What Clinicians Should Know

About Blood Transfusions

Ong Tee Chuan

Hospital Ampang

Risk of Every Transfusion

Wrong blood causing hemolysis

Transfusion reactions
Bacteremia
Transfusion related acute lung injury
(TRALI)
Transfusion transmitted infections

Red Cell Transfusion

When oxygen delivery to tissue is
compromised
Factors to be considered
Tempo of anemia
Any on-going blood loss
Age of the patient
Co-morbidities

Red Cell Transfusion

% blood volume loss

Blood volume (ml)

Need for transfusion

15

750

No*

15 - 30

800 - 1500

No*

30 - 40

1500 - 2000

Probably

> 40

> 2000

Yes

Hb level (g/dL)

Need for transfusion

<7

Yes

7 - 10

No*

> 10

No

* Except for patients who tolerate anemia poorly, e.g. severe cardiac or respiratory
disease, age > 65. (ATLS 2010, BJH 2001)

Platelets Transfusion
Indications
Thrombocytopenia with life threatening
bleeding
DIC or massive transfusion with excessive
bleeding
Uremia with bleeding failed to be controlled by
DDAVP or cryoprecipitate
Post cardiac bypass with bleeding not due to
surgical reason or heparin

Platelets Transfusion
Indications
Glanzmanns thrombasthenia or Bernard
Soulier with life threatening bleeding
< 10 x 109/L in patients with marrow failure
to keep safe platelets count prior to surgery or
other invasive procedures

Platelets Transfusion
Platelets Dose
Random

Apheresis

Pediatrics

10 ml/kg

1 unit/10 kg

Adult

6 8 units

1 unit

Transfusion of Fresh Frozen Plasma

Indications
Reversal of warfarin effect (PCC is preferred)
Bleeding or prior to invasive procedure in
significant liver coagulopathy
Massive transfusion with excessive bleeding
Plasma exchange for TTP
Multiple coagulation factors deficiency
DIC with bleeding

Transfusion of Cryoprecipitate
Indications
Hypofibrinogenemia states with bleeding e.g.
DIC

NO LONGER USED for Hemophilia A, von Willebrand Disease

FFP & Cryoprecipitate

FFP

Cryoprecipitate

Pediatrics

10 ml/kg

1 unit/10 kg

Adult

15 ml/kg

1 unit/10 kg

Reversal of Warfarin
Warfarin Reversal
Non-Emergency
INR 5 8
No bleeding

Stop Warfarin

INR > 8, or lower

INR but bleeding

IV Vitamin K 2-5
mg

Emergency & Life threatening bleed

STOP Warfarin
IV Vitamin K 2-5 mg
IV 4-factor PCC
INR
<5
>5

PCC Dose (IU/kg)

15
30

Acute Transfusion Reactions

Occur within 24 hours
Suspect a reaction if
Sudden rise in temperature > 1 degree C
Rigors
Rash
Unwell

Acute Transfusion Reactions

Major reactions reaction needing
immediate actions
Anaphylaxis
Hemolysis
Septic shock

Minor reactions
Urticaria
Non-hemolytic febrile reaction

Major Reactions Requiring Immediate Action

Hemolysis
Gram negative septic shock
Often not possible to differentiate during acute
episodes
Suspect when
Shortness of breath/chest pain not due to cardiac
or pulmonary causes
Back pain/loin tenderness
Profound hypotension

Major Reactions Requiring Immediate Action

Hemolysis
Gram negative septic shock
Action

Resuscitate: ABC
Disconnect blood and giving set
Put up new saline infusion
Send samples
Blood for re-GXM & antibody, FBC, Coombs, DIC screen, RP,
bilirubin, Blood culture, urine for Hb

Check documentation
Send samples + unit giving set + all previous units +
completed trasnfusion reaction form to transfusion lab
Inform the transfusion unit

Major Reactions Requiring Immediate Action

Hemolysis
Gram negative septic shock
Management
ARF and DIC: Fluid, blood component, dialysis
Start antibiotics if suspect gram negative bacteria
Tazocin +/- Aminoglycosides

Major Reactions Requiring Immediate Action

Anaphylaxis
Diagnosis: brochospsm, edema, circulatory
collapse
Action: As for Hemalosis & Sepsis
Management
IM Adrenaline 0.05-0.1 ml/kg of 1:10,000 repeated
every 10 minutes as necessary
IV Piriton 0.1 mg/kg every 6-8 hours

Minor Reactions
Urticaria
Diagnosis: urticarial skin rashes
Action

Temporary stop transfusion

IV Piriton 10 mg
Review
If settles, can resume

Minor Reactions
Non-hemolytic febrile reaction
Diagnosis: sudden rise in temperature
Action

Temporary stop transfusion

Give Paracetamol
IV hydrocortisone 50-100 mg
Review
If settles, can resume at slower rate

Acute Transfusion Reactions

If in doubt, treat and investigate as a

MAJOR TRANSFUSION REACTION

Massive Transfusion
Actual or anticipated blood loss of > 30%
volume (+/- 1500 mls in average adult)
within 3 hours or 150ml/min
Massive Transfusion Protocol is established
in Hospital Ampang

In Real Life
Transfuse or not transfuse?
Pre-operative assessment
The key is to take a significant bleeding
history
Investigate the cause of low platelets
Investigate the cause of anemia
Coagulation tests (PT, aPTT) DO NOT predict
bleeding
Abnormal coagulaton tests warrant
investigating the underlying cause, NOT
transfusion.

Significant Bleeding History

Epistaxis not stopped by 10 minutes of
adequate compression
Multiple and large skin bruises without
trauma
Prolong bleeding from trivial wound
Post-op non-surgical cause of bleeding
Menorrhagia especially since menarche

Significant Bleeding History

Appropriateness of bleeding to injury

Focal or generalised bleeding
Past history of prolonged bleeding
Family history of bleeding
Medical illness
Medications

Take Home Messages

The next time you decide to

transfuse
STOP. THINK. ASK.
IS IT REALLY NECESSARY?

Ensure a safe Transfusion

Correct practice at every step
Appropriate indications for blood transfusion
Correct patient identification prior to sampling
Bedside sample labeling
Check previous transfusion records
Proper collection and inspection of blood
Correct patient identification at bedside prior
to transfusion
Monitoring during transfusion

Thank You