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packed red blood cells (RBCs)

A unit of packed RBCs is obtained from centrifugation of 500 mLof whole blood. 200 mL of plasma is separated leaving a volume of 300 mL & a hematocrit of 70-80% in a unit of packed of red blood cells. Constituents: - iron: 1 mg/mL of packed RBCs or (0.25 g/unit) Storage: at 6 degrees centigrade Indications: 1) acute anemia a) signs & symptoms of hypovolemia b) failure of crystalloid alone 2) chronic anemia associated with symptoms a) angina b) cerebral ischemia c) dyspnea 3) AABB blood hemoglobin threshold for transfusion < 7 gm/dL [12] with few exceptions (see perioperative guidelines below) Perioperative guidelines: - hemoglobin levels of 8-9 gm/dl are adequate in young, healthy patients - transfusion theshold for most patients is hemorglobin > 7 g/dL [2] - after acute surgical blood loss, normovolemic blood hemoglobin > 7 gm/dl can be tolerated in most asymptomatic patients - symptomatic elderly with heart disease or pulmonary disease & blood hemoglobin 7-10 gm/dL [3] - AABB perioperative threshold for transfusion is 7 gm/dL [12]], excepting - cardiac surgery 7.0-7.5 gm/dL [12] - orthopedic surgery in patients with cardiovascular disease 7.0-8.0 g/dL [12] In hospital guidelines: - in stable hospitalized patients, adhere to a restrictive transfusion strategy (hemoglobin level of 7-8 g/dL) - linked to better outcomes & lower rates of nosocomial infection - in intensive care unit patients, consider transfusion when hemoglobin level is 7 g/dL - in postoperative surgical patients & patients with preexisting cardiovascular disease, consider transfusion when the blood hemoglobin level is 8 g/dL or when patients are symptomatic - do not base transfusion decisions solely on hemoglobin levels: symptoms & clinical context should be taken into account [5] Procedure: 1) Pretransfusion screening: a) blood grouping - ABO typing - group O erythrocytes may be transfused to anyone - Rh typing - RhD- patients must receive RhD- packed RBC & platelet units [2] b) antibody screen using patient's serum for antibodies against common erythrocyte antigens c) cross match using patient's serum & donor's blood immediately before transfusion 2) Transfusion: a) normal saline may be infused with packed RBCs b) 5% glucose & Ringers lactate should not be infused with packed RBCs secondary to red cell damage or coagulation c) intravenous (IV) catheter should be 20 gage or larger d) vital signs should be checked every 15 min for 1st hour & every 30 min until transfusion is complete e) a hemoglobin rise of 1 gm/dL can be expected from each unit of packed RBCs [2] f) transfusion of fresh packed RBC of no benefit over those stored for longer periods of time [10,11] Notes: === Special preparations === 1) leukocyte-free (reduced) RBCs a) transfusion through microaggregate filters b) indications: - history of 2 or more transfusion reactions - all RBC transfusions in Denmark & Canada [4] c) < 1 x 10E06 leukocytes/product delays onset of primary but not secondary alloimmunization to HLA antigens d) not reliable for preventing transfusion-associated GVHD e) decreases febrile non-hemolytic transfusion reactions 2) washed RBCs a) free of plasma proteins b) indications: - avoidance of anaphylactic reactions in IgA deficient patients with antibodies to IgA - RBC from IgA-deficient donors do not need waching - history of severe, recurrent allergic reactions [2] - complement-dependent autoimmune hemolytic anemia ? c) reduces transfused K+ in patients at risk for hyperkalemia 3) irradiated RBC - indications - severe immnuodeficiency - immunocompetent patients receiving HLA-matched platelets or transfusions from relatives [2] - used to prevent graft vs host disease [2,9] - T-cell immunodeficiency - Hodgkin's lymphoma - hemotopoietic stem cell transplantation (allogeneic or autologous) - chemotherapy with purine analog - alemtuzumab - destroys lymphocytes - irradiadion can weaken erythrocyte membrane === Prevention of RBC transfusions === - small-volume blood collection tubes - 10 fewer units/100 patients per ICU stay - small-volume tubes almost always provide sufficient blood for analysis [15]

Related

blood blood volume erythrocyte; red blood cell (RBC)

General

transfusion component

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 613-614
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Journal Watch 24(12):94-95, 2004 Muller U, Exadaktylos A, Roeder C, Pisan M, Eggli S, Juni P. Effect of a flow chart on use of blood transfusions in primary total hip and knee replacement: prospective before and after study. BMJ. 2004 Apr 17;328(7445):934-8. PMID: 1508734 http://bmj.bmjjournals.com/cgi/content/full/328/7445/934
  4. Journal Watch 24(15):123, 2004 van Hilten JA, van de Watering LM, van Bockel JH, van de Velde CJ, Kievit J, Brand R, van den Hout WB, Geelkerken RH, Roumen RM, Wesselink RM, Koopman-van Gemert AW, Koning J, Brand A. Effects of transfusion with red cells filtered to remove leucocytes: randomised controlled trial in patients undergoing major surgery. BMJ. 2004 May 29;328(7451):1281. Epub 2004 May 13. PMID: 15142885 http://bmj.bmjjournals.com/cgi/content/full/328/7451/1281
  5. Carson JL et al Red blood cell transfusion: A clinical practice guideline from the AABB. Ann Intern Med 2012 Mar 26 PMID: 22454395 http://www.annals.org/content/early/2012/03/26/0003-4819-156-12-201206190-00429.long corresponding NGC guideline withdrawn June 2017 - Vincent JL Indications for blood transfusions: Too complex to base on a single number? Ann Intern Med 2012 Mar 26 PMID: 22454394 http://www.annals.org/content/early/2012/03/26/0003-4819-156-12-201206190-00431.long
  6. Marik PE, Corwin HL. Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Crit Care Med. 2008 Sep;36(9):2667-74 PMID: 18679112
  7. Wang JK, Klein HG. Red blood cell transfusion in the treatment and management of anaemia: the search for the elusive transfusion trigger. Vox Sang. 2010 Jan;98(1):2-11 PMID: 19682346
  8. Rohde JM et al Health Care-Associated Infection After Red Blood Cell Transfusion. Systematic Review and Meta-analysis. JAMA. 2014;311(13):1317-1326 PMID: 24691607 https://jama.jamanetwork.com/article.aspx?articleid=1853162 - Carson JL Blood Transfusion and Risk of InfectionNew Convincing Evidence. JAMA. 2014;311(13):1293-1294. PMID: 24691604 http://jama.jamanetwork.com/article.aspx?articleid=1853139
  9. Treleaven J, Gennery A, Marsh J et al Guidelines on the use of irradiated blood components prepared by the British Committee for Standards in Haematology blood transfusion task force. Br J Haematol. 2011 Jan;152(1):35-51. PMID: 21083660
  10. 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 PMID: 27775503 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 PMID: 27775504 http://www.nejm.org/doi/full/10.1056/NEJMe1612444
  11. Cooper DJ, McQuilten ZK, Nichol A et al. Age of red cells for transfusion and outcomes in critically ill adults. N Engl J Med 2017; 377:1858-1867. Nov 9, 2017 Online Sept 27. PMID: 28952891 http://www.nejm.org/doi/full/10.1056/NEJMoa1707572
  12. Carson JL, Stanworth SJ, Guyatt G et al Red Blood Cell Transfusion. 2023 AABB International Guidelines. JAMA. Published online October 12, 2023. PMID: 37824153 https://jamanetwork.com/journals/jama/fullarticle/2810754
  13. Kuehn BM Could Universal Donor Blood Be Made in the Laboratory? JAMA. Published online October 12, 2023. PMID: 37824127 https://jamanetwork.com/journals/jama/fullarticle/2810760
  14. Raasveld SJ et al. Red blood cell transfusion in the intensive care unit. JAMA 2023 Oct 12:e2320737 [e-pub]. PMID: 37824112 https://jamanetwork.com/journals/jama/fullarticle/2810759
  15. Siegal DM et al. Small-volume blood collection tubes to reduce transfusions in intensive care: The STRATUS randomized clinical trial. JAMA 2023 Oct 12:e2320820 PMID: 37824152 https://jamanetwork.com/journals/jama/fullarticle/2810758
  16. Perioperative Red Cell Transfusion: NIH Consensus Statement http://consensus.nih.gov/cons/070/070_intro.htm