5. BLOOD COMPONENTS AVAILABLE
• 1-6° C (stored); 1-10° C (shipped)
• 21, 35, or 42 days depending on preservative or
additive
RBCs
Types
- Frozen
- Washed
- Irradiated
- Leukoreduced
Irradiated - 25 GY
- Prevents TA -GVHD
LEUKOREDUCED
patients who receive a lot of transfusions
- Reduce frequency and severity of FNHTR
- Reduced risk of CMV transmission
- Reduced frequency of HLA
alloimunisation
6. RBC INDICATIONS
Indications for the transfusion of packed red blood cells (RBCs) in critically ill patients
• Acute hemorrhage with hemodynamic instability
• Acute anemia with inadequate oxygen delivery (eg, cool vasoconstricted skin, obtundation or
• restlessness, oliguria or anuria, lactic acidosis)
• Hemoglobin concentration of <7 to 8 g/dL, depending on patient characteristics
Crit Care Med 2009; 37:3124
7. RBC INDICATIONS
• Restrictive transfusion strategy (transfusion threshold of <7 g/dL) or
• Liberal transfusion strategy (threshold of<10 g/dL)
Restrictive strategy decreased hospital mortality
Lower hemoglobin thresholds are also supported for specific subgroups of
critically ill patients
Sepsis – The Transfusion Requirements in Septic Shock (TRISS) trial
Gastrointestinal bleeding – acute severe upper gastrointestinal (GI) bleeding
Patients with active ischemic cardiovascular disease had a trend toward improved
clinical outcomes when a hemoglobin level of <10 g/dL was used as the threshold for
transfusion
N Engl J Med 2014; 371:1381
N Engl J Med 2013; 368:11
TRICC trial- N Engl J Med 1999; 340:409
9. PLASMA INDICATIONS*
Common indications in critical situations
• Active bleeding (known/ suspected coagulation abnormalities)
• Massive transfusion
• Prior to invasive and surgical procedures for which there is a HIGH risk of
bleeding complications
(ANY potentially significant abnormality of their coagulation tests (ie, prothrombin time, international normalized ratio
[INR], or partial thromboplastin time)
• Prior to invasive procedures for which there is a LOW risk of bleeding
complications ( SEVERE abnormality of coagulation tests (ie, prothrombin time >2-times control, INR >2, or
partial thromboplastin time >2- times control))
J Trauma 2009; 66:41
Transfusion 2012; 52:1673
• Paucity of evidence
• Indications provided here are primarily based
upon clinical
experience and biological rationale
Transfusion 2012; 52:1673
10. PLASMA RESPONSE
Response to a plasma transfusion is directly proportional to the
difference between the patient's levels of coagulation factors and that of
the infused plasma
severe factor deficiencies (manifested as severely abnormal
coagulation tests) are more likely to see a significant decrease in their
INR
Transfusion 2006; 46:1279
11. PLASMA PREPARATIONS
FFP
ABO compatibility req
coagulation factors for
Bleeding
Abnormal clotting due to
massive transfusion
Patients on warfarin who
are bleeding
Treatment of TTP and
HUS
Factor deficiencies
ATIII deficiency
DIC when fibrinogen is
<100 mg/dL
CRYOPRECIPITATE
ABO compatibility not req
2° treatment for Factor
VIII deficiency
(Hemophilia A)
2 ° treatment for von
Willebrand’s Disease
Congenital or acquired
fibrinogen deficiency
FXIII deficiency
“Fibrin Glue” applied to
surgical sites
CRYOSUPERNATANT
ABO compatibility req
leftover plasma AFTER
extraction of called
cryoprecipitate
TTP
Factor Concentrates
Intravenous
Immunoglobulin
Autoimmune (ITP)
Immunodeficiency
Transfus Clin Biol 2007; 14:551
12. PLATELET INDICATIONS
Platelet
transfusion
Prophylactic
(to prevent bleeding)
Therapeutic
(to arrest active bleeding)
Platelet count <10 X 103 platelets/microliter
to prevent spontaneous hemorrhage
Platelet count <50 X 103 platelets/microliter
actively bleeding
scheduled invasive procedure
qualitative intrinsic platelet disorder
Platelet count <100 X 10 platelets/microliter
central nervous system injury,
multisystem trauma
neurosurgery, or require an intrathecal catheter for anesthesia
Patients with a normal platelet count who have ongoing active
bleeding WITH reason for platelet dysfunction
congenital platelet disorder
chronic antiplatelet therapy
uremia
Br J Haematol 2003; 122:10
13. SPECIAL CONSIDERATIONS
• Heparin-induced thrombocytopenia (HIT)
• Thrombotic thrombocytopenia purpura (TTP)
• Hemolytic-uremic syndromes (HUS)
• Disseminated intravascular coagulation (DIC)
• Thrombocytopenia associated with antiplatelet alloantibodies
• Immune thrombocytopenia (ITP)
less effective (due to platelet consumption, eg, DIC)
associated with clinical worsening (due to additional thrombosis, eg, TTP)
Reserved for life-threatening
bleeding
Am Soc Hematol Educ Program 2007; :172
15. PLATELET RESPONSE
• Each unit of transfused platelets should increase the platelet count by 5 to 10 X
103 platelets/microliter in an average 70 kg adult
Transfusion of six units of platelets can be expected to increase the platelet count
by 30 X 103 platelets/microliter
Alloantibodies – platelet destruction
SINGLE DONOR
HLA Crossmatch
Br J Haematol 2003; 122:10
16. MASSIVE TRANSFUSION
HEMORRHAGIC SHOCK
• Requirement for > 4 RBC units in 4 hour with ongoing need for transfusion
• Blood loss > 150 ml/min with hemodynamic instability and need for transfusion
Transfusion Medicine Reviews, Vol 25, No 3 (July), 2011:pp 217-231
Bleeding
• Cxm, CBC, PT (INR),APTT, fibrinogen,
ABG, Biochem
MTP
• Predefined ratio of RBCs, FFP/cryoprecipitate and
platelets units (random donor platelets) in each pack
• (1:1:1 or 2:1:1) with PCC, Factor VIIa
NOT
CONTROLLED
• Bleeding controlled
Aim
Temp > 35C
Ph > 7.2
Ca2+ > 1.1
PLT > 50000
PT/APTT < 1.5 times
normal
INR < 1.5 normal
Fibrinogen >150 mg/dl
18. TRANSFUSION REACTIONS
Immunologic reactions
• Acute hemolytic reactions
• pain at the infusion site
• fever, chills, back and substernal pain
• mental status changes
• dyspnea, hypotension, elevated jugular venous pressure
• cyanosis
• bleeding diathesis due to disseminated intravascular coagulation
critically ill patient - difficult to detect
• unexplained hypotension
• Hemoglobinuria
• bleeding diathesis occurs during or shortly after transfusion
When an acute hemolytic
reaction is suspected:
Transfusion should be
stopped immediately
blood samples
• Free haemoglobin
• Haptoglobin
• Coombs’ testing.
Crystalloid infusion to maintain
the urine output above 100
mL/h should be given, and other
measures to protect against
possible pigment nephropathy
Br J Haematol 2013; 160:445
19. TRANSFUSION REACTIONS
• Delayed hemolytic transfusion reactions
• Allergic reactions
infusion of an antigen with preexisting antibodies
do not require previous blood exposure
• Febrile non-hemolytic transfusion reactions
Antileukocyte antibodies
Accumulation of cytokines in stored blood components
Avoided by using leukoreduced blood components
Br J Haematol 2013; 160:445
