- Blood Product Menu:
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pRBC's
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Fresh Frozen Plasma
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Platlets
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Cryoprecipitate
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Transfusion Therapy
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Coag Pathway
- Clinical Value of Transfusion:
- in the report by Wen-Chih Wu et al, studied in the effects of blood transfusion in patient experiencing MI;
- retrospective study of data on 78,974 Medicare beneficiaries 65 years old or older who were hospitalized with acute MI;
- patients were categorized according to the hematocrit on admission (5.0 to 24.0 %, 24.1 to 27.0 %, 27.1 to 30.0 %, 30.1 to 33.0 %, 33.1 to 36.0 %, 36.1 to 39.0 %,
or 39.1 to 48.0 %), and data were evaluated to determine whether there was an association between use of transfusion and 30-day mortality.
- patients with lower Hct values on admission had higher 30-day mortality rates;
- blood transfusion was associated with a reduction in 30-day mortality among patients whose Hct on admission fell
into the categories ranging from 5.0 to 24.0 % to 30.1 to 33.0 %;
- ref: Blood Transfusion in Elderly Patients with Acute Myocardial Infarction Wen-Chih Wu NEJM. Vol 345:1230-1236 Oct 25, 2001 No 17
- Predicting the Need for Transfusion in Orthopaedic Patients:
- preoperative hemoglobin is main indicator for need of postoperative transfusion;
- preoperative Hgb less than 11 g/dl is a strong indicator for need for transfusion in total joint replacement;
- in the report by Jose A. Salido, MD et al (JBJS 2002), the authors studied risk factors for transfusion in patient undergoing joint replacement;
- patients with a preoperative hemoglobin level of <130 g/L had a four times greater risk of having a transfusion than did those with
a hemoglobin level between 130 and 150 g/L and a 15.3 times greater risk than did those with a hemoglobin level of >150 g/L;
- preoperative hemoglobin level (p = 0.0001) and weight of the patient (p = 0.011) were shown to predict the need for blood transfusion after hip and knee replacement.;
- ref:
Preoperative Hemoglobin Levels and the Need for Transfusion After Prosthetic Hip and Knee Surgery. Analysis of Predictive Factors
Jose A. Salido, MD. The Journal of Bone and Joint Surgery (American) 84:216-220 (2002)
- in the report by AM. Hatzidakis MD (JBJS. Jan 2000), the authors studied the role of transfusion in 247 total knee replacements (157 unilateral primary,
thirty-two revision, and twenty-nine one-stage bilateral primary procedures) and 271 total hip replacements;
- they found that patients who have an initial hemoglobin level of at least 150 grams per liter or an initial hemoglobin level of between 130 and 150 grams per
liter and an age of less than sixty-five years have a minimal risk of needing a transfusion during or after a primary total joint replacement.
- references:
- Blood management experience: relationship between autologous blood donatoin and transfusion in orthopaedic surgery. TP Sculco and J. Gallina. Orthopedics. Jan 1999. Vol 22. No 1. Supp. 129.
- Alternatives to Transfusion Therapy:
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Erythropoietin
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The effects of recombinant human erythropoietin on perioperative transfusion requirements in patients having a major orthopaedic operation. The American Erythropoietin Study Group.
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Use of erythropoietin to increase the volume of autologous blood donated by orthopedic patients.
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iron supplementation:
- ref:
Iron supplementation after femoral head replacement for patients with normal iron stores;
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autologous blood: (see
pRBC transfusion)
- in the total hip replacement study by Sculco and Gallina 1999, 82% of these patients (autologous or PAD patients) required transfusion of their own
blood (vs 50% in patients that did not donate autologous blood), but only 8% of PAD patients required allogenic transfusion;
- 34 to 45% of autologous blood was discarded;
- w/ a preoperative Hgb level of less than 11 g/dl about 93-96% of patients required a transfusion vs. only 52-59% of patients w/ a preoperative Hgb of greater than 14 g/dl;
- w/ THR, expected transfusion requirements are 0.8 units when the Hgb level is more than 14 g/dl vs 1.6 units when the Hgb level is less than 11 g/dl;
- in the prospective randomized study by DB Billote MD et al (JBJS- Am Aug 2002, p 1299), the authors noted that preoperative autologous donation provided
no benefit for nonanemic patients undergoing primary total hip replacement;
- preoperative autologous donation increased the likelihood of autolgous transfusion, wastage of predonated units, and costs;
- references:
- Preoperative Autologous Donation for Total Joint Arthroplasty. An Analysis of Risk Factors for Allogenic Transfusion*
AM. Hatzidakis MD JBJS. Jan 2000. Vol 82-A. No 1. p 89.
- Methods to Decrease Transfusion:
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aprotinin:
- cell saver:
- references:
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Use of recombinant human erythropoietin (r-HuEPO) in a Jehovah's Witness refusing transfusion of blood products: case report.
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Reinfusion of whole blood after revision surgery for infected total hip and knee arthroplasties.
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Methylmethacrylate monomer and fat content in shed blood after total joint arthroplasty.
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Unwashed Filtered Shed Blood Collected After Knee and Hip Arthroplasties: A Source of Autologous Red Blood Cells.
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Postoperative Blood Salvage Using the Cell Saver after Total Joint Arthroplasty.
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Reinfusion of shed blood after orthopaedic procedures in children and adolescents.
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Blood salvage after total hip arthroplasty.
- Technical Considerations:
- all blood productsshould be administered thru 170 um filters to prevent infusion of macroaggregates of fibrin and debris;
- patients should be observed for the first 5-10 min of a transfusion and then examined frequently for signs of fluid overload and other adverse reactions;
- emergent transfusion:
- in most cases an Rh type and screen takes 10 minutes and is safer than using O negative blood;
- Transfusion Complications:
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transfusion related infectious complications:
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post-transfusion alkalosis:
- the early net result of succesful resusitation is post-transfusion alkalosis in the patient;
- the sodium citrate is converted to
bicarbonate
- the alkalosis is associatted with increased potassium excretion;
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hypocalcemia:
- some recommend calcium supplementation for patients receiving greater than 100 ml/min;
- give 0.2 gm of CaCl in a separate line for each 500 ml given;
- some believe that most patients will tolerate 1 unit pRBC q 5 min without requiring calcium supplementation;
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non hemolytic reaction:
- typically, this reaction occurs after a significant portion of the blood has already been transfused;
- note: hives + hypotension = anaphylaxis
- management:
- by itself, may continue the transfusion (
benadryl 50mg PO/IV);
- prior to future transfusions, the patient should be pre-medicated w/ benadryl 50mg PO/IV (not IM);
- if this fails to prevent urticarial rxn, washed RBC's should be given;
- w/ mild febrile transfusion reactions fever w/o evidence of hemolysis or more severe symptoms), antipyretics can be used;
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acute hemolytic reaction:
- most severe and potentially dangerous transfusion reactions;
- acute intravascular hemolysis occurs during or shortly after transfusion of incompatible blood and is usually due to preformed antibodies;
- typically this reaction occurs early w/ as little as 30 cc of transfused blood;
- manifestations:
- fever, chills, back or chest pain, N/V, and evidence of hemodynamic instability;
- required labs:
- spin a hematocrit to look for a pink plasma layer indicates hemolysis;
- pink-red (spun) plasma indicates that greater than 20 mg/dl of free hemoglobin is present;
- send off a DIC screen: PT/PTT, fibrinogen, fibrinogen degradation products, serum bilirubin;
- culture of the patient and the donor blood is indicated if there is suspicion of bacterial contamination;
- repeat cross match;
- Coomb's Test, Free Hb;
- CBC, RBC morphology;
- send Donor's Blood back to the blood back;
- repeat cross match;
- management:
- try to preserve intravascular volume and protect against acute renal failure;
- NS 500 ml IV "wide open"
- monitor the urine output closely and maintain a brisk diuresis (greater than 100 ml/hr);
- consider alkalinization of the urine with bicarbonate (1 mEq/kg IV until urine pH =7.5-9.0)
- will facilitate the excretion of free hemoglobin
Outcome of massive transfusion exceeding two blood volumes in trauma and emergency surgery.
Perioperative blood transfusions are associated with increased rates of recurrence and decreased survival in patients with high-grade soft-tissue sarcomas of the extremities.
