1. INDICATIONS FOR EMERGENT TRANSFUSIONS Manjushree Matadial DO Saint Joseph Hospital and Medical Center, April 27,2009

2. Red Blood Cells Indications Hemoglobin less than 7.0 g/dl in the absence of coronary disease or ischemia Hemoglobin less than 7.0 g/dl during surgery associated with major blood loss or impaired oxygen transport Hemoglobin less than 8.0 g/dl in patients with chronic transfusion regimen or during marrow suppressive therapy

3. Red Blood Cells Hemoglobin less than 10.0 g/dl in select populations ie. Neonates, coronary disease or cerebrovascular disease Age less than 40 with Hct = 24 Age 40 – 60 with Hct = 27 Age 60 – 70 with Hct = 30

4. Pathophysiology Consequences of Anemia Increased cardiac output when Hgb < 7.0 g/dl in acute situations Not the case in chronic anemia has been compensated Increased oxygen extraction systematically at the capillary level

5. Pathophysiology Decreased hemoglobin decreases the oxygen delivery and the oxygen extraction ratio increases which maintains a constant oxygen uptake into the tissues A hemoglobin below 3.0 g/dl increases the lactic acidosis

6. Blood Products Type and Screen Determines the ABO and Rh status and the presence of antibodies Takes anywhere from 5 mins – 30 mins Risk of adverse reaction is 1: 1000 Type O red cells are mixed with the patient’s serum

7. Blood Products Type and Cross Determines ABO and Rh status as wells as adverse reactions to low incidence antigens— risk of reaction is 1 : 10,000 Takes 60 mins Type O red cells are mixed with the patient’s serum and the donor red cells are then mixed with the patient’s serum to determine incompatibility

8. Transfusions Type specific crossmatch Type specific uncrossmatch Type O Rh(-) used emergently

9. Transfusions Donor O A B AB Recipient O, A, B, AB A, AB B, AB AB

10. Blood Products Whole blood Contains 510 ml PRBC’s Prepared by centrifuging whole blood and removing 250 ml of plasma supernatant Each unit of PRBC contains 200 ml of erythrocytes and 50 – 100 ml of plasma and CPD solution The concentration of hemoglobin is 23-27 g/dl 10 ml/kg will increase HCT by 10%

11. Blood Products Leukocyte-Poor Red Cells Used in transfusing patients that are febrile Patients with a history of non-hemolytic transfusion reactions (caused by antibodies to leukocytes in donor blood) Transplant recipients or candidates Patients requiring CMV (-) transfusions

12. Blood Products Washed Red Cells These are packed cells washed with isotonic saline to remove leukocytes and residual plasma The removal of plasma prevents allergic reactions caused by prior sensitization to plasma proteins in donor blood Is to be used in patients with hypersensitivity reactions

13. Blood Products CMV (-) Blood CMV infects many tissues ie. Blood, kidney, lung, liver and brain Following patients are susceptible to transfusion-transmitted CMV primary infections and disease therfore they should receive CMV (-) blood

14. Blood Products CMV (-) Blood Low birth weight neonates < 1200 grams CMV seronegative pregnant women CMV seronegative recipients of, or candidates for bone marrow or peripheral blood cell transplants CMV seronegative HIV (+) patients

15. Blood Products CMV seronegative recipients of, or candidates for solid organ transplants CMV PCR screening tool A large portion of CMV seronegative donors are CMV PCR positive

16. Blood Products Irradiated Prevents graft versus host disease in the immune compromised patients Gamma irradiation eliminates the ability of lymphocytes to proliferate and preventing them from mounting and immune response to the host tissue

17. Blood Products Bone marrow and stem cell transplant recipients Congenital T cell immunodeficiency syndromes: SCIDS, Wiskott-Aldrich, DiGeorge Intrauterine transfusion Neonatal exchannge transfusion

18. Blood Products Irradiated Cells Premature neonates < 1200 grams Transfusions from blood relatives Patients with hematologic malignancies: ie.Hodgkin’s, Non-Hodgkin’s and acute leukemia and neuroblastoma

19. Platelet Therapy Indications for transfusions Platelets < 10, 000 with no risk factor Active bleeding Bone marrow failure Platelets < 20, 000 with the following risk factors: febrile, bleeding, ICH, antibiotic therapy

20. Platelet Therapy Indications Surgery with a high risk of bleeding or an invasive procedure Endoscopy with biopsy Lumbar puncture Surgical intervention

21. Platelet Therapy Indications Platelet function defects ie CABG (maintain the platelets > 50, 000) Bleeding/ massive transfusion (maintain the platelets > 100, 000 ) Ie. DIC or CNS trauma

22. Platelet Transfusion Prepared by centrifuging fresh whole blood and suspending the supernatant pellet in a small volume 1 unit of whole blood has 50 – 100 billion platelets in 50 ml of plasma Stored up to 7 days Effectiveness declines after 3 days Transfused in (6-10 ) units at a time

23. Cyropprecipitate Useage Replaced in the following manner (5-10 ml/kg) Replaces VIII (Hemophilia A), factor XIII, fibrinogen, fibronectin, and vWF Used also in DIC and Trauma

24. Fresh Frozen Plasma Indications Used in life threatening bleeding in patients on coumadin Liver disease if bleeding with abnormal coagulation profile Acute DIC Following massive transfusions or CABG