09 Transfusion Therapy

1. what is normal
2. do lab tests that support a need
3. is the patient symptomatic
4. does the benefit outweight the risks
5. Do i need to do anything "special"

Female: 12 - 16 g/dL
Male: 13 - 18 g/dL

Female: 36% - 48%
Male: 39% - 54%

150,000 - 450,000 / uL

Bleeding time, TT, PT, PTT, Coag factors

~ 8 min

17 - 23 secs

11 - 13 secs

25 - 35 secs

1. Anemia - low hgb/hct ( LOW RBCS)
➢ Hgb - ≤ 7.0 g/dL / 21.0% …as opposed to 10 g/dL
2. Thrombocytopenia - low Plt ct
➢ < 50,000/μL for pre-surgical patient
➢ < 10,000/μL for therapeutic non-bleeding
3. Coagulopathy / Coagulation Deficiencies or Acute
Hemorrhaging; could include Plt therapy, too
➢ FFP -INR* > 1.5 * International Normalized Ratio (Prothrombin Time Test calc)
➢ Cryo - Fibrinogen < 80-100 mg/dL

the transfusion of blood and other blood components

1. Routine / ASAP (As Soon As Possible
2. Emergency
3. Refusal

1. Therapeutic
✓ Oncology
✓ Coagulation Deficiencies (non-bleeding)
✓ Neonate
2. Surgery
✓ SBOS-Surgical Blood Order Schedule
✓ TS / T&S-Type & Screen
✓ Autologous

▪ STAT(L: Statim)
▪ Massive Transfusion Protocol (MTP)

not needed until hours later or next day (not priority)

needed within the next few hours
- patient going to surgery
- low Hgb

usually give blood when ready (after all tests, compatibility, etc)

corrects anemia via maintaining oxygen-carrying capacity to all the vital organs, e.g., heart, brain, liver, etc.

Maintains coagulation scheme; corrects coagulopathy, blood volume, and osmotic pressure

corrects thrombocytopenia & maintains clotting mechanism

STAT (L: Statim) - IMMEDIATE without delay (PRIORITY)

STOP the bleeding

❑ Infuse osmotic-balanced solutions, e.g., crystalloids, colloids until blood / blood components arrive.
❑ However, these clear fluids (because of the osmotic imbalance) do NOT stay within the intravascular vessels. It goes extravascularly into the tissue area which results in extreme edema.
❑ Plasma is the preferred product; use "AB" plasma only, if ABO blood type is unknown.

❑The less clear fluid you give the trauma patient, the better off the patient will be!
❑Give LTOWB
❑Plasmas (osmotic-balanced fluids) -FFP, thawed plasma, & liquid plasma
❑ Can use "A" plasma on patients of unknown ABO blood type.
❑ Cold-Stored Platelets, if available and usually used enroute to the hospital

❑ Oxygen-carrying capacity to all the vital organs, e.g., heart, brain, liver, etc.
❑ Coagulation scheme & clotting mechanisms
❑ Balanced osmotic pressure
❑ Body temperature (37°C) or close to it
➢ Warm (as opposed to cold) blood by using blood warmer
➢ Trauma room ambient temperature may be warmer than other rooms in the ED or Surgery

❑ Massive Transfusion Protocol (MTP) - usually seen in Trauma cases or in certain types of surgeries; 1:1:1 ratio (RBC:Plsm:Plt)
❑ Special Procedure used to issue large quantities of blood & blood products in a very short time to a severely hemorrhaging patient
❑ This is a focal point where "routine" BB tasks are set aside and the BB CLSs come together as a "Team" to issue blood
❑ Can issue a MTP packet every 5 - 10 minutes

Massive transfusion protocol - special procedure used to issue large quantities of blood & blood products n a very short time to a secerely hemorrhading patient

Within a few hour period, a patient could use enough blood to completely exchange all of his / her total blood volume greater than 1 time.
In general, after the patient receives approx. 10 WB units (or 20 component units [half pint each]), it is considered as "an exchange". The human body contains about 10 ± 2 pints of blood or 5 L.
OR
2 MTP Batches / Packets (≈12 WB units)

YES!

Jehovah's Witness
Certain religious groups
Adults have the right to refuse - their right - considered an "assault" if violating the request

➢ On the other hand, if the patient is a minor, it is considered that "they lack experience / knowledge to make a sound judgement related to the consequences", therefore, the courts can intervene.
➢ Court orders may or may not grant approval unless the lack of blood results in end organ failure or death of the patient.

Blood is sacred / the prohibition to "eating" of blood:

This is the medical alert tag worn

1. Perfluorocarbons (PFCs)
2. Hemoglobin-based oxygen carriers (HBOC)

- artificial blood
- a white-colored emulsion
- a chemical compound that can carry and release oxygen

- artificial blood
- derived from animal (Bovine) or artificially via recombinant technology

NO! Not yet

➢ Adverse effects & toxicity
➢ Inefficient oxygen delivery in the microvasculature (lacks resuscitation abilities)
➢ Retention of PFC compound in liver
➢ Can not mimic blood & its properties (plts & coag)

- artificial RBC
➢ A synthetic artificial cell that uses nanoencapusulated human hgb
➢ Has capability to release O2 in the body
➢ Stable on shelf for several months
➢ No need for blood typing or Xmat

- artifical platelet
- A synthetic nanoparticle that mimics and amplifies platelet adhesion, activation, aggregation, & prothrombotic functions (clotting mechanism)

1. Leuko-reduced blood
2. CMV - Negative Blood
3. Irradiation of Blood Products

Reduces the following:
➢ Febrile Reactions
➢ HLA antibody alloimmunization

Reduces the following:
➢ Cytomegalo Virus (CMV) Infections - can cause death in neonates

- Prevents a condition called, Transfusion-Associated Graft-vs-Host Disease (TA-GVHD), occurring in an immunocompromised recipient (patient).
- Irradiation "kills" (renders inactive) the donor WBCs (specifically T-lymphocytes) found in the unit of blood.

They fail to suppress the transfused donor T-cells which become "activated" because it's in the patient's environment. The activated donor lymphocytes causes organ rejection in the patient.

✓ A cancer patient who underwent massive chemotherapy
✓ An immune medical condition or disease
✓ A neonate.

it also effects the integrity of the RBC membrane causing it to become weak (lesions) which, during storage, allows K+ & Hgb to leach out into the unit.

- must use blood filter (170 micron) for all blood / blood component transfusion
- a new filter is used for each unit of blood

≤ 4 hrs, but commonly, 1 - 2 hrs; slower, if patient has cardiac complications

- Use of normal saline (NS) only
- NO other medications or IV solutions (ex. Ringers Lactate) are allowed to be used

2 RNs must verify / compare the TRF info against the attached patient's armband / wristband to the unit's affixed label

❑ Do NOT ask a "yes" or "no" question, e.g., Are you Mr. John Smith?
❑ Instead, ask a question(s) that requires the patient's conscientious verbal response, e.g., "What is your full name?"

❑ RN / physician / anesthesiologist must check the patient's wrist band along with the medical record
❑ In these cases, the patient's proper identification rests on the hospital's proper identification processes that occurred prior to surgery
❑ If the patient enters the hospital in an unconscious state, many times the family members verify the patient's name and give the patient's info

❑ The Transfusionist (RN, MD, PA, or Perfusionist) is ultimately responsible for ensuring that the patient's and unit information are correct prior to initiating the transfusion; LVNs are not licensed to perform IVs.
❑ Any questions or discrepancies must be resolved prior to infusing the unit.
❑ It is common practice for the RN / MD to call the Blood Bank and ask questions.

- the first 15 minutes
- Within the first 15 minutes, if patient exhibits any adverse reaction to the transfusion, the transfusion MUST STOP IMMEDIATELY and the Blood Bank must be notified immediately

❑ The transfusion MUST STOP IMMEDIATELY and the Blood Bank must be notified immediately
❑ The Blood Bank must immediately perform the Transfusion Reaction Investigation process / testing
❑ The Blood Bank Medical Director (a Pathologist) must review the testing results, evaluate / interpret the test results, and conclude whether further patient medical treatment is warranted.

1. Emergent & in a hurry
2. Stressed & in a hurry
3. Not paying "close" attention
4. Distracted
5. Multi-tasking

Peer review for the appropriateness of all blood / blood component transfusions

➢ Established transfusion criteria / triggers that must be adhered:
✓ Hgb-≤ 7.0 g/dL …as opposed to 10 g/dL
✓ Plt Ct- ≤ 10,000/μL …as opposed to 20,000/μL
➢ Review any "outliers", e.g., coagulopathies, FFP transfusions, cryo uses, etc.

➢ Usually an RN
➢ Has extensive clinical knowledge
➢ Has been extensively trained in Transfusion Medicine
➢ Monitors PBM & the transfusion criteria
➢ Speaks to blood ordering / transfusing MDs & RNs