Chapter 15 Transfusion Therapy

• Transfusion therapy includes all aspects of transfusing patients
• Each blood component has unique indications, expected outcomes, and other considerations
• Patients with special conditions require tailored strategies to optimize therapy

Blood Products

• Blood and blood products are drugs used to treat illnesses
• Adverse effects can occur, requiring careful consideration
• Transfusion of blood cells constitutes a transplantation; cells must survive and function post-transfusion for a therapeutic effect
• Red blood cell (RBC) transfusion, is the most tolerated form of transplantation, but can still cause rejection, like hemolytic transfusion reactions
• Rejection of platelets occurs, marked by refractoriness to platelet transfusion, is relatively common in multiply transfused patients
• Transfusion therapy primarily addresses inadequate oxygen-carrying capacity due to anemia or blood loss, and insufficient coagulation proteins or platelets for hemostasis
• Each patient needs an individualized plan considering clinical condition, anticipated blood loss, compensatory mechanisms, and lab results
• Some patients do not require transfusion despite anemia or thrombocytopenia if their clinical conditions are stable and they have little risk of adverse outcomes
• Appropriate blood therapy involves transfusing the specific blood product the patient needs
• Selecting the right blood products allows multiple patients to be treated from a single donor, maximizing blood donation use

Whole Blood

• Whole blood in the donor's vessels is diluted in an 8:1 ratio with anticoagulant
• Citrate anticoagulant chelates ionized calcium, preventing coagulation system activation
• Glucose, adenine, and phosphate serve as substrates for RBC metabolism during storage

Red Blood Cells

• Red blood cells (RBCs) increase RBC mass in patients needing increased oxygen-carrying capacity
• Indicators: pulse rates above 100 bpm, respiration rates above 30 breaths per minute, dizziness, weakness, angina, and difficulty thinking
• Decreased RBC mass occurs due to decreased bone marrow production, decreased RBC survival, or bleeding from trauma
• The human body compensates for anemia by increasing plasma volume, heart rate, respiratory rate, and oxygen extraction from RBCs
• Normally, about 25% of oxygen is extracted, but up to 50% with increased demand
• Transfusion is needed when demand exceeds 50% of the oxygen content
• Critical hemoglobin level is 6 g/dL or less, with suggested trigger values less than 7 g/dL for most patients and less than/equal to 8 g/dL for specific patients with heart disease
• Contraindicated in patients well-compensated for anemia
• Should not treat nutritional anemia (e.g., iron deficiency) unless signs of decompensation are present
• Not for enhancing general well-being, promoting wound healing, preventing infection, expanding blood volume when oxygen-carrying capacity is adequate, or preventing future anemia
• Transfused RBCs should increase hemoglobin level 1 g/dL and hematocrit level 3% in a typical adult, similar to whole blood
• In pediatric patients, 10 to 15 mL/kg will increase hemoglobin 2 to 3 g/dL or hematocrit 6% to 9%
• Hemoglobin/hematocrit increases quicker than whole blood due to less blood volume adjustment
• RBCs prepared with additive solutions (AS-1/AS-3) have greater volume but less plasma compared to citrate phosphate dextrose (CPD)/citrate phosphate dextrose adenine (CPDA-1)

Leukocyte-Reduced RBCs

• An average RBC unit contains roughly 2 x 10^9 leukocytes which can cause febrile non-hemolytic transfusion reactions, transfusion-associated graft-versus-host disease (TA-GVHD), transfusion-related immune suppression
• Human leukocyte antigens (HLA) are responsible for HLA alloimmunization
• Leukocytes can harbor cytomegalovirus (CMV)
• To reduce HLA alloimmunization and CMV transmission, reduce leukocyte content 5 × 10^6 via leukocyte reduction filters
• Standard content is less than 5 × 10^6 in the US; in Europe, less than 1 × 10^6
• Leukocyte-reduced blood decreases febrile nonhemolytic transfusion reactions, CMV transmission, and HLA alloimmunization

Washed and Frozen/Deglycerolized RBCs

• Patients who have allergic reactions to ordinary RBC units may benefit from washed RBCs
• The washing process removes plasma proteins, which cause allergic reactions
• Used for rare patients with moderate to severe allergic transfusion reactions and anti-IgA antibodies because of IgA deficiency
• Freezing RBCs allows long-term storage of rare, autologous, and special-purpose units
• Deglycerolizing removes nearly all the plasma, making these units interchangeable with washed RBCs at a higher cost
• The 24-hour outdate of washed or deglycerolized RBCs limits their use
• Hematocrit increase for washed/deglycerolized RBCs is the same as regular RBC units

Platelets and Plateletpheresis

• Platelets are essential for primary hemostatic plug formation and hemostasis maintenance
• Patients with thrombocytopenia/abnormal platelet function may experience petechiae, ecchymoses, and mucosal/spontaneous hemorrhage
• Thrombocytopenia can occur via decreased platelet production or increased destruction
• Massive transfusion can also cause thrombocytopenia because of platelet consumption for hemostasis and platelet dilution
• Platelet transfusions treat or prevent bleeding resulting from thrombocytopenia/abnormally functioning platelets and lower than normal platelet counts

Platelet Dosing

• Plateletpheresis component, prepared from one donor, contains at least 3 × 10^11 platelets
• One plateletpheresis should increase an adult patient's platelet count to 20,000-60,000/µL
• One whole blood platelet unit must contain at least 5.5 x 10^10 platelets and should increase platelet count by 5,000-10,000/µL in a 70-kg human
• A pool of 5 units contain roughly 3 x 10^11 platelets, increasing platelet count a similar amount to plateletpheresis

Refractory Patients

• Massive splenomegaly, high fever, sepsis, DIC, and platelet/HLA antibodies can cause lower-than-expected platelet count increment and survival
• The 10-minute to 1-hour post-transfusion platelet count increment is less impacted by splenomegaly, high fever, and DIC than by platelet/HLA antibodies
• If the10-minute increment is less than 50% of the expected amount on two occasions, the patient is considered refractory
• Positive platelet crossmatch/HLA antibody screen indicates alloimmunization
• Platelet crossmatching with available inventory is useful as HLA-typing and recruiting HLA-compatible platelet donors can be time-consuming
• HLA-matched platelets should be irradiated
• Corrected count increment using a 10-minute to 1-hour post-transfusion platelet count offers insight on patient response to platelet component
• Platelet count increment is corrected for body size differences, creating more reliable increment estimates
• Expected corrected platelet increment is greater than 10,000/µL per m²

Granulocyte Pheresis

• Patients receiving intensive chemotherapy for leukemia/bone marrow transplant may develop severe neutropenia/serious infections
• Granulocyte transfusions benefit those with fever, neutrophil counts less than 500/µL, septicemia/bacterial infection unresponsive to antibiotics, reversible bone marrow hypoplasia, and a reasonable survival chance
• Prophylactic use is of doubtful value for neutropenic patients without demonstrable infection
• Studies show that neonatal granulocyte transfusions are beneficial for newborns that develop infection
• Adults/children usually get one granulocyte pheresis product daily for 4+ days
• Neonates usually get a portion of a granulocyte pheresis unit once or twice
• Components should be administered ASAP and within 24 hours of collection
• Must be crossmatched due to the significant RBC content
• Monitor the patient for symptom resolution and clinical efficacy evidence
• Neutrophil count will increase to 1,000/µL+ in response to infusion of granulocyte colony-stimulating factor (GCSF)-mobilized granulocyte pheresis

Plasma

• Plasma includes fresh frozen plasma, plasma 24 (frozen within 24 hours), and thawed plasma
• All contain coagulation factors
• After thawing, they can become thawed plasma and be stored for 5 days at 4°C
• 5-day storage reduces outdating and allows rapid response to urgent orders for bleeding patients
• Thawed plasma after 5-day storage has less factor V and VIII but is still therapeutic
• Can treat multiple coagulation deficiencies in patients with liver failure, DIC, vitamin K deficiency, warfarin overdose, or massive transfusion
• Can treat patients with single factor deficiencies, such as factor XI deficiency
• Vitamin K deficiency/warfarin overdose treated with vitamin K if liver function is adequate and there's an adequate interval (4-24 hours) before a hemostatic challenge
• Plasma is given if the patient is actively bleeding or if there is no time for warfarin reversal before surgery
• Liver failure patients may develop clinical coagulopathy due to impaired hepatic synthesis of all coagulation factors and antithrombotic factors
• Plasma treats patients with multiple-factor deficiencies and impending surgery
• Usually 4-6 units of plasma will effectively control hemostasis, though it may not correct coagulation tests to normal range because of dysfibrinogenemia
• Mild hemostatic abnormalities do not predict bleeding, so correction is not indicated for minor procedures
• Plasma is not a concentrate so volume overload can be a serious complication of transfusion
• Congenital coagulation factor deficiencies are rarely treated with plasma, because the dose requirement for surgical procedures and serious bleeding is so high volume overload results
• Factor concentrates offer more effective modes of therapy
• Factor XI deficiency is still treated with plasma infusion, requiring 20-30% factor XI levels for adequate hemostasis
• Milder than hemophilia A/B, has a long half-life, so treatment is not needed daily
• A coagulation factor unit is the activity in 1 mL of pooled normal plasma
• 100% activity is 1 unit/mL or 100 units/dL
• 30% activity of each of the coagulation factors is required for adequate hemostasis
• Less than half of the plasma volume, or about 4-6 plasma units, is required to correct a coagulopathy such as in liver disease or DIC
• Additional doses are needed with continued hemorrhage if prothrombin time is more than 1.5 times normal or international normalized ratio is greater than 1.5
• Several key clotting factors (VII, VIII, or IX) have half-lives less than 24 hours, so repeated transfusions are required to control post-operative bleeding or to maintain hemostasis
• Factor IX requires daily transfusions, given its 18-24 hour half-life
• Plasma can be used as a replacement fluid during plasma exchange (therapeutic plasmapheresis) and can provide a metalloprotease (ADAMTS13) during thrombotic thrombocytopenic purpura
• Plasma should not be used for blood volume expansion or protein replacement because safer products are available
• Plasma should be ABO-compatible with the recipient's RBCs, but the Rh type can be disregarded

Cryoprecipitate

• Primarily used for fibrinogen replacement
• AABB requires 150+ mg fibrinogen per unit, though quality control levels are often 250+ mg
• Generally, 5 units are pooled, rinsing each bag with saline at the blood center
• Each pool contains 750-1,250 mg of fibrinogen
• Fibrinogen replacement may be required in patients with liver failure, DIC, or massive transfusion and in rare patients with congenital fibrinogen deficiency
• Fibrinogen plasma level of about 100 mg/dL is recommended for adequate hemostasis with surgery or trauma
• To calculate the amount to be infused, convert milligrams per deciliter to milligrams per milliliter by dividing by 100
• Multiply the answer by the plasma volume
• To calculate the number of pools needed, divide by 750 mg/pool
• Instead, plasma volume can be converted to deciliters
• Cryoprecipitate was used for fibrin sealant, though FDA-approved fibrin sealants, treated to reduce viral transmission, are preferred
• Cryoprecipitate was originally prepared as a source of factor VIII, requiring each unit to contain at least 80 units of factor VIII
• However, mild/moderate factor VIII deficiency is now treated with desmopressin acetate or factor VIII, or both, whereas severe factor VIII deficiency is treated only with factor VIII
• Cryoprecipitate was used to treat patients with von Willebrand's disease
• Virus-safe factor VIII with assayed amounts of factor VIII and vWF is available

Factor VIII

• Patients with hemophilia A or factor VIII deficiency have spontaneous hemorrhages, treatable with recombinant/human plasma-derived factor VIII replacement
• Plasma-derived factor VIII is prepared from plasma obtained from paid donors by plasmapheresis or from volunteer whole blood donors
• Factor VIII is treated by different methods to ensure sterility for HIV, hepatitis B virus, and hepatitis C virus (HCV)
• Recombinant human product is virus-safe
• Plasma-derived/recombinant factor VIII are refrigerator-stored and reconstituted with saline at infusion, allowing self-therapy for individuals with hemophilia

Factor VIII Dosing

• {desired factor VIII (units/mL) – initial factor VIII (units/mL)} x plasma volume (mL) = units of factor VIII required
• Blood volume = weight (kg) x 70 mL/kg
• Plasma volume = blood volume (mL) × (1.0 – Hct)
• The assayed value on the label divided into the number of units required to obtain the number of vials to be infused

Factor IX

• Factor IX complex (prothrombin complex) is prepared from pooled plasma using various methods of separation and viral inactivation
• A product containing factors II, VII, IX, and X is recommended for factor IX-deficient patients (hemophilia B), patients with factor VII/X deficiency, and selected patients with factor VIII inhibitors/reversal of warfarin overdose
• Activated coagulation factors present in prothrombin complex may cause thrombosis, especially in those those with liver disease
• Recombinant human factor IX is effective only in factor IX deficiency management
• Dose is calculated same as factor VIII concentrate
• Half the dose of factor IX rapidly diffuses into tissues, and half remains within the intravascular space, so the initial dose must be doubled

Antithrombin and Other Concentrates

• Antithrombin is a protease inhibitor with activity toward thrombin
• Heparin accelerates thrombin binding and inactivation by antithrombin
• Hereditary antithrombin deficiency is associated with venous thromboses, whereas acquired deficiency is usually DIC
• Licensed for use in with hereditary deficiency of antithrombin
• Product is pasteurized to eliminate HIV or HCV infections
• Has been shown to provide no significant clinical benefit in acquired deficiency, though thawed plasma is an alternative source of antithrombin
• Protein C and protein S are vitamin K-dependent proteins synthesized in the liver
• Protein S cofactor for activated protein C, which inactivates factors V and VIII, thus preventing thrombus formation
• Deficiency leads to a hypercoagulable state
• Human plasma-derived protein C concentrates are approved for use in hereditary deficiency states
• Recombinant-human activated protein C has been used for DIC and sepsis
• Recombinant human activated factor VII (rFVIIa) treats bleeding episodes in hemophilia A/B patients with inhibitors
• Used in patients with a wide variety of bleeding disorders
• Large randomized controlled trials are needed to define dose, indications, and adverse effects
• Reports of use for liver disease, massive transfusion, and other bleeding disorders have been promising

Albumin

• Prepared by chemical/physical fractionation of pooled plasma
• Available as a 5% or a 25% solution, of which 96% of the protein content is albumin
• Heat-treated and virus-safe
• Useful in treating patients requiring volume replacement
• Colloids vs. crystalloid (i.e., saline or electrolyte) solutions are debated in terms of treatment for hypovolemia with shock
• Routinely used in many plasmapheresis procedures as the replacement fluid for the colloid removed
• Can used to treat burn patients by replacing colloid pressure
• With diuretics, can induce diuresis in patients with low total protein because of severe liver/protein-losing disease
• 25% solution brings about five times its volume from extravascular water into the vascular space, so patients need adequate extra-vascular water and compensatory mechanisms to deal with the expansion of the blood volume

Immune Globulin

• Prepared from pooled plasma, primarily IgG
• Small amounts of IgM and IgA may be present, though others are free of these contaminants
• Available for intramuscular/intravenous administration
• The intramuscular product must not be given intravenously due to severe anaphylactic reaction risk
• Intravenous product must be given slowly to lessen reaction risk
• Used for patients with congenital hypogammaglobulinemiall and patients exposed to diseases such as hepatitis A/measles
• For hypogammaglobulinemia, monthly injections are typically given due to 22-day half-life of IgG
• Intravenous preparation is increasingly being used in autoimmune disease therapy, increases like immune thrombocytopenia and myasthenia gravis
• Various hyperimmune globulins are available to prevent diseases such as hepatitis B, varicella zoster, rabies, mumps, and others
• Prepared from the plasma of donors who have high antibody titers to the specific virus causing the disease
• Hepatitis B hyperimmune globulin only provides exposure passive immunity and does not provide permanent immunity, so must be accompanied by active immunization
• Rh immune globulin (RhIG) protects the Rh-negative woman who is pregnant or delivers an Rh-positive infant, where IgG in this protection is directed against the D antigen within the Rh system
• Administration of this preparation allows attachment of anti-D to any Rh-positive cells of the infant that have entered the maternal circulation
• Antibody-bound cells are subsequently removed by the mother's macrophages, preventing active immunization or sensitization
• Rh immune globulin products, which can be administered intravenously or intramuscularly, and are also used in idiopathic thrombocytopenic purpura patients who are Rh-positive
• Proposed mechanism is blockage of the reticuloendothelial system by anti-D-coated RBCs, thereby reducing destruction of autoantibody-coated platelets
• For RBC transfusion accidents, the number of RhIG vials is calculated by dividing the volume of Rh-positive packed RBCs transfused by 15 mL, the amount of RBCs covered by one vial
• The number of vials can be large, so the entire dose is often divided and administered in several injections at separate sites and over 3 days
• The intravenous preparation may also be used
• Another approach is to perform an exchange transfusion with Rh-negative blood and then calculate the dose based on the number of Rh-positive RBCs remaining in the circulation
• For platelets pheresis, one vial is sufficient for 30+ products, because each unit contains fewer than 0.5 mL RBCs
• Dose for leukocyte concentrates can be calculated by obtaining the hematocrit and volume of the product from the supplier
• Immune globulins may cause anaphylactic reactions (flushing, hypotension, dyspnea, nausea, vomiting, diarrhea, and back pain)
• Caution should be used in patients with known IgA deficiency and previous anaphylactic reactions to blood components

Special Transfusion Considerations

• Certain patient categories require leukocyte-reduced, CMV-negative, or irradiated blood selection
• Leukocyte-reduction filters are designed to remove 99.9+% of leukocytes from RBCs and platelet products
• The goal is fewer than 5 × 10^6 (1 × 10^6 in Europe) leukocytes remaining in the RBC unit
• Prestorage filtration in the lab/collection is more reliable than bedside filtration
• Leukocyte-reduced RBCs/platelets can prevent febrile nonhemolytic transfusion reactions, prevent/delay HLA antibody development, and reduce CMV risk
• Controversial effects include decreased mortality and length of hospital stay
• CMV is carried, latently or infectiously, in neutrophils and monocytes
• Transfusion of these virus-infected cells in a cellular product such as RBCs or platelets can transmit infection
• CMV infection of the patient can be reduced by using leukocyte-reduction filters/providing CMV antibody-negative blood
• Components are indicated for CMV-negative recipients who are at risk for severe CMV infections

Special Considerations: Irradiation

• Blood components are irradiated with gamma radiation to prevent graft-versus-host disease, requiring three conditions to occur:
  • Transfusion/transplantation of immunocompetent T lymphocytes
  • Histocompatibility differences between graft and recipient (major/minor HLA or other histocompatibility antigens)
  • Typically, an immunocompromised recipient
• Common after allogeneic bone marrow or hematopoietic progenitor cell transplantation, GVHD affects mainly skin, liver, and gut
• Transfusion-associated graft-versus-host disease (TA-GVHD) is infrequently caused by viable T lymphocytes in cellular blood components (e.g., RBCs/platelets)
• Mortality is high, so prevention is key
• Prevents centers on irradiating cellular components before administration to significantly immunocompromised individuals
• Irradiation doses range from 2,500-5,000 cGy, with higher doses being more effective but more damaging to RBCs
• Irradiation decreases/eliminates mitogenic capacity of transfused T cells, rendering donor T cells immunoincompetent
• Transfusion recipients run the risk for TA-GVHD who have congenital immunodeficiencies, Hodgkin's lymphoma, bone marrow transplants, intrauterine transfusion of fetuses, exchange transfusion of neonates, blood relative donations, and HLA-matched platelets
• Immunocompetent recipients have experienced TA-GVHD after receiving nonirradiated directed donations primarily from first-degree relatives
• Related donor is homozygous for one of the patient's (host's) HLA haplotypes, so the patient is incapable of rejecting the donor's (graft's) T lymphocytes, which then can act against the HLA antigens encoded by the patient's other haplotype
• Donor lymphocytes reject the host
• The level of immunosuppression needed to develop TA-GVHD is unknown, although patients with the severe immunosuppressive conditions listed previously are most at risk
• For this reason, prevention depends on irradiation and not on reduction of lymphocytes by filtration

Transfusion in Special Conditions

• Some patients require policies and procedures that address particular clinical situations
• Patients undergoing elective surgery, autologous collection/transfusion, and emergency/massive transfusion will be discussed here
• Transfusion of neonatal, pediatric, and oncology patients and those with congenital coagulation deficiencies will be detailed here

Surgical Blood Order Schedule, Type, and Screen

• Most surgical procedures do not require blood transfusion
• Crossmatching for procedures with a low likelihood of transfusion increases the number of crossmatches performed, increases the amount of blood inventory in reserve and unavailable for transfusion, and contributes to the aging and possible outdating of the blood components
• Patients can be better served by performing only a type and antibody screen
• If the antibody screen is positive, antibody identification must be completed and compatible units found
• However, if the antibody screen is negative, ABO- and Rh-type-specific blood may be released after an immediate spin or electronic crossmatch when transfusion is required
• For a patient who is likely to require blood transfusion, the number of crossmatched units should be no more than twice those usually required for that surgical procedure
• The crossmatch-to-transfusion (C/T) ratio will be between 2:1 and 3:1, which has been shown to be optimal practice
• Some transfusion services extend this practice to nonsurgical patients, crossmatching only when the RBCs are requested for issue to the patient
• This practice increases the inventory of uncrossmatched units, which can be used for immediate needs

Autologous Transfusion

• Autologous (self) transfusion is the donation of blood by the intended recipient
• Homologous Transfusion utilizes infusion of blood from another donor
• One type of autologous transfusion is the predeposit of blood by the patient
• Collected by regular blood donation procedure, blood can be stored as liquid or, for longer storage, frozen
• Patients may donate several units of blood over a period of weeks, taking iron supplements to stimulate erythropoiesis
• Predeposit autologous donation is usually reserved for patients anticipating a need for transfusion, such as for a scheduled surgery
• Predeposit autologous transfusion is expensive because about half of the donated units are not used
• Another type of autologous transfusion, intraoperative hemodilution, is the collection of 1 or 2 units of blood from the patient just before a surgical procedure, replacing the removed blood volume with crystalloid/colloid solution
• Then, at the end of surgery, the blood units are infused into the patient
• Care must be taken to label and store the blood units properly and to identify the blood units with the patient before infusion

Emergency Transfusion

• Patients who are rapidly or uncontrollably bleeding may require immediate transfusion
• Group O RBCs are selected for patients for whom transfusion cannot wait until their ABO and Rh type can be determined
• Group O-negative RBC units should be used if the patient is a female of childbearing potential
• An Rh-negative male patient or an older female patient can be switched from Rh-negative to Rh-positive RBCs if few O-negative units are available or if massive transfusion is required
• Delaying blood transfusion in emergency situations may be more dangerous than the small risk of transfusing incompatible blood before the antibody screen and crossmatch are completed
• After issuing O blood or type-specific blood, the antibody screen can be completed, and decisions can then be made for the selection of additional units of blood
• If the patient has been typed and screened for a surgical procedure and his or her antibody screen is negative, ABO- and Rh-type-specific blood can be given after an immediate spin crossmatch
• Transfusions should be reserved for those patients losing more than 20% of their blood volume
• The condition of most patients allows determination of ABO and Rh type and selection of ABO- and Rh-type-specific blood for transfusion

Massive Transfusion

• Defined as replacing one+ blood volume(s) in a day, or ten blood products in an adult
• Preventable treatment to avoid coagulopathy
• Must analyze clinical factors and lab tests to guide appropriate therapy
• Massive transfusion pack can be adjusted for low hemoglobin, platelets, or prolonged coagulation tests
• Monitoring for fibrinogen levels because replacement by cryoprecipitate may be indicated when the fibrinogen level is less than 100 mg/dL
• A patient in critical condition and a limited supply of type-specific blood may require a change in ABO or Rh types
• An Rh-negative male or postmenopausal female patient may be switched from Rh-negative to Rh-positive blood to avoid depleting the inventory of Rh-negative blood
• However, an Rh-negative potentially childbearing woman should receive Rh-negative RBC products for as long as possible

Neonatal Transfusion

• Premature infants require small RBC transfusions frequently to replace blood for tests/treat anemia
• Various methods for preparing small aliquots are available for transfusion
• Aliquot must be clearly labeled with patient/donor numbers, blood has to be fully tested as adult transfusion
• Blood units less than 7 days old are preferred to lessen hyperkalemia/maximize 2,3-diphosphoglycerate levels
• In some institutions, CPDA-1 RBCs are used for 14-21 days
• Very-low-birth-weight infants should get seronegative/leukocyte reduced CMV to prevent CMV infection which is serious for preemies
• Pregnant women should be given leukocyte reduced/ CMV-Negative if they test negative for CMV
• Irradiation is recommended to prevent TA-GVHD whenever blood is used for intrauterine transfusions/exchange transfusions
• Premature infants less than 1,200 g
• Full term infants do not need routine irradiation
• Infants who are hypoxic/acidotic should receive blood tested for hemoglobin S

Transfusion in Oncology

• Marrow issues can be caused by chemotherapy, marrow infiltration with suppression
• Rare RBC units could be needed d/t repeated transfusions d/t suppression
• Rh Immunoglobulin must be given carefully to childbearing-age women but otherwise Rh changes could be made.
• Autoimmune hemolytic anemia occurs in some malignancies which can increase testing problems as well as the need for red cells
• Hodgkin's Disease also could cause TA-GVHD from chemo as well, in which case irradiated components must be used

Coagulation Factor Deficiencies

• Factor VIII is usually complexed to vWF.
• Hemophilia A means a deficiency of factor VIII, a disease of less than 50% (level) although less than 10% levels means clinical disease shows itself
• Low (less than 1 %) could mean severe spontaneous bleeding into joint, but von Willebrand Factor amount would be normal
• vWF deficiencies are different types however, most are lowered, some are IIA with weight issues, and another IIB has abnormal, increased binding affinities. Patients with normal production ability would still produce multimers
• Hemophilia B would be factor IX deficiencies, with treatment similar to factor VIII

Continued Coagulation Factor Deficiencies

• All coagulation factors but one (vWF) is made in liver so multiple deficiences of these could exist in failure, also with possibly abnormal production to add
• Vit K can regulate coagulation factor as well, or there would be other factors stopping and also inhibiting clotting, therefore there would be an indication for transfusion to have normal protein levels
• DIC is uncontrolled consumption of coagulation factors with thrombi formed on the body, treatment means aiming to correct cause, while sometimes adding transfusions
• Discontinuing certain blood pressure regulating drugs for up to a week prior might allow for a massive transfusion

General Blood Transfusion Advice

• Patient safety is paramount (identify)
• Compatibility is essential
• Errors in clerical work lead to fatalities
• Difficult vein patients must have IV in place before issued, should be filtered and administered for 10-15- minutes for transfusion reaction monitoring
• Pulse and other vitals should be checked regularly to find a reaction to transfusion as well
• Should not be assumed to be an immediate reaction, but an ongoing issue days later on
• Standard blood sets must be used in administration
• Rapid transfusions should be warmed or arrhythmia and damage could occur
• Only blood-type solutions should diluters, and never home heating devices

Hospital Transfusion Committee

• The Joint Commission requires reviewing transfusions for appropriateness
• The blood bank staff interacts with departments to identify patterns, therefore blood transfers have been published
• Other parts of the information system are reviewed to ensure appropriateness and avoid side effects
• Appropriate practices help ensure blood supply safety