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CE
Transfusion Medicine
Sarah Haldane, BVSc, MACVSc
Jennifer Roberts, DVM
Steven L. Marks, BVSc, MS, MRCVS, DACVIM
Marc R. Raffe, DVM, MS, DACVA, DACVECC
University of Illinois

ABSTRACT:
Transfusion therapy is indicated in patients with many different diseases and conditions,
including anemia, hemorrhage, coagulopathy, and hypoproteinemia. After whole blood is
collected from a donor animal, it may be administered immediately or fractionated into
its component parts (e.g., packed red blood cells, fresh-frozen plasma, cryoprecipitate,
platelet products).Transfusion reactions may manifest as complications of blood product
administration. However, selecting the appropriate blood product and carefully collecting,
storing, and handling blood, in combination with blood-typing and crossmatching, can
decrease the risk of transfusion reactions.

T
here are many indications for transfusion of age) dogs and cats. Dogs should weigh more
therapy in veterinary practice, and with than 66 lb (30 kg); have a packed cell volume
the increased availability of blood prod- (PCV) of 40% or more; be fully vaccinated; and
ucts, it is becoming more widespread. Fraction- be free of heartworm infection, brucellosis, and
ating whole blood into its component products tick-borne diseases (e.g., Ehrlichia canis, Babesia
has made it easier to treat a broad range of con- canis, Rickettsia rickettsi, Borrelia burgdorferi
ditions when donors are not available. Blood infections).3 It is also recommended that canine
components accessible to veterinarians include donors test negative for dog erythrocyte antigen
fresh and stored whole blood, packed red blood (DEA) 1.1 (universal donors would also need
cells (pRBCs), fresh-frozen plasma (FFP), cryo- to test negative for DEA 1.2 and 7).4,5 Purebred
precipitate, and platelet products. However, and crossbred Akitas have high levels of intra-
administering blood products is not a benign cellular potassium in their RBCs and should
procedure. Red blood cells (RBCs) are very not be used as blood donors.6
antigenic and can promote a significant immune Cats should weigh more than 11 lb (5 kg), be
response. 1 Administering foreign proteins, lean, and preferably be shorthaired. Feline
leukocytes, or platelets may also stimulate the donors should have a PCV greater than 35%; be
immune system.2 The appropriate blood product fully vaccinated; and be free from FeLV, FIV,
should be selected based on maximum benefit Toxoplasma gondii, and Hemobartonella felis (now
with minimum risk to the patient. called Mycoplasma hemofelis) infections. Cats
should be blood typed before blood collection.5,7
Email comments/questions to SELECTING BLOOD Withdrawal of 10% to 20% of the blood vol-
compendium@medimedia.com, DONORS ume from a blood donor should not result in
fax 800-556-3288, or log on to Blood donors should be clinically significant anemia. An 11-lb (5-kg)
www.VetLearn.com healthy adult (i.e., 2 to 8 years cat may have 50 to 60 ml of blood collected in

COMPENDIUM 502 July 2004


Transfusion Medicine CE 503

one donation, whereas a 66-lb (30-kg) dog may have Crossmatching a


450 ml of blood collected. Hypovolemia can result if
20% or more of the blood volume is withdrawn; if this • Collect serum and EDTA blood samples from the
occurs, administering IV fluids is indicated. Blood donor and recipient (at least 1 ml in each sample).
should not be collected more than once every 4 to 6 • Separate the serum and RBCs into separate
labeled tubes.
weeks.8
• A whole-blood transfusion requires both a major
and minor crossmatch, whereas transfusion of
Canine Blood Groups pRBCs requires only a major crossmatch.
Nine blood groups (i.e., DEA 1.1, 1.2, 1.3, 3, 4, 5, 6,
7, 8) have been identified in dogs.9 The most clinically Major Crossmatch
significant are DEA 1.1 and 1.2.10 Spontaneously occur- • Prepare a 3%–5% suspension of the washed donor
ring antibodies (i.e., alloantibodies) to these antigens RBCs in saline.
have not been identified; thus immunologic reactions — Pipette 0.1 ml of the pRBCs into 3 ml of 0.9%
NaCl.
are rare for the first transfusion administered to dogs.
— Centrifuge the sample for 1 min, remove the
However, if a transfusion of blood positive for DEA 1.1
supernatant, and resuspend the RBCs in 3 ml
is administered to a recipient with blood negative for of 0.9% NaCl.
DEA 1.1, antibody induction will occur. If a second — Repeat this three or four times to wash donor
transfusion of blood positive for DEA 1.1 is adminis- cells. Following the last wash, there should be a
tered, an immune-mediated transfusion reaction may 3%–5% suspension (3 ml total).
destroy all transfused cells in less than 12 hours.9,10 Preg- • Place two drops of the donor RBC suspension
nancy can also induce alloantibodies to DEA 1.1 in up into a clean, dry tube.
to 25% of dogs.10 • Add two drops of the recipient serum to the same
Alloantibodies against DEA 7 are present in up to tube.
15% of dogs. These antibodies cause a delayed-type • Centrifuge the serum for 30 sec at low speed.
immune response against RBCs positive for DEA 7, • Check the sample for evidence of macroagglutination
resulting in hemolysis 1 to 3 days after transfusion.8,11 or microscopic agglutination.
Delayed-type hemolytic reactions may also occur if the • If no agglutination is present, let the sample sit for
15 min at room temperature.
donor animal has alloantibodies to DEA 3 or 5; how-
• Centrifuge the sample for 30 sec at low speed.
ever, these occur rarely in the general population.12
• Check the sample for evidence of macroagglutination
or microscopic agglutination.
Feline Blood Groups
There are three feline blood types: A, B, and AB. Minor Crossmatch
There is no universal donor group because cats with • Prepare a 3%–5% suspension of the recipient
type A blood have anti–type B antibodies and cats with RBCs in 0.9% NaCl (as described above).
type B blood have anti–type A antibodies. 13 Type B • Pipette two drops of the recipient RBC suspension
blood transfused into a cat with type A results in into a clean, dry tube.
hemolysis of transfused cells within 2 to 3 days. How- • Add two drops of the donor’s serum to the same
tube.
ever, even a small amount of type A blood transfused
• Centrifuge the sample immediately for 30 sec at
into a cat with type B blood results in acute hemolysis
low speed.
and may be fatal.14 Therefore, crossmatching (see box on
• Check the sample for the presence of
this page) is essential for all feline blood transfusions. macroagglutination or microscopic agglutination.
Cats with type AB blood have been considered universal • If no agglutination is present, let the sample sit for
recipients because they have no RBC alloantibodies in 15 min at room temperature.
their blood. However, if type B blood is transfused into • Centrifuge the sample for 30 sec at low speed.
a recipient with type AB blood, the anti-A alloantibod- • Check the sample for the presence of
ies present in the donor blood can cause a significant macroagglutination or microscopic agglutination.
transfusion reaction. Cats with type AB blood should be a Modifiedwith permission from the University of Illinois
transfused with type-specific blood, if available, or type Standard Operating Procedure for Crossmatching.
A blood if it is not.15

July 2004 COMPENDIUM


504 CE Transfusion Medicine

Blood-typing cards (Rapid Vet-H Feline blood- of 35 days, and ACD has a shelf life of 21 days. Addi-
typing cards, DMS Laboratories, Inc., Flemington, NJ) tive solutions can be used to preserve RBC function for
are available for feline donors to discriminate among up to 42 days.17–19 Heparin has no preservative action,
types A, B, and AB (Figure 1). There are also canine and heparinized blood should be administered within 8
blood-typing cards (Rapid Vet-H Canine blood-typing hours of collection.5
cards, DMS Laboratories, Inc.) that identify the pres- Units of fresh whole blood may be centrifuged and
ence or absence of DEA 1.1 on donor RBCs. These fractionated into their component parts. RBCs precipi-

Understanding transfusion component therapy allows


practitioners to match specific products with disease entities.
cards can be quickly and easily used and may be helpful tate after centrifugation at 5000g for 5 minutes at 42.8˚F
in emergencies.16 However, blood-typing cards should (6˚C). The RBCs can then be separated from the plasma
not be considered a substitute for crossmatching. fraction and stored at 33.8˚F to 42.8˚F (1˚C to 6˚C).20
Plasma can be rapidly frozen (within 6 hours of blood
PREPARING BLOOD COMPONENTS collection) at –4˚F to –94˚F (–20˚C to –70˚C) for later
Whole blood can be collected (usually into commer- use as FFP.5 FFP contains albumin, globulins, and all
cially prepared blood bags) from donors via aseptic the coagulation factors, including the labile factors V
venipuncture. Anticoagulants used for blood products and VIII. The coagulation factors in FFP remain rela-
are citrate–phosphate–dextrose–adenine (CPDA-1) and tively stable for up to 1 year, after which FFP is no
acid–citrate–dextrose (ACD). CPDA-1 has a shelf life longer considered fresh but can be used as a source of

COMPENDIUM July 2004


Transfusion Medicine CE 505

albumin and vitamin K–dependent clotting factors II,


VII, IX, and X.3,5
Cryoprecipitate is formed when FFP is briefly thawed
and recentrifuged at 39.2˚F (4˚C) and 5000g for 5 min-
utes. After separation, the precipitate should be rapidly
refrozen at –4˚F to –94˚F (–20˚C to –70˚C). Cryopre-
cipitate contains concentrated von Willebrand factor
(vWF), clotting factors VIII and XIII, and fibrinogen.
To prepare platelet-rich plasma, whole blood should
be centrifuged at room temperature and 2000g for 3
minutes. Additional centrifugation at 4000g for 6 min-
utes can be used to separate platelets from plasma to
produce a platelet-concentrated unit.5 Platelet products
prepared in this way should be administered as soon as
possible (ideally, within 8 to 12 hours of collection).5,21,22
Plateletpheresis involves removing whole blood from a
donor, separating the platelet fraction, and transfusing
the remaining blood components into the animal.5 This
technique is used in large blood-banking institutions to
prepare platelet concentrates, which can then be sus-
pended and frozen in dimethyl sulfoxide (DMSO) and
stored for 6 months.23,24

USING BLOOD COMPONENTS


Whole Blood
Fresh whole blood contains RBCs, serum proteins,
clotting factors, and platelets. When whole blood is
stored, the labile clotting factors V and VIII are
destroyed within 24 hours and platelets within 2 to 4
hours. Concentrations of 2,3-diphosphoglycerate (2,3-
DPG) progressively decline with storage,20 adversely
affecting the ability to unload oxygen into peripheral
tissues. However, human studies have shown that 2,3-
DPG in transfused blood regenerates to 50% of normal
levels within 7 hours of administration and reaches nor-
mal levels in 24 to 72 hours.25
Transfusing fresh or stored whole blood may be indi-
cated during acute hemorrhage or when multiple blood Figure 1. A blood-typing card showing a positive result
components are required.26 Animals with hemolytic (via agglutination) for type A feline blood. (Courtesy of dms
laboratories)
anemia or decreased production of RBCs often have
increased intravascular volume as a compensatory
response to decreased oxygen delivery to tissues.27 Vol-
ume overload may be a concern with whole blood trans- Packed Red Blood Cells
fusions in these patients. Ammonia levels increase while pRBCs have the advantage of containing the same
blood products are stored. It has been suggested that amount of RBCs, and therefore oxygen-carrying capac-
animals with liver disease should be transfused with ity, as a unit of whole blood, but in a significantly
products that have been stored for less than 2 weeks, smaller volume. The PCV of a unit of pRBCs may vary
although posttransfusion hyperammonemia in veteri- from 55% to 80% in dogs or 45% to 65% in cats,
nary patients has not been documented.28 depending on the PCV of the donor, diluting effects of

July 2004 COMPENDIUM


506 CE Transfusion Medicine

added preservatives, and amount of residual plasma vol- Dilutional coagulopathy may occur with acute massive
ume in the bag. Some residual plasma is required to hemorrhage (e.g., trauma, hemoabdomen)36 or when
provide a healthy environment for RBCs.29 large volumes of fluids are rapidly administered during
pRBC transfusion is indicated in patients with ane- resuscitation (e.g., shock). In these situations, immedi-
mia caused by decreased erythropoiesis, hemolysis, or ately administering FFP may not be warranted unless
blood loss. The smaller volume is also an advantage there is clinical evidence of hemorrhage; however, the
when transfusing animals with concurrent cardiac or coagulation profile of patients with dilutional coagu-
renal compromise.30 lopathy should be monitored closely.
Transfusing specific coagulation factors for congenital
Leukocytes coagulation factor defects is not commonly performed in
Leukocyte transfusion has not been shown to be benefi- veterinary medicine. The exception is using cryoprecipi-
cial in critically ill veterinary patients.29 Leukocyte transfu- tate for surgical prophylaxis or to treat active hemorrhage
sions are expensive and difficult because they must be har- in vWF- or factor VIII–deficient patients.37,38 FFP trans-
vested from the buffy coat layer of multiple units of blood. fusions do not predictably increase the concentration and

Administering fractionated blood components


decreases the risk of transfusion reactions and volume
overload in critically ill patients.
Transfusing foreign leukocytes is unlikely to provide an duration of activity of vWF and factor VIII; thus large
immune benefit to a recipient animal and may more likely volumes of FFP may be required to control hemorrhage,
cause an immune reaction against the transfused cells.29 placing patients at risk for hypervolemia.37,38

Plasma Products Hypoproteinemia


The indications for using plasma products include Increased morbidity and mortality are well docu-
treating inherited and acquired factor deficiencies, treat- mented in humans with hypoalbuminemia (<2.5 g/dl)
ing coagulopathy, enhancing protective enzyme levels compared with those with normal albumin levels, 39
(i.e., α1-antitrypsins, α2-macroglobulins), and augment- although total proteins, rather than albumin alone, con-
ing intravascular colloid concentration.31 tribute to colloid osmotic pressure.40 In chronic condi-
tions, FFP transfusions have only a transient effect on
Coagulopathy albumin concentrations, and the volume of plasma
Liver failure or vitamin K deficiency (from either required to achieve a measurable increase in albumin is
cholestatic disease or vitamin K–antagonist ingestion) quite large, placing patients at risk for volume over-
may result in clinical coagulopathy.32,33 Patients that are load.40 Because nutrition and colloid osmotic pressure
actively hemorrhaging benefit from immediate supple- have the most influence on albumin synthesis, the most
mentation of clotting factors in FFP. 34,35 Fresh and effective way to increase long-term albumin concentra-
stored whole blood also contain vitamin K–dependent tions is with nutritional support.39,41 In the short term,
coagulation factors II, V, VII, and X and may be used if hypoproteinemic patients may benefit from a mild
an animal’s RBC count or PCV is decreased. increase in albumin from FFP in combination with
Disseminated intravascular coagulopathy (DIC) is a sec- oncotic support from synthetic colloids.3
ondary syndrome characterized by hemostatic dysfunction.
Correcting the primary pathology is specific therapy for Pancreatitis
DIC. Supportive therapy for patients with DIC includes FFP transfusion has been advocated in treating pan-
administering FFP to supplement clotting factors, anti- creatitis to provide coagulation factors, maintain albu-
thrombin, C-reactive protein (an acute-phase protein), and min concentrations, and supplement plasma protease
fibronectin (a glycoprotein that aids cellular adhesion).3,32 inhibitors (e.g., α2-macroglobulins, α1-antitrypsins).42

COMPENDIUM July 2004


510 CE Transfusion Medicine

However, human clinical trials have not shown consis- gen tension (P50) at a given oxygen saturation than do
tent improvement in morbidity and mortality when canine or feline RBCs and has enhanced carbon dioxide
FFP is administered to patients with pancreatitis.43,44 and oxygen affinity. This leads to improved uptake and
transport at a given oxygen tension.49,50 Economically
Antioxidant Properties appealing qualities include its long shelf life (i.e., 3
The primary mechanism whereby plasma has antioxi- years), ability to be stored at room temperature, and
dant properties is through iron sequestration, which abundant supply.49
limits the production of free hydroxyl radicals and pre- The oxygen-carrying effects of Oxyglobin last up to 3
vents subsequent cellular injury.45 There are no current days in circulation. However, in the absence of hemo-
guidelines for FFP administration with regard to its lytic processes, transfused RBCs should remain in circu-
antioxidant effects. lation more than 28 days. Oxyglobin also has significant
colloidal properties,51 and patients should be monitored
Platelet Products for signs of volume overload during administration.
Platelets are extremely labile in serum and may be lost Adverse gastrointestinal effects have been reported.52
from blood within a few hours of collection. Prophylactic After infusion, patients can demonstrate transient dis-
platelet transfusion is not recommended because platelet coloration (i.e., yellow–orange, orange–brown) of their
products are difficult to store24 and transfused platelets mucous membranes and, less frequently, skin. Urine may
are not retained for long periods in circulation, especially be similarly discolored, making interpretation of a urine
if the primary cause of thrombocytopenia is platelet dipstick inaccurate. After administration, total hemo-
destruction.33 However, if platelet loss or dysfunction is globin, rather than hematocrit, levels should be evalu-
causing ongoing bleeding, transfusion of platelet-rich ated. Depending on the dose administered, serum may
plasma or platelet concentrates may be indicated.46,47 appear red-tinged or red–brown. This color change may
Platelet concentrates frozen in DMSO (canine frozen influence chemistry analyzers by causing interference
platelet concentrate with 6% DMSO, Midwest Animal with colorimetric assays but does not alter noncolori-

Hemoglobin-based oxygen carriers can be used in


patients with acute hemorrhage and immune-mediated
anemia to reduce the risk of a transfusion reaction.

Blood Services, Stockbridge, MI) are available for use in metric tests, including most electrolyte panels, hemo-
veterinary medicine. There have not been studies on the grams, and coagulation assays.49,53 This effect is manu-
efficacy of these products in veterinary patients. facturer and machine dependent and is discussed in
detail in the package insert.
Hemoglobin-Based Oxygen Substitutes The manufacturer’s recommended dose of Oxyglobin
Hemoglobin-based oxygen carriers (HBOCs) have is 10 to 30 ml/kg IV up to a maximum rate of 10
been under investigation as a type of blood substitute, ml/kg/hr.54 In general, an initial dose of 10 ml/kg is rec-
principally to augment oxygen delivery to tissues. 48,49 ommended. Patients should be monitored because the
Oxyglobin (hemoglobin glutamer–200 [bovine], Bio- colloidal effects of Oxyglobin in circulation may lead to
pure) is a purified, polymerized bovine hemoglobin decreased cardiac output, increased systemic vascular
solution with an average hemoglobin concentration of resistance, and hemodilution.51,55 Oxyglobin is currently
13 g/dl. It is considered a universally compatible blood not registered for use in cats but has been used as an
product because it lacks cell surface antigens and re- off-label product at a dose of 5 to 15 ml/kg IV at a rate
duces the risk of contamination with infectious disease. of 5 ml/kg/hr.56 Cats are prone to volume overload and
Bovine hemoglobin does not rely on 2,3-DPG for influ- should be monitored closely during O xyglobin
encing oxygen affinity; thus Oxyglobin has a lower oxy- infusion.56

COMPENDIUM July 2004


Transfusion Medicine CE 511

Transfusion Rate ing calcium, such as lactated


Ringer’s solution, should not be
Example: A 44-lb (20-kg) dog with a PCV of 15% needs a pRBC transfusion. The
pRBCs have a PCV of 80%; the desired PCV for the dog is 28%. administered with blood prod-
ucts. Calcium deactivates the
Using the calculation: Using the guideline: citrate in the anticoagulant
Volume to be transfused: Desired PCV = 28% solution, possibly leading to
Desired PCV – Recipient PCV Recipient PCV = 15% thrombus formation. 29 Coad-
= kg × 90 ×
Donor PCV PCV must be raised by 13% ministering hypotonic or dex-
trose-containing fluids with
28 – 15 1 ml/kg of pRBC raises the PCV 1% blood products may result in
= 20 kg × 90 ×
80 13 ml/kg raises the PCV 13% hemolysis of RBCs and is
therefore not recommended.29
= 20 × 90 × 0.1625 Volume to be transfused:
= 13 × 20 kg All blood products should be
= 292.5 ml = 260 ml transfused within 4 hours to
reduce the risk of contamination
and bacterial colonization. 22,58
More rapid transfusion may be
ADMINISTERING BLOOD COMPONENTS indicated if there is ongoing blood loss or hypovolemia.
RBC products should be transfused to attain a PCV Care should be taken in patients with concurrent cardiac
8,29
of 25% to 30% in dogs or 20% in cats. This corre- or renal disease because of the risk of volume overload.29,32
sponds to results in human studies that do not recom- Plasma products should be thawed in a warm-water
mend transfusion above hemoglobin concentrations of 7 bath at 98.6˚F (37˚C) before transfusion. The access
to 10 g/dl (PCV: 21% to 30%), depending on a patient’s ports in the bag should be covered with plastic to avoid
27,57
clinical status. The volume of whole blood or pRBC contamination with water. Plasma products should be
required can be calculated using the following equation: administered through a dedicated IV line with a 170-
Volume to be transfused (ml) = µm filter. Once FFP has been thawed, it should be used
within 4 hours because the labile clotting factors deteri-
90 (Dogs) Desired PCV – Recipient PCV orate quickly and there is increased risk of subsequent
kg × or ×
Donor PCV bacterial contamination. The recommended starting
70 (Cats)
dose for FFP is 6 to 10 ml/kg3,29,31 (Table 1). Plasma
As a guideline, 2 ml/kg of whole blood raises the infusion should continue in coagulopathic patients until
PCV 1% (therefore, 20 ml/kg raises the PCV 10%). For hemorrhage is controlled or clotting times are within
pRBC, 1 ml/kg raises the PCV 1% (therefore, 10 ml/kg 1.5 times the upper limit of normal. A dose of 45 ml/kg
raises the PCV 10%)29 (see box on this page). These is required to raise the albumin concentration 1 g/dl in
general guidelines depend on the PCV of the donor hypoproteinemic patients,3 thus making FFP adminis-
blood and may underestimate the amount of blood tration for hypoalbuminemia generally unfeasible.
required for transfusion. In cases of known canine von Willebrand’s disease,
It is not necessary to warm pRBC or stored whole administering cryoprecipitate is recommended at an ini-
blood before transfusion, except for very small or pedi- tial dose of 1 unit/10 kg before a surgical procedure or
32
atric patients, which are at greater risk of hypothermia. as needed to stop ongoing hemorrhage.33,38
Blood products should not be warmed to higher than Platelet-rich plasma should be administered within 12
98.6˚F (37˚C) because this leads to hemolysis of cells, hours of collection at a dose of 1 unit/3 kg. Platelet concen-
precipitation of fibrinogen, and degradation of serum trates frozen in DMSO should be allowed to thaw at room
22
coagulation factors and proteins. temperature, with gentle mixing every 5 minutes. The ini-
Blood products should be administered via a dedi- tial dose of platelet concentrate should be 1 unit/10 kg.33
cated IV fluid line or in combination with 0.9% sodium
chloride (NaCl). The line should always contain a 170- TRANSFUSION REACTIONS
µm filter. pRBCs, in particular, may require dilution Transfusion reactions can be classified as immuno-
with fluids to facilitate administration. Fluids contain- logic or nonimmunologic. Acute immunologic reactions

July 2004 COMPENDIUM


512 CE Transfusion Medicine

Table 1. Blood Products: Indications for Use and Doses


Product Indications Infusion Rate Comments
Fresh whole blood Anemia 2 ml/kg to raise Risk of volume overload when
Hemorrhage PCV 1% administered to normovolemic
Coagulopathy patients
Stored whole blood Anemia 2 ml/kg to raise Loss of labile clotting factors V
Hemorrhage PCV 1% and VIII as well as platelets
pRBCs Anemia 1 ml/kg to raise Useful in patients with low
Hemorrhage PCV 1% PCV and normal total protein
Platelet concentrate Thrombocytopenia with 1 unit/10 kg Platelet transfusions have variable
active hemorrhage (as needed to efficacy in recipient animals
stop hemorrhage)
Platelet-rich plasma Thrombocytopenia 1 unit/3 kg All clotting factors and platelets
Coagulopathy present
Risk of volume overload in
normovolemic patients
FFP Antiprotease or antioxidant Coagulopathy: Multiple infusions may be needed
activity 6–10 ml/kg because of the short half-life of
Coagulopathy (as needed to the clotting factors
Hypoproteinemia stop hemorrhage)
Hypoalbuminemia:
45 ml/kg
Cryoprecipitate von Willebrand’s disease 1 unit/10 kg Administer 30 min before surgery
Hemophilia A
Hypofibrinogenemia
Oxyglobin Anemia Dogs: 10–20 ml/kg Monitor for volume overload
Shock Cats: 5–10 ml/kg Monitor hemoglobin levels, rather
than PCV, after transfusion

usually occur within the first 1 to 2 hours of transfusion changes in blood products during storage or administer-
but can be seen up to 48 hours later.4,14 Common clini- ing excessive volumes or rates of fluids 4 (Table 2).
cal signs are listed in Table 2. Acute hemolysis can also Changes in blood products may include hyperammone-
be seen if incompatible blood is administered, and this mia, 28 hypophosphatemia, hyperkalemia, 59 bacterial
reaction can be life threatening.4,9 contamination, or clot formation within the unit. Circu-
Fever is a common acute transfusion reaction that is latory (volume) overload, erythrocytosis, or hyper-
usually transient and does not require treatment. 4,7 proteinemia are also possible complications of blood
However, fever may also indicate acute hemolysis or product transfusion.4 Massive transfusions (greater than
bacterial contamination of the blood product, both of one blood volume) can lead to dilutional coagulopathy
which require prompt intervention. Evaluating the (thrombocytopenia and prolonged coagulation times) or
blood bag for evidence of infection is warranted. Vomit- cause citrate intoxication, which leads to clinical signs of
ing, diarrhea, abdominal pain, hypotensive shock, or hypocalcemia or hypomagnesemia.60
DIC may develop with bacterial contamination.4
Delayed immunologic reactions usually involve Preventing Transfusion Reactions
hemolysis and shorten the life span of transfused RBCs. Preventing transfusion reactions begins with screening
The normal life span of a transfused RBC is 21 to 48 blood donor animals and aseptically collecting and
days. A delayed transfusion reaction may result in an administering blood products. For cats, recipient blood
RBC life span of 2 to 5 days.30 should always be crossmatched with donor blood before
Nonimmunologic reactions occur because of either a transfusion.7 Dogs that have had a previous transfu-
(text continues on p. 516)

COMPENDIUM July 2004


Transfusion Medicine CE 513

Table 2. Transfusion Reactions


Transfusion Reaction Clinical Signs Treatment
Anaphylactic shock Collapse Stop the transfusion, administer epinephrine and
Respiratory and/or corticosteroids, and commence CPCR.
cardiac arrest

Type 1 hypersensitivity Tachypnea Stop the transfusion, administer corticosteroids and/or


Fever antihistamines, and restart the transfusion at a slower rate.
Cardiac arrhythmia
Vomiting
Urticaria
Pruritus
Angioedema
Erythema
Vomiting

Acute hemolysis Tachypnea Stop the transfusion and administer corticosteroids and
Fever IV fluids with or without vasopressor to maintain arterial
Hemoglobinemia blood pressure.
Hemoglobinuria
Collapse
Shock

Microbial infection Tachypnea Stop the transfusion and remove all contaminated lines
Tachycardia and catheters, collect donor blood sample and recipient
Fever blood and urine samples for culture, and administer
Vomiting systemic antibiotics and IV fluids to maintain blood
Shock pressure.
Collapse

Citrate overdose Hypocalcemia: Administer 10% calcium gluconate (1 ml/kg slow IV), and
Tremors monitor the ECG.
Fever
Cardiac arrhythmia
Vomiting
Seizures
Hypomagnesemia: Add magnesium sulfate (0.75–1 mEq/kg/day) to IV
Cardiac arrhythmia fluids.
Muscle weakness

Hypothermia Depression Stop the transfusion, administer warm blood products,


Shivering and begin active external warming of the patient.
Low temperature

Circulatory overload Tachypnea Stop the transfusion; administer diuretics with or without
Normal to low heart rate vasodilators; and restart the transfusion at a lower rate, if
Increased central appropriate, or use a different blood product (e.g., pRBCs
venous pressure rather than whole blood).
Pulmonary edema

Hyperkalemia Bradycardia Stop the transfusion, administer 0.9% NaCl IV for


Cardiac arrhythmia diuresis, and administer dextrose (0.5 g/kg) with insulin
ECG changes (0.01 units/kg).
CPCR = cardiopulmonary cerebral resuscitation; ECG = electrocardiogram.

July 2004 COMPENDIUM


516 CE Transfusion Medicine

sion or pregnancy also require crossmatching.10 Before transfusion, blood


products should be examined for changes in color or consistency that may
indicate hemolysis, clotting, or microbial infection. Transfusions should be
started at half the calculated rate for 15 minutes, and animals should be
constantly monitored for signs of tachypnea, increased heart rate, fever,
urticaria, or vomiting.8 Once the administration rate increases, animals
should be monitored every 15 to 30 minutes for signs of transfusion reac-
tions. Some authors recommend administering an antihistamine before any
transfusion to prevent type 1 hypersensitivity reactions.4,29

Managing Transfusion Reactions


If signs of acute transfusion reaction are detected, the transfusion should
be stopped immediately and crystalloid fluids infused to maintain blood
pressure, heart rate, and diuresis4 (Table 2). If the reaction is mild, the trans-
fusion may be restarted at a lower rate and the animal monitored closely for
progression of clinical signs.4

REFERENCES
1. Garratty G, Telen MJ, Petz LD: Red cell antigens as functional molecules and obstacles to transfusion.
Hematology (Am Soc Hematol Educ Prog):445–462, 2002.
2. Anniss AM, Sparrow RL: Expression of CD47 (integrin-associated protein) decreases on red blood cells
during storage. Transfus Apheresis Sci 27:233–238, 2002.
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10. Young LE, O’Brien WA, Swisher SN, et al: Blood groups in dogs: Their significance to the veterinarian.
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16. Feldman BF: In-house canine and feline blood typing. JAAHA 35:455–456, 1999.
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COMPENDIUM July 2004


Transfusion Medicine CE 517

26. Laine E, Steadman R, Calhoun L, et al: Comparison of RBCs and FFP with 40. Kaminski Jr MV, Haase TJ: Albumin and colloid osmotic pressure implica-
whole blood during liver transplant surgery. Transfusion 43:322–327, 2003. tions for fluid resuscitation. Crit Care Clin 8:311–321, 1992.
27. American Society of Anesthesiologists: Practice guidelines for blood compo- 41. Center SA: Pathophysiology of liver disease: Normal and abnormal function,
nent therapy. Anesthesiology 84:732–747, 1996. in Guilford WG, Center SA, Strombeck DR, et al (eds): Strombeck’s Small
28. Waddell LS, Holt DE, Hughes D, et al: The effect of storage on ammonia Animal Gastroenterology. Philadelphia, WB Saunders, 1996, pp 553–632.
concentration in canine packed red blood cells. J Vet Emerg Crit Care 42. Cuschieri A, Wood RA, Cumming JR, et al: Treatment of acute pancreatitis
11:23–26, 2001. with fresh frozen plasma. Br J Surg 70:710–712, 1983.
29. Kristensen AT, Feldman BF: General principles of small animal blood compo- 43. Goodman AJ, Bird NC, Jognson AG: Antiprotease capacity in acute pancre-
nent administration. Vet Clin North Am Small Anim Pract 25:1277–1290, 1995. atitis. Br J Surg 73:796–798, 1986.
30. Kerl ME, Hohenhaus AE: Packed red blood cell transfusions in dogs: 131 44. Leese T, Holliday M, Heath D, et al: Multicentre trial of low volume fresh
cases (1989). JAVMA 202:1495–1499, 1993. frozen plasma therapy in acute pancreatitis. Br J Surg 74:907–911, 1987.
31. Logan JC, Callan MB, Drew K, et al: Clinical indications for use of fresh 45. Marino PL: Oxidant injury, in Wingfield WE, Raffe MR (eds): The Veteri-
frozen plasma in dogs: 74 dogs (October through December 1999). JAVMA nary ICU Book. Jackson, WY, Teton NewMedia, 2002, pp 24–39.
218:1449–1455, 2001. 46. Schlossberg HR, Herman JH: Platelet dosing. Transfus Apheresis Sci 28:221–
32. Cotter SM: Clinical transfusion medicine. Adv Vet Sci Comp Med 36:187– 226, 2003.
223, 1991.
47. Rebulla P: Revisitation of the clinical indications for the transfusion of
33. College of American Pathologists: Practice parameter for the use of fresh-
platelet concentrates. Rev Clin Exp Hematol 5:288–310, 2001.
frozen plasma, cryoprecipitate and platelets. JAMA 271:777–781, 1994.
48. Moore EE: Blood substitutes: The future is now. J Am Coll Surg 196:1–17,
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rodenticide poisoning. Vet Med 94:466–471, 1999.
35. Kaul VV, Munoz SJ: Coagulopathy of liver disease. Curr Treat Options Gas- 49. Hughes Jr GS, Francome SF, Antal EJ, et al: Hematologic effects of a novel
troenterol 3:433–438, 2000. hemoglobin-based oxygen carrier in normal male and female subjects. J Lab
36. Lewis DC, Bruyette DS, Kellerman DL, et al: Thrombocytopenia in dogs Clin Med 126:444–451, 1995.
with anticoagulant rodenticide-induced hemorrhage: Eight cases (1990– 50. Muir WW, Wellman ML: Hemoglobin solutions and tissue oxygenation. J
1995). JAAHA 33:417–422, 1997. Vet Intern Med 17:127–135, 2003.
37. Stokol T, Parry B: Efficacy of fresh-frozen plasma and cryoprecipitate in dogs 51. Driessen B, Jahr JS, Lurie F, et al: Arterial oxygenation and oxygen delivery
with von Willebrand’s disease or hemophilia A. J Vet Intern Med 12:84–92, after hemoglobin-based oxygen carrier infusion in canine hypovolemic shock:
1998. A dose response study. Crit Care Med 31:1771–1779, 2003.
38. Meyers KM, Wardrop KJ, Meinkoth J: Canine von Willebrand’s disease: 52. Rentko VT, Wohl JS, Murtagh R, et al: A clinical trial of hemoglobin-based
Pathobiology, diagnosis and short-term treatment. Compend Contin Educ oxygen carrying (HBOC) fluid in the treatment of anemia [abstract]. 14th
Pract Vet 14:13–22, 1992. Annual ACVIM Forum:177, 1996.
39. Kaminski Jr MV, Williams SD: Review of the rapid normalization of serum 53. Callas DD, Clark TL, Moreira PL, et al: In vitro effects of a novel hemoglo-
albumin with modified total parenteral nutrition solutions. Crit Care Med bin-based oxygen carrier on routine chemistry, therapeutic drug, coagulation,
18:327–335, 1990. hematology, and blood bank assays. Clin Chem 43:1744–1748, 1997.
518 CE Transfusion Medicine

54. Food and Drug Administration 21CFR522.1125: Hemoglobin glutamer-200 d. Crossmatching is not required for the first transfu-
(bovine). 63 Federal Register 11598 10:1998. sion to any cat but is mandatory for all subsequent
55. Driessen B, Jahr JS, Lurie F, et al: Inadequacy of low-volume resuscitation
with hemoglobin-based oxygen carrier hemoglobin-200 (bovine) in canine transfusions.
hypovolemia. J Vet Pharmacol Ther 24:61–71, 2001.
56. Gibson GR, Callan MB, Hoffman V, et al: Use of a hemoglobin-based oxygen- 4. An 11-lb (5-kg) cat with a PCV of 15% will
carrying solution in cats: 72 cases (1998–2000). JAVMA 221:96–102, 2002. receive a transfusion of pRBCs with a PCV of
57. Hebert PC, Wells G, Marshall J, et al: Transfusion requirements in critical 55%. A transfusion rate of ___ ml/hr will most
care. JAMA 273:1439–1444, 1995.
likely increase the PCV by 10% in 4 hours.
58. Widmann FK: American Association of Blood Banks Technical Manual, ed 9.
Arlington, VA, American Association of Blood Banks, 1985. a. 10 c. 20
59. Price GS, Armstrong PJ, McLeod DA, et al: Evaluation of citrate–phos- b. 15 d. 30
phate–dextrose–adenine as a storage medium for packed canine erythrocytes.
J Vet Intern Med 2:126–132, 1988. 5. Which statement about Oxyglobin is incorrect?
60. Jutkowitz LA, Rozanski EA, Moreau JA, et al: Massive transfusion in dogs. a. Oxyglobin is a purified, polymerized, equine hemoglo-
JAVMA 220:1664–1669, 2002.
bin solution.
b. Oxyglobin is less likely to cause transfusion reactions
than are RBC products.
ARTICLE #1 CE TEST
This article qualifies for 1.5 contact hours of continuing CE c. Administering excessive Oxyglobin may lead to vol-
ume overload resulting from its colloidal properties.
education credit from the Auburn University College of d. Oxyglobin transfusion commonly causes skin and
Veterinary Medicine. Subscribers who wish to apply this serum discoloration, which may affect blood chem-
credit to fulfill state relicensure requirements should consult istry results.
their respective state authorities regarding the applicability
of this program. To participate, fill out the test form inserted 6. Which statement about platelet products is
at the end of this issue.To take CE tests online and get real- incorrect?
time scores, log on to www.VetLearn.com. a. Platelets should be rapidly collected and stored after
blood donation.
1. Which statement about blood donors is incorrect? b. Platelets should be transfused to thrombocytopenic
a. Dogs should be healthy adults and test negative for animals only if they have ongoing hemorrhage.
DEA 1.1. c. Platelet concentrates can be stored frozen in DMSO
b. Cats should be screened for retroviral, T. gondii, and for up to 6 months.
M. hemofelis infections before donating blood. d. Transfused platelets last for long periods in recipient
c. Purebred Akitas should not be used for blood dona- animals.
tions because of the high level of potassium in their
RBCs. 7. Which condition is not a sign of type 1 hypersen-
sitivity reactions?
d. Blood-donor dogs should weigh more than 66 lb (30
a. thrombocytopenia c. vomiting
kg) and have a PCV greater than 45%.
b. urticaria d. cardiac arrhythmia
2. Which statement regarding 2,3-DPG is incorrect?
8. For which condition is an FFP transfusion not
a. 2,3-DPG is required to unload oxygen from hemo-
indicated?
globin into peripheral tissues.
a. DIC
b. 2,3-DPG levels decline with storage of RBC products. b. vitamin K–antagonist intoxication
c. 2,3-DPG levels return to normal in transfused RBCs c. immune-mediated thrombocytopenia
within 7 hours of administration. d. fulminant liver failure
d. Oxyglobin contains bovine hemoglobin, which does
not rely on 2,3-DPG for oxygen affinity. 9. For which condition is a cryoprecipitate transfu-
sion indicated?
3. Which statement regarding feline blood types is a. von Willebrand’s disease
correct? b. hemophilia A (factor VIII deficiency)
a. Because they have no alloantibodies in their blood, c. hemophilia B (factor IX deficiency)
cats with type AB blood can be used as universal d. a and b
donors.
b. Type A blood transfused into a cat with type B blood 10. Which condition is not a delayed-type transfu-
results in hemolysis of RBCs within 2 to 3 days. sion reaction?
c. Cats with type AB blood should be transfused with a. hypocalcemia c. hyperammonemia
type A blood if type-specific blood is not available. b. hypokalemia d. pulmonary edema

COMPENDIUM July 2004