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]

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
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018, 2022
  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. ↑ 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
  7. ↑ Goodell PP, Uhl L, Mohammed M, Powers AA. Risk of hemolytic transfusion reactions following emergency- release RBC transfusion. Am J Clin Pathol. 2010 Aug;134(2):202-6 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20660321
  8. ↑ Boucher BA, Hannon TJ. Blood management: a primer for clinicians. Pharmacotherapy. 2007 Oct;27(10):1394-411. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17896895
  9. ↑ Hebert PC, Wells G, Blajchman MA et al A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999 Feb 11;340(6):409-17. PMID: https://www.ncbi.nlm.nih.gov/pubmed/9971864
  10. ↑ 10.0 10.1 Hicks LK et al. The ASH Choosing Wisely Campaign: Five hematologic tests and treatments to question. Blood 2013 Dec 5; 122:3879. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24319155 <Internet> http://bloodjournal.hematologylibrary.org/content/122/24/3879
  11. ↑ Carson JL, Grossman BJ, Kleinman S et al Red blood cell transfusion: a clinical practice guideline from the AABB*. Ann Intern Med. 2012 Jul 3;157(1):49-58 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22751760 corresponding NGC guideline withdrawn June 2017
  12. ↑ Carson JL, Terrin ML, Magaziner J et al Transfusion trigger trial for functional outcomes in cardiovascular patients undergoing surgical hip fracture repair (FOCUS). Transfusion. 2006 Dec;46(12):2192-206. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17176334
  13. ↑ Carson JL, Terrin ML, Noveck H et al Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011 Dec 29;365(26):2453-62 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22168590
  14. ↑ 14.0 14.1 Brett AS Incidence of Transfusion Complications in Noncardiac Surgery Patients. NEJM Journal Watch. Jan 13, 2015 Massachusetts Medical Society (subscription needed) http://www.jwatch.org
    Clifford L et al. Characterizing the epidemiology of perioperative transfusion- associated circulatory overload. Anesthesiology 2015 Jan; 122:21 PMID: https://www.ncbi.nlm.nih.gov/pubmed/25611653
  15. ↑ 15.0 15.1 Pinheiro de Almeida J et al. Transfusion requirements in surgical oncology patients: A prospective, randomized controlled trial. Anesthesiology 2015 Jan; 122:29. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25401417 <Internet> http://anesthesiology.pubs.asahq.org/Article.aspx?articleid=2043033
  16. ↑ 16.0 16.1 16.2 Murphy GJ et al. Liberal or restrictive transfusion after cardiac surgery. N Engl J Med 2015 Mar 12; 372:997. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25760354 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1403612
    Spertus J. "TITRe"ing the approach to transfusions after cardiac surgery. N Engl J Med 2015 Mar 12; 372:1069. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25760360 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1415394
  17. ↑ 17.0 17.1 Lacroix J et al. Age of transfused blood in critically ill adults. N Engl J Med 2015 Mar 17; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25776801 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1500704
  18. ↑ 18.0 18.1 18.2 Steiner ME et al. Effects of red-cell storage duration on patients undergoing cardiac surgery. N Engl J Med 2015 Apr 9; 372:1419. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25853746 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1414219
  19. ↑ 19.0 19.1 19.2 19.3 The NNT: Using Liberal Hemoglobin Levels As Indication for Blood Transfusion
    http://www.thennt.com/nnt/liberal-hemoglobin-levels-for-blood-transfusions/
    Carless PA, Henry DA, Carson JL, Hebert PP, McClelland B, Ker K. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev. 2010 Oct 6;(10):CD002042 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20927728
  20. ↑ 20.0 20.1 20.2 20.3 Abdelsattar ZM et al. Variation in transfusion practices and the effect on outcomes after noncardiac surgery. Ann Surg 2015 Jul; 262:1. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26020111
  21. ↑ 21.0 21.1 Murphy EL, Kwaan N, Looney MR et al Risk factors and outcomes in transfusion-associated circulatory overload. Am J Med. 2013 Apr;126(4):357.e29-38 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23357450
  22. ↑ Salpeter SR, Buckley JS, Chatterjee S. Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review. Am J Med. 2014 Feb;127(2):124-131.e3. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24331453
  23. ↑ Ortega R, Canelli RJ, Quillen K et al (video) Transfusion of Red Cells. N Engl J Med 2016; 374:e12. March 17, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26981950 (video) <Internet> http://www.nejm.org/doi/full/10.1056/NEJMvcm1504413
  24. ↑ Hogshire LC, Patel MS, Rivera E, Carson JL. Evidence review: periprocedural use of blood products. J Hosp Med. 2013 Nov;8(11):647-52. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24124069
  25. ↑ 25.0 25.1 25.2 25.3 25.4 25.5 Carson JL, Guyatt G, Heddle NM et al Clinical Practice Guidelines From the AABB. Red Blood Cell Transfusion Thresholds and Storage. JAMA. Published online October 12, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27732721 <Internet> http://jamanetwork.com/journals/jama/article-abstract/2569055
    Yazer MH, Triulzi DJ AABB Red Blood Cell Transfusion Guidelines. Something for Almost Everyone. JAMA. Published online October 12, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27732707 <Internet> http://jamanetwork.com/journals/jama/fullarticle/2569053
  26. ↑ 26.0 26.1 Heddle NM, Cook RJ, Arnold DM et al Effect of Short-Term vs. Long-Term Blood Storage on Mortality after Transfusion. N Engl J Med. October 24, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27775503 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1609014?query=pfw&jwd=000000793830&jspc=FPG
    Tobian AA, Ness PM Red Cells - Aging Gracefully in the Blood Bank. N Engl J Med. October 24, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27775504 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1612444
  27. ↑ 27.0 27.1 Bergamin FS et al. Liberal versus restrictive transfusion strategy in critically ill oncologic patients: The Transfusion Requirements in Critically Ill Oncologic Patients randomized controlled trial. Crit Care Med 2017 May; 45:766. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28240687 <Internet> http://insights.ovid.com/crossref?an=00003246-201705000-00003
  28. ↑ Rothaus C Red-Cell Transfusion. Resident 360. Sept. 27, 2017 https://resident360.nejm.org/content_items/red-cell-transfusion
  29. ↑ 29.0 29.1 29.2 Caram-Deelder C, Kreuger AL, Evers D et al Association of Blood Transfusion From Female Donors With and Without a History of Pregnancy With Mortality Among Male and Female Transfusion Recipients. JAMA. 2017;318(15):1471-1478 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29049654 https://jamanetwork.com/journals/jama/article-abstract/2657377
    Cable RG, Edgren G Blood Transfusions From Previously Pregnant Women and Mortality. Interpreting the Evidence. JAMA. 2017;318(15):1445-1447. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29049638 https://jamanetwork.com/journals/jama/article-abstract/2657356
  30. ↑ 30.0 30.1 Mazer CD, Whitlock RP, Fergusson DA et al Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery. N Engl J Med. Nov 12, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29130845 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1711818
  31. ↑ 31.0 31.1 31.2 Mazer CD, Whitlock RP, Fergusson DA et al. Six-month outcomes after restrictive or liberal transfusion for cardiac surgery. N Engl J Med 2018 Aug 26; PMID: https://www.ncbi.nlm.nih.gov/pubmed/30146969 Free Article https://www.nejm.org/doi/10.1056/NEJMoa1808561
  32. ↑ Choosing Wisely. July 23, 2018 Society for the Advancement of Blood Management. http://www.choosingwisely.org/societies/society-for-the-advancement-of-blood-management/
  33. ↑ 33.0 33.1 Goel R et al. Association of perioperative red blood cell transfusions with venous thromboembolism in a North American registry. JAMA Surg 2018 Sep 1; 153:826 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29898202
  34. ↑ Roubinian NH, Murphy EL, Mark DG et al. Long-term outcomes among patients discharged from the hospital with moderate anemia: A retrospective cohort study. Ann Intern Med 2018 Dec 18; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/30557414 <Internet> http://annals.org/aim/article-abstract/2719218/long-term-outcomes-among-patients-discharged-from-hospital-moderate-anemia
    Shander A, Goodnough LT. From tolerating anemia to treating anemia. Ann Intern Med 2018 Dec 18; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/30557445 <Internet> http://annals.org/aim/article-abstract/2719220/from-tolerating-anemia-treating-anemia
  35. ↑ 35.0 35.1 Kherad O, Restellini S, Martel M et al. Outcomes following restrictive or liberal red blood cell transfusion in patients with lower gastrointestinal bleeding. Aliment Pharmacol Ther. 2019 Apr;49(7):919-925: ePub Feb 25 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30805962 https://onlinelibrary.wiley.com/doi/full/10.1111/apt.15158
  36. ↑ 36.0 36.1 36.2 Roubinian NH, Plimier C, Woo JP et al. Effect of donor, component, and recipient characteristics on hemoglobin increments following red blood cell transfusion. Blood 2019 Sep 26; 134:1003. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31350268 https://ashpublications.org/blood/article-abstract/134/13/1003/374918/Effect-of-donor-component-and-recipient?redirectedFrom=fulltext
  37. ↑ 37.0 37.1 Ducrocq G, Gonzalez-Juanatey JR, Puymirat E et al Effect of a Restrictive vs Liberal Blood Transfusion Strategy on Major Cardiovascular Events Among Patients With Acute Myocardial Infarction and Anemia. The REALITY Randomized Clinical Trial. JAMA. 2021;325(6):552-560 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33560322 https://jamanetwork.com/journals/jama/fullarticle/2776201
  38. ↑ 38.0 38.1 Carson JL et al. Restrictive or liberal transfusion strategy in myocardial infarction and anemia. N Engl J Med 2023 Nov 11; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/37952133 https://www.nejm.org/doi/10.1056/NEJMoa2307983
  39. ↑ Raasveld SJ, de Bruin S, Reuland MC et al Red Blood Cell Transfusion in the Intensive Care Unit JAMA. 2023;330(19):1852-1861. https://jamanetwork.com/journals/jama/fullarticle/2810759
  40. ↑ 40.0 40.1 Portela GT, Carson JL, Swanson SA et al for the MINT Investigators Effect of Four Hemoglobin Transfusion Threshold Strategies in Patients With Acute Myocardial Infarction and Anemia: A Target Trial Emulation Using MINT Trial Data. Ann Intern Med. 2024 Oct 1. PMID: https://www.ncbi.nlm.nih.gov/pubmed/39348705
    Bloch EM, Tobian AAR. Relaxing Transfusion Thresholds for Patients With Myocardial Infarction: Findings From the MINT Trial. Ann Intern Med. 2024 Oct 1. PMID: https://www.ncbi.nlm.nih.gov/pubmed/39348694 No abstract available.
  41. ↑ 41.0 41.1 Taccone FS, Rynkowski Bittencourt C et al. Restrictive vs liberal transfusion strategy in patients with acute brain injury: The TRAIN randomized clinical trial. JAMA 2024 Oct 9; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/39382241 https://jamanetwork.com/journals/jama/fullarticle/2824930
    Turgeon AF, Lauzier F. Shifting balance of the risk-benefit of restrictive transfusion strategies in neurocritically ill patients - Is less still more? JAMA 2024 Oct 9; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/39382236 https://jamanetwork.com/journals/jama/fullarticle/2824932
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