blood transfusion

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Introduction

Emergencies

Indications

* post acute myocardial infarction, a transfusion threshold of hemoglobin < 8 g/dl was non-inferior to a transfusion threshold of hemoglobin < 10 g/dl in preventing major cardiovascular events within 30 days[37] (no statistical difference[38]

* cardiac-related death at 30 days occurs less often with threshold of < 10 g/dl (4% vs. 6%)[42]

* all-cause mortality at 6 months less common with threshold of < 10 g/dl (19% vs. 21%)[42]

* cncidences of acute heart failure & other adverse events are similar[2]

Contraindications

* discuss alternative strategies during informed consent

* Rh-negative females of child-bearing potential should never be given Rh-positive blood[2]

Benefit/risk

* largest trial used a blood hemoglobin of 10.0 g/dL for liberal & 7.0 g/dl for conservative transfusion threshold[19]

* other studies used varying hematocrit levels as the trigger, or followed a protocol of immediate post-operative transfusion vs transfusing at a blood hemoglobin below 9.0 g/dL[19]

* 30-day mortality is higher in transfused than in nontransfused post surgical patients (13% vs 10%)[20]

* 30-day incidence of postoperative complications is higher in transfused patients (43% vs 39%)[20]

* restrictive strategy (Hgb < 7.5 g/dL) equivalent to liberal strategy (Hgb < 9.5 g/dL if in ICU, 8.5 g/dL not in ICU) 6 months after cardiac surgery[31]

* myocardial infarction occurs less commonly in transfused post surgical patients cohort (4% vs 7%)[20]

* blood hemoglobin target in post myocardial infarction with anemia is 9 g/dL[40]

* no consensus on what defines conservative transfusion threshold

Laboratory

Procedure

large bore peripheral intravenous access if large volumes of blood & crystalloid are needed quickly[2]

use the minimum number of units needed to relieve symptoms

the goal in stable, non-cardiac patients is a hemoglobin of 7 to 8 g/dL[10]

normal saline (0.9%) is the only IV solution to be used with a blood transfusion

An RN must start the infusion

Another person must verify the patient's identity

  • an MD, an RN or an LPN

Vital signs must be checked

  • before the transfusion starts
  • 15 minutes after transfusion starts
  • hourly until the transfusion is complete
  • 15 minutes post completion of transfusion

Transfusion of blood must be initiated within 30 minutes of release from the blood bank

Transfusion of 1st 50 mL of blood over a period of 15 minutes, remainder should be tranfused in < 3-4 hours

Verification prior to starting transfusion:

  • patient's id
  • patient's ABO type
  • patient's RH type
  • transfusion number

Patients may be observed for transfusion reactions by

  • RN, LPN, nursing assistant

The development of fever during transfusion requires the tranfusion be stopped until a hemolytic reaction can be ruled out[2]

Prophylaxis

Complications

Notes

  • also see blood donation
  • blood products transfused to patients with stem cell transplantation should be irradiated to prevent graft vs host disease[2]
  • ICU patient survival unaffected by the age of transfused blood[17]
  • AABB recommends using standard-issue blood rather than limiting transfusions to fresher blood (<10 days' storage)[25]
  • organ dysfunction after cardiac surgery unaffected by the age of transfused packed RBC[18]
  • fresh packed red blood cells no better than those stored for longer period of time[26]
  • receipt of blood transfusion from an ever-pregnant female donor, compared with a male donor, associated with increased all-cause mortality among male recipients (RR=1.13) but not among female recipients (RR=0.99)[29]
  • receipt of bllod ransfusions from never-pregnant female donor is not associated with increased mortality among male or female recipients[29]
  • factors influencing blood hemoglobin increases after transfusion[36]
    • larger hemoglobin increments observed in recipients of male-donor units vs female-donor units
    • larger hemoglobin increases in recipients of whole-blood-derived units compared with apheresis-derived units
    • donor- or recipient-positive RhD status associated with increased hemoglobin increments
    • donor age > 70 years & RBC storage durations > 35 days associated with decreased hemoglobin increment 24 & 48 hours after transfusion
    • irradiation results in smaller hemoglobin increments after transfusion
    • characteristics additive: lowest increments observed in recipients of irradiated or apheresis-derived units from female donors[36]

More general terms

More specific terms

Additional terms

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 613-616
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  3. Veterans Administration
  4. [No authors listed] Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the american society of anesthesiologists task force on perioperative blood transfusion and adjuvant therapies. Anesthesiology. 2006 Jul;105(1):198-208. No abstract available. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16810012 corresponding NGC guideline updated Feb 2016 http://www.anesthesiology.org/pt/re/anes/fulltext.00000542-200607000-00030.htm
  5. Jump up to: 5.0 5.1 Carson JL et al Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB Annals of Internal Medicine, March 26, 2012 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22454395 <Internet> http://www.annals.org/content/early/2012/03/26/0003-4819-156-12-201206190-00429.full corresponding NGC guideline withdrawn June 2017
    Vincent JL Indications for Blood Transfusions: Too Complex to Base on a Single Number? Annals of Internal Medicine, March 26, 2012 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22454394 <Internet> http://www.annals.org/content/early/2012/03/26/0003-4819-156-12-201206190-00431
  6. Transfusion medicine. A series of papers. The Lancet. May 24, 2013 http://www.thelancet.com/themed/transfusion-medicine
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