0.5 mL SQ adults, 0.1 mL/kg pediatric), and pressors as needed. Premedicate
(antihistamines, steroids) for future transfusions; use only leukocyte-washed red
cells.
○ Acute lung injury: Provide ventilatory support as needed; use only leukocyte-
washed red cells for future transfusions.
○ Sepsis: Culture the transfusion product and the patient; treat empirically by
monitoring and administering pressors and antibiotics (third- or fourth-generation
cephalosporin or piperacillin/tazobactam along with an aminoglycoside) until
cultures are returned.
○ Volume overload: Use a slow rate of infusion with selective use of diuretics.
○ Acute intravascular hemolysis: Prevent acute renal failure. Place a Foley
catheter, monitor urine output closely, and maintain brisk diuresis with plain
D5W, mannitol (1–2 g/kg IV), furosemide (20–40 mg IV), and/or dopamine (2–
10 mcg/kg/min IV) as needed. Alkalize the urine with bicarbonate and pressure
support (fluids, vasopressors). Monitor for DIC. Request renal and hematologic
consults.
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