Red Blood Cells (RBCs)

provide oxygen-carrying capacity

Red cell transfusion

treat acute or chronic anemia

A patient's ability to tolerate anemia depends on:

1. 2. 3.

degree of anemia physiologic adaptive mechanisms cardiac or respiratory disease

Normal physiologic adaptations to anemia

increased cardiac output redistribution of blood flow increased oxygen extraction increased red cell 2,3-DPG

Symptomatic anemia
-indication for transfusion

Symptoms of anemia - Fatigue - Tachycardia - Tachypnea - Dyspnea - Postural hypotension - Impaired mentation

*Acute bloodblood greatergreater than 15% of a than 15% patient's *Acute loss of loss of indicationof ared cell blood volume may be an for patient's transfusion blood volume may be an indication

for red cell transfusion

Red Cell Transfusion Guidelines Symptomatic anemia in a euvolemic patient Acute blood loss of < 15% of estimated blood volume Preoperative Hb < 9.0 g/dL with expected blood loss > 500 mL Hb < 7.0 g/dL in a critically ill patient Hb < 8.0 g/dL in a patient with an acute coronary syndrome Hb < 10.0 g/dL with uremic or thrombocytopenic bleeding Sickle cell disease: Acute sequestration: Hb < 5.0 g/dL or decrease of 20% from baseline Acute chest syndrome: Target Hb =10 g/dL, HbS fraction < 30% Stroke prophylaxis: Target HbS fraction < 30% General anesthesia: Target Hb =10.0 g/dL, HbS fraction < 60%

Sickle Cell Disease (SCD)

Indications for transfusion in SCD x to augment oxygen-carrying capacity x to improve microvascular circulation by decreasing the proportion of sickle red cells.
Oxygen delivery in SCD is a balance between oxygencarrying capacity and blood viscosity.

Autoimmune Hemolytic Anemia

transfusion may be indicated if there are

cardiac or neurologic symptoms

Most patients with autoimmune Most patients with autoimmune hemolytic hemolytic anemia tolerate transfusion of anemia tolerate transfusion of incompatible incompatible red cells, if alloantibodies red cells, if alloantibodies have been excluded. have been excluded.

Bleeding Associated with Uremia

There is an inverse relationship between

hematocrit and bleeding time in patients with chronic renal failure.

Transfusion of one unit of red blood cells raises:

Hemoglobin= 1 g/dL Hematocrit= 3%

A platelet transfusion is an intravenous transfer of platelets collected from a donor or pooled from multiple donors. Indicated for prevention or treatment of hemorrhage due to:
Thrombocytopenia Platelet dysfunction

Thrombocytopenia due to decreased production

Stable patient: Plt. Count <10 000/ L Fever: Plt. Count < 20 000/ L Bleeding, invasive procedure or surgery: Plt.

Count < 40 000-50 000 L Retinal or CNS bleeding: Plt. Count < 100 000/ L

Microvascular bleeding due to platelet dysfunction

Relatively contraindicated in immune thrombocytopenic purpura (ITP) Can be deleterious heparin-induced thrombocytopenia or thrombotic thrombocytopenic purpura

Transfusion of one apheresis platelet unit, or equivalent of whole blood platelet concentrates, can typically be expected to raise the platelet count of an adult by 20 000-40 000/ L Approximately one hour post-transfusion, the blood platelet count should increase by 8000-10 000/ L for each 1x1011 platelets transfused for each square meter of body surface area

Consumption or bleeding Splenomegaly Platelet antibodies Drugs

o o o o o

antibiotics heparin antiplatelet agents (clopidogrel, tirofiban) quinidine antithymocyte globulin

Used in assessing platelet transfusion effectiveness Takes into account dose and body size

CCI = Platelet count increment x BSA_ No. of platelets transfused (x1011)

BSA= body surface area (m2)

Pretransfusion platelet count = 8000/ L Post-transfusion platelet count = 36 000/ L BSA = 1.5 m2 Platelet dose = 3.0 x 1011

CCI = 24 000 x 1.5 3 CCI = 12 000

A CCI > 7500 at 1 hour or a CCI of > 4500 at 24 hours generally indicates a successful transfusion. Obtaining a platelet count within 1 hour of completing the transfusion may be helpful to distinguish immune from nonimmune causes of platelet refractoriness.

Typically, the immune refractoriness will result in an inadequate platelet increment when measured at 1 hour. Typical non-immune refractoriness will manifest as an adequate CCI at 1 hour, but shortened survival time so that the platelet count by 24 hours may be back to the baseline.

It must be appreciated that the CCI does not indicate that an adequate platelet count has been achieved. It only indicates the adequacy of platelet count increment in relation to the number of platelets transfused.

Febrile (fever/chill) Reactions Bacterial Contamination Transfusion Related Acute Lung Injury

Plasma may be used to replace any plasma protein deficiency and is the most commonly used component for the replacement of coagulation factor deficiencies when no factor concentrate is available However, purified protein concentrates (e.g. factor VIII, albumin, or immunoglobulin) are preferable for replacement of specific deficiencies

It is the preferred choice for rapid reversal of warfarin, although factor IX complex conentrate is also effective Plasma is a source of von Willebrand Factor (vWF) protease activity and is, thus, used in cases of thrombotic thrombocytopenic purpura Plasma may also be used to treat multifactorial diseases due to:

liver disease massive bleeding multiorgan system failure warfarin therapy

Single-Donor Plasma
Fresh Frozen Plasma (FFP) Plasma Frozen Within 24 hours after

phlebotomy (PF24) Plasma cryoprecipitate-reduced

Plasma and Liquid Plasma S/D-Pooled Plasma

Plasma is frozen within 8 hours of collection if CPD, CD2D, or CPDA-1 was used as an anticoagulant

Contains maximum levels of labile and nonlabile clotting factors about 1 IU per mL

Fresh Frozen Plasma (FFP)

Frozen within 6 hours when the preservative used was ACD

Thawed at temperatures between 30C and 37C

Stored at 18C for 1 year or 65C for 7 years

Plasma is frozen within 8 to 24 hours of collection

Contains all stable proteins found in FFP

PF24

Stored at 18C

Thawed at temperatures between 30C and 37C

Patients who are actively bleeding Patients with multiple clotting deficiencies

Massive trauma Surgery Liver disease DIC

Note: 1 unit of FFP or PF24 contains

150 to 250 mL of plasma Around 400 mg of fibrinogen 1 unit of activity per mL of each of the stable clotting factors

Used exclusively for treatement of thombotic thrombocytopenic purpura Cyroprecipitate is removed from plasma and the product is stored at -18C or older Expires 1 year from time of collection

Can be prepared directly from whole blood or as a product of platelet concentrate or cryoprecipitate production Used as volume expanders or for manufacturing plasma fractionation products such as plasma protein fraction (PPF), normal serum albumin (NSA), and immune serum globulin

Consists of pools of no more than 2500 units of ABO type-specific plasma that has been treated with solvent-detergent in the thawing process to inactivate lipidenveloped viruses such as HIV and hepatitis B Solvent: tri-n-butyl phosphate Detergent: triton X-100

contains labile and stable clotting factors but lacks von Willebrands factor multimers does not protect against non-enveloped viruses

Coagulation factor deficiency Dilutional coagulopathy Hemorrhage in liver disease Disseminated intravascular coagulation (DIC) Coumadin reversal Thrombotic thrombocytopenic purpura

tests used to assess the need for plasma transfusion poorly predictive, however, of bleeding risk if PT and aPTT are less than 1.5 times the midpoint of the reference range, there is no benefit to be obtained from plasma transfusion

Normal Values: (HemoStat) PT = 10 -14 seconds aPTT = 23.4 -26.2 secodns

established by the WHO for reporting the results of blood coagulation (clotting) tests if less than 1.5, no benefit can be obtained from plasma transfusion For nervous system and retinal hemorrhage, plasma may be reasonably used unless the INR is less than 1.3

For maximal hemostatic effect, plasma should be transfused immediately before an invasive procedure For the bleeding patient, plasma transfusion may need to be repeated every 3-4 hours to maintain adequate coagulation factor levels A dose of 10-20 mL per kilogram is necessary to achieve a hemostatic effect

neonates particularly receive RBC transfusions because of:

anemia of prematurity HDN iatrogenic blood loss

unique physiology of the neonatal period and the relative fragility of the developing brain vasculature necessitate some differences from the approach to older children or adults

RBC Transfusion Hct <20% with symptomatic anemia Hct <30% with supplemental O2 <35% or mechanical ventilation with MAP <6 cm H2O Hct <35% with supplemental O2 >35% or mechanical ventilation with MAP >6 cm H2O Hct <45% with cyanotic congenital heart disease or extracorporeal oxygenation *MAP, mean arterial pressure

Plasma Transfusion Coagulation factor deficiency, factor concentrate unavailable Disseminated intravascular coagulation (DIC)

Platelet Transfusion Platelet count <30,000/ L in term infant with platelet production failure Platelet count <50,000/ L in stable premature infant Platelet count <100,000/ L in unstable premature infant

RBC transfusion of 15 mL/kg will increase the Hb by 2 3 g/dL Platelet transfusion of 10 mL/kg will increase the platelet count by 40,00050,000/ L Large-volume transfusions (exchange transfusion or cardiac surgery) fresh RBCs (typically <10 days old) may be indicated For transfusions of 15 mL/kg, most infants tolerate transfusion of RBCs stored until outdate without adverse effects. For a premature infant with an expected ongoing transfusion requirement, the use of aliquots of a single unit until outdate can significantly reduce donor exposures

Premature and low-birthweight infants are at greater risk of CMV infection and graft-versushost disease Transfusion of the neonate with hyperbilirubinemia - indicated if the total bilirubin is greater than 25 mg/dL.

Relating the total bilirubin to hours since birth is predictive of kernicterus risk Two-blood volume exchange is typically used
x expected to reduce the total bilirubin by 25% and the fetal red cell mass by about 70%

Whole blood or RBCs reconstituted with compatible plasma to Hct of 45% can be used

Cryoprecipitate is indicated in the treatment of:

Classic Hemophilia A (Factor Vlll deficiency)

Von Willebrands disease

Factor Xlll deficiency

Hypofibrinogenemia (Cryoprecipitate as a source of fibrinogen)

Prepared from a single whole blood unit collected into CPDA-1 or CPD and suspended in less than 15 mL of plasma and from FFP thawed slowly between 1 and 6C Must be transfused within 6 hours of thawing or 4 hours of pooling Typical adult dose= 10units Cryoprecipitate
- A coldprecipitated concentration of factor Vlll, AHF, rich in FVlll, vWF, fibrinogen and fibronectin

Infusion rate= 5-10 mL/min

Shelf life: 12 months in the frozen state (18C)

Contains at least 80 units of AHF activity and 250 mg of fibrinogen

Like FFP and PF24, cryoprecipitate should be thawed quickly at 37C Once thawed, FDA recommends storing at roo temperature (22 - 24 C) until transfused

1. Venipuncture must be non traumatic

2. At least 200 mL plasma(205g) should be used to ensure at least 80 AHF units in the final product

3. Plasma must be frozen within 8 hours of collection and within 1 hour from the time freezing was initiated

4. Allow frozen plasma to thaw slowly in the blood bank refrigerator at 1-6C (14-16 hrs) or in 4C water bath (4hrs) until plasma becomes slushy (endpoint)

5. hard spin centrifuge the plasma at 4C

6. Express supernatant plasma into attached satellite bag. Cryoprecipitate= small white mass in the original plasma bag

7. Separate and freeze cryoprecipitate immediately (no more than 1hr from the time plasma becomes slushy). Delay in freezing or exposure to elevated temp. will significantly decrease FVlll activity level in final product.

Production of cryoprecipitate (cryoPP)