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blood transfusion

Emergencies 1) group O erythrocytes can be transfused to anyone - indicated in emergencies when blood type is unknown [2] 2) Rh-positive patients can safely receive D-positive or D-negative blood, but Rh-negative patients must receive D-negative blood & platelets 3) group AB plasma may be tranfused to anyone 4) transfusion of incompatible blood in patients with severe autoimmune hemolytic anemia may be life-saving (autoantibody reacts with both donor & patient's erythrocytes) Indications: 1) symptomatic anemia [2] 2) hemoglobin < 6 g/dL (most patients) [2] 3) hemoglobin < 7 g/dL - hospitalized patients without end-organ damage - includes hemodynamically stable ICU patients [2,25] - target blood hemoglobin 7-9 g/dL [2] - post-surgical patients) [2,5] - excepting abdominal cancer & cardiac surgery 4) hemoglobin < 8 g/dL a) critically ill patients on ventilatory support b) critically ill patients without heart failure do not benefit from blood transfusion when hemoglobin > 7 g/dL [2] c) abdominal cancer surgery patients [15] d) cardiac surgery patients [2,16,25] - lower 3 month mortality with liberal transfusion [16] - no benefit of transfusion with hemoglobin > 7.5 g/dL [30] e) orthopedic surgery [2,25] f) cardiovascular disease [2,25] 5) hemoglobin < 9 g/dL septic cancer patients [27] 6) hemoglobin < 10 g/dL post acute myocardial infarction* 7) maintain hemoglobin > 9 g/dL for acute brain injury [41] 8) similar outcome of restrictive vs liberal transfusion for lower GI bleed [35] * 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: - delay elective surgery in patients who have correctable anemia until the anemia has been treated - avoid plasma transfusion unless there is active bleeding or there is laboratory evidence of coagulopathy - manage surgical bleeding with antifibrinolytic drugs (tranexamic acid) rather than blood transfusion when possible - in nonemergent settings, avoid transfusion when other treatments are available [31] * discuss alternative strategies during informed consent * Rh-negative females of child-bearing potential should never be given Rh-positive blood [2] Benefit/risk: - no benefit to liberal transfusion policy* - number needed to harm from liberal transfusion policy - 18 for pulmonary edema [19] * 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: - type & screen showing no unexpected antibodies eliminates need for type & cross-match 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 1) before the transfusion starts 2) 15 minutes after transfusion starts 3) hourly until the transfusion is complete 4) 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 - hepatitis B vaccine for any patients requiring frequent blood transfusions - routine prophylaxis with antihistamines or glucocorticoids not indicated in patients with history of mild transfusion reaction [2] Complications: - volume overload [21] - 3-5% of transfused post-surgical patients [14] - hypoxia, dyspnea, tachycardia, hypertension, headache [2] - elevated serum BNP [2] - pulmonary edema - within 6 hours of transfusion [2] - iron overload: deferoxime for iron overload - transfusion-related acute lung injury [2] - postoperative venous thromboembolism is more common after transfusion (RR=2) [33] - see blood transfusion reaction 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] - serum bilirubin increases more in the longer-term storage of packed RBC which translates to more frequent serious hepatobiliary adverse events (9% vs 5%) [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]

Related

autologous blood donation (transfusion) blood banking (transfusion medicine) blood donation blood products blood transfusion reaction blood type indications for CMV seronegative blood products irradiation of cellular blood products transfusion-associated infection

Useful

crossmatch type & screen

Specific

exchange transfusion intrauterine transfusion massive blood transfusion (washout) transfusion of blood component transfusion of plasma substitute transfusion of plasma volume expander

General

clinical procedure

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 613-616
  2. 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: 16810012 corresponding NGC guideline updated Feb 2016 http://www.anesthesiology.org/pt/re/anes/fulltext.00000542-200607000-00030.htm
  5. Carson JL et al Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB Annals of Internal Medicine, March 26, 2012 PMID: 22454395 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 PMID: 22454394 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
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  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: 17176334
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  16. Murphy GJ et al. Liberal or restrictive transfusion after cardiac surgery. N Engl J Med 2015 Mar 12; 372:997. PMID: 25760354 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. PMID: 25760360 http://www.nejm.org/doi/full/10.1056/NEJMe1415394
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  19. 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: 20927728
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  28. Rothaus C Red-Cell Transfusion. Resident 360. Sept. 27, 2017 https://resident360.nejm.org/content_items/red-cell-transfusion
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  31. 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: 30146969 Free Article https://www.nejm.org/doi/10.1056/NEJMoa1808561
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  35. 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: 30805962 https://onlinelibrary.wiley.com/doi/full/10.1111/apt.15158
  36. 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: 31350268 https://ashpublications.org/blood/article-abstract/134/13/1003/374918/Effect-of-donor-component-and-recipient?redirectedFrom=fulltext
  37. 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: 33560322 https://jamanetwork.com/journals/jama/fullarticle/2776201
  38. Carson JL et al. Restrictive or liberal transfusion strategy in myocardial infarction and anemia. N Engl J Med 2023 Nov 11; [e-pub]. PMID: 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. 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: 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: 39348694 No abstract available.
  41. 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: 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: 39382236 https://jamanetwork.com/journals/jama/fullarticle/2824932