Transfusion ComplicationRisk per UNIT Allergic3:100 Febrile (Leuko-reduced Units) 1:100 TACO1:100 TRALI1:5,000 Sepsis1:5,000 Acute hemolytic1:75,000 HBV1:160,000 HIV & HCV1:2 million Blood product consent form checklist: Reasons for transfusion Risks of transfusion vs benefit Alternative treatments (if any) ** Must give Pts opportunity to ask questions!** -Type and Screen: Determines ABO type & Rh status and screens for non-ABO RBC antibodies. - AT UNMH, crossmatch is done when orders to transfuse are submitted in Powerchart. Blood is held by blood bank until pick up at time of transfusion. UNMH Blood Bank Premedication with acetaminophen is only advised for patients already receiving anti-pyretics. Premedication with diphenhydramine is only advised for patients with REPEAT allergic reactions. Blood Products and Indications Packed red blood cells (PRBCs) For hemodynamically stable patients without active bleeding: - Hgb < 7 g/dL - Generally indicated - Hgb g/dL - Consider in pre-op Pts & Pts w stable cardiovascular disease - Hgb g/dL - Consider in select Pts only (symptomatic anemia, cardiac ischemia). For actively bleeding patients, transfuse as needed to maintain adequate oxygenation Notes: 1 U PRBC ≈ 300mL, 1 U PRBC =>↑Hb ̴ 1 g/dL, Large trxn→↓Ca,↑K, ↓ Coagulation factors Platelets (plts) - <10,000/μL Generally indicated or <20,000/μL w/ infection/line placement/minor biopsy - <50,000/μL With active bleeding or prior to moderate-high risk invasive procedure - <100,000 Neurosurgery or ocular surgery *Threshold-based trxn not appropriate for Pts bleeding 2 ° to platelet dysfunction Notes: 1 U Apheresis plt ≈ 300mL ≈ “6 pack” of pooled plts =>↑plt count ̴ 25,000 /μL. Refractory = Pts with < 5000/μL plt ↑ min post txn x 2 after r/o other causes (e.g. drugs) Plasma (FFP) - Correction of bleeding 2 ° to↓ in multiple coag factors ( eg, warfarin, vit K def, DIC, liver disease, dilution) Consider lower risk coagulation factor complex (e.g. Bebulin) - Prophylactic use in non-bleeding Pts prior to mod-high risk procedures when INR>2.* *Available studies do not support the efficacy of FFP as prophylaxis for most invasive procedures in patients with a mild coagulopathy (ie, INR <2.0) Notes: 1U FFP ≈ 250mL, Initial dose: 15 mL/kg ( ̴ 3 to 5 units of FFP for average adult). Transfuse close to time of procedure due to short half-life of coagulation factors Cryo- precipitate (Cryo) - Correction of significant bleeding 2° ↓fibrinogen (<160) - Emergency use for bleeding in vWD Pts Notes: 1 U of cryo ≈ mL, 10U of cryo will ↑ fibrinogen ̴70 mg/dL in 70kg Pt Irradiated (IRR) To prevent Txn-assoc. GVHD (eg, in Pts w/cellular immune-def, stem cell recipients, premature neonates, heme malignancies, and Pts receiving Fludarabine or Cladribine, HLA matched plts or directed units.) *May cause delay in availability Leuko- reduced To ↓ Risk of febrile rxns, ↓ risk of trxn transmission of CMV. Notes: Risk of CMV transmission w/ leukoreduction ≈ risk w/CMV sero-negative products **All blood products at UNM (with the exception of granulocytes) are pre-storage leukoreduced** WashedTo ↓ risk of allergic rxns for Pts with h/o prior severe allergic rxn. Rarely indicated. NOT recommended for platelets (reduces yield ~ ½, plts less functional)

Acute Transfusion Reactions Febrile non- hemolytic Symptoms & Signs*: Fever (>1C°↑ and >38°) and chills Severity: Low morbidity Ddx: Acute Hemolytic Rxn, Sepsis & TRALI Prevention & Tx: Prevented by using leukoreduced products. In RCTs acetaminophen not shown to ↓ incidence; premed advised only if Pt is already febrile. Allergic/ Anaphylactic Symptoms & Signs*: Urticaria, pruritus Anaphylaxis =>Dyspnea, tightening of throat, ↓BP Severity: Low morbidity (simple allergic) to life threatening (anaphylaxis) Ddx: TRALI, TACO (consider both in Pt’s with shortness of breath) Prevention & Tx: Reactions dose-dependent => STOP Trxn and wait for symptoms to resolve with treatment. For repeated rxns, consider pre-medication with diphenhydramine, famotidine and/or steroids. Rx anaphylaxis w/ Epi. Consider washed units for Pts with h/o anaphylaxis. Acute Hemolytic Symptoms & Signs*: Fever, chills, hypotension, dyspnea, chest pain, flank pain, and anxiety Severity: Life threatening Ddx: Febrile Non-Hemolytic, Sepsis, TRALI Prevention & Tx: Proper ID of Pt and blood product. Only transfuse RBC with normal saline. Maintain urine output (IV fluids, mannitol and/or diuretics), CV support. TACO (Transfusion – Assoc. Circulatory Overload) Symptoms & Signs*: Dyspnea, hypertension, hypoxia, pulmonary edema, ↑BNP Severity: Moderate morbidity to life threatening Ddx: TRALI, Acute Hemolytic Transfusion Rxn, Anaphylaxis, Non-Txn ARDS Prevention & Tx: Conservative transfusion, ID at risk Pts (eg, elderly, h/o heart disease, and pediatric Pts) and transfuse slowly over max of 4hrs. Rx with supplemental O 2 and diuretics. TRALI (Transfusion- Related Acute Lung Injury) Symptoms & Signs*: SOB, fever, hypoxia, pulmonary edema, ↓ BP, within 6 hrs of transfusion. Severity: Life threatening Ddx: TACO, Sepsis, Acute Hemolytic Transfusion Reaction, Anaphylaxis, non-Trxn ARDS Prevention & Tx: Conservative transfusion. Treat like ARDS. Sepsis Symptoms & Signs*: Hypotension, fever, and rigors Severity: Life threatening Ddx: Acute Hemolytic Transfusion Rxn, TRALI, Febrile Non-Hemolytic Rxn Prevention & Tx: Bacterial testing of blood units. Rx w/antibiotics and supportive care UNMH Transfusion Service (Ramos, Reyes, Crookston & Koenig) Draw 2 purple tops and send to BB with remainder of unit for trxn rxn work-up. Send urine if s/s of hemolysis. Unless emergent, wait for results and pathology approval to transfuse another unit. Transfusion Reaction Suspected STOP Transfusion Fill out Trxn Rxn form & call Blood Bank Trxn can resume AFTER symptoms resolve (Rx with diphenhydramine) Itching and hives only All other symptoms - Stabilize patient - Notify attending - Perform Clerical Check * Not all signs and symptoms may be present