Transfusion Guidelines & Tips

MMC Blood Bank & Transfusion Guidelines

Tim Hayes, MD updated April 2011 Blood Bank Phone 662-2121

TA-GvHD (Transfusion-Associated Graft vs. Host Disease)

Massive Transfusion Guidelines UPDATED

Emergency Release of Uncrossmatched Blood

Autologous Blood and Directed Transfusions

MMC Transfusion Guidelines
    Red Blood Cells
    Cryoprecipitate
    Fresh Frozen Plasma
    Platelets

Unexpected Large Blood Loss at Scarborough Surgery Center

TA-GvHD (Transfusion-Associated Graft v. Host Disease)

A. Comparison with Bone Marrow Graft versus Host Disease:

Symptoms	BMT-GvHD	TA-GvHD
Onset	35-70 days	2-30 days
Skin Rash	Present	Present
Symptoms	Severe	Mild
Liver enzymes	elevated	elevated
Pancytopenia	rare	frequent
Marrow Hypoplasia	negative	positive
Occurence	70%	about 1%
Response to Therapy	80-90%	None
Mortality	10-15%	90-100%

B. Patients at Risk for TA-GvHD:

* Hx of bone marrow/stem cell transplant (allogenic or autologous)
* Current or past treatment with alemtuzumab (Campath) or a purine analogue, including fludarabine (Fludara), cladribine (Leustatin), and pentostatin/deoxycoformycin
* Congenital immunodeficiency syndromes (cellular or combined)
* Hodgkins disease (current or past)
* B cell malignancy (current or past)

C. Prevention of TA-GvHD:
Blood Component Irradiation before transfusion

attenuates Donor Lymphocytes in blood products
Gamma radiation of 1500-3000 rads
does NOT kill viruses, bacteria, or protozoa

If you have a Patient At Risk, let the Blood Bank know you need:

Irradiated Blood Components (part of Order Set on Sunrise)

Massive Transfusion Guidelines (MTG) UPDATED

Definition: Massive Transfusion is defined as:

Expected transfusion of >10 units PRBCs in a 24 hour period, or
Replacement of at least one blood volume within the first 24 hours of resuscitation, or
50% of blood volume replaced in a 3 hour period, or
Blood loss >150cc/minute.

(Estimated Blood Volume of an adult =70cc/kg)

Goals of Treatment:

-avoid dilutional coagulopathy
-avoid anemia, with resultant tissue hypoxia and acidosis

Identification & Notification: the responsible Attending Physician/Surgeon or Attending Anesthesiologist identifies patients eligible for the MTG. The Transfusion Service must be notified ASAP phone 662-2121).
When possible, if the patient is anticipated to go to the OR, the MTG leader or physician designee should personally call the anesthesiologist on-call in the OR (pager 0610) to discuss the management of the emergency.

Criteria for Activation of the MTG:

1. Adult patients requiring > 4 units of PRBCs in first hour of resuscitation or pediatric patient requiring > 20 ml/kg of PRBCs in first hour of resuscitation.

2. Adult patients with the high likelihood of requiring transfusion of > 10 units of PRBCs within the first 12 hours of resuscitation or pediatric patient with the high likelihood of requiring transfusion of > 0.1 units/kg of PRBCs within the first 12 hours of resuscitation.

Information Given to Transfusion Service (Blood Bank) for MTG Activation:

1. Responsible Physician/Surgeon
2. Patient name, medical record number and gender and age
3. Status of blood specimen for type and cross:

?Has the blood been drawn? and
? Has the blood been sent to Transfusion Service?

Blood Products from Blood Bank:

First "Round": 4 units O-neg Packed RBCs, 2 Units AB FFPlasma
2nd & Subsequent Rounds: 4 Units Crossmatched PRBCs, 4 units Crossmatched FFPlasma

1 unit Pooled Platelets for each 10-12 units PRBCs transfused.

Ordering Lab Studies In SunRise (SCM):

search for "Post Open Heart Coag Panel" or "Massive Transfusion". Both will direct you to the INR, PTT, Fibrinogen, and Platelets.

Labs to be Drawn/Sent:

TIME	LABS	Tubes
0	Type & Crossmatch CBC Post Open Heart Panel (INR, PTT, Fibrinogen, Platelet Ct) CMP, Mg, Ionized Ca ABG	What Color Tubes?
After every round of Massive Transfusion Components (4 PRBCs, 4 FFP)	CBC, Post Open Heart Panel (INR, PTT, Fibrinogen, Platelet Ct)	What Color Tubes?
every 1-2 hours during Massive Transfusion	BMP, Mg, ionized Ca⁺⁺ ABG	What Color Tubes?
Clinically Stable after Massive Transfusion, with expect arrest of hemorrhage	CBC, INR, PTT, fibrinogen: q 1 hr x2, then q 2 hours x 2, then q 4 hours until stable BMP, Mg, ionized Ca⁺⁺: q 4 hours until stable	What Color Tubes?

Emergency Release of Uncrossmatched Blood

The Blood Bank always has stored 4 units of O-Negative RBCs for emergency release.
Call 662-2121.

Autologous & Directed Blood Donations

Autologous blood donation & directed donation of blood from family or friends can be arranged through the American Red Cross (ARC).

1. Directed donations must be made within 42 days and no less than 6 days prior to surgery date.

2. Patient's physician must phone American Red Cross to request directed donation.

3. ARC then contacts patient for information, appointments, testing, and donation.

4. There is a service fee charged by ARC, payable at the time arrangements are made.

5. For more info:
    Portland Office ARC
    524 Forest Avenue
    Portland, ME 04101
    207-775-2367 or 1-800-482-0743
    Hrs: T,W,Th 12-7; F 9-4

MMC Transfusion Guidelines (5/98)

Red Blood Cells
Cryoprecipitate
Fresh Frozen Plasma
Platelets

All specimen tubes destined for the Blood Bank (T+C, T+S), must have a patient label attached,

**signed (w/ date & time) by:
the person drawing the blood (anesthesia provider)

**witnessed by:
circulator or other nurse, who also signs the label

Please be accurate and legible.

RBCs	Acceptable Indications:
	1. Symptomatic anemia in a normovolemic patient, regardless of Hgb level
	2. Acute blood loss of >15% of estimated blood volume
	3. Acute blood loss with evidence of inadequate oxygen delivery
	4. Preop Hgb level <8g/dl, & operative procedure associated with major blood loss
	5. Hgb < 9g/dl in a patient on a chronic transfusion regimen.
Lab Tests	A. Pre-transfusion Hgb/Hct B. Post-transfusion Hgb/Hct.

Cryo- pcpt.	Acceptable Indications:
	1. Diffuse microvascular bleeding and fibrinogen <100 mg/dl
Lab Tests	A. Pre-transfusion Fibrinogen B. Post-transfusion Fibrinogen

Fresh Frozen Plasma	Acceptable Indications:
	1. In a patient with diffuse microvascular bleeding, and a Prothrombin Time (PT) >16 sec., and/or a Partial Thromboplastin Time (PTT) >45 seconds
	2. In a non-bleeding patient scheduled for surgery or invasive procedure with a PT > 16 sec +/or PTT>45 sec.
	3. Warfarin overdose with major bleeding or impending surgery.
	4. Thrombotic thrombocytopenic purpura.
	5. Anticoagulation deficiencies such as: Protein C, Protein S, or Antithrombin III when specific therapy is not available or advisable
Lab Tests	A. Pre-tranfusion PT/PTT B. Post-tranfusion PT/PTT

Platelets	Acceptable Indications:
	1. Platelet count <10-20,000 in a non-bleeding patient with a failure of platelet production
	2. Platelet count < 50,000 and impending surgery or invasive procedure
	3. Diffuse microvascular bleeding in a patient with documented DIC or transfusion >= 1 blood volume and platelet count < 50,000, or lab values not yet available.
	4. Diffuse microvascular bleeding following cardiopulmonary bypass or IABP and Platelet ct. <100,000, or lab values not yet available.
	5. Bleeding in a patient with a qualitative platelet defect, regardless of platelet ct.
Lab Tests	A. Pre-tranfusion Platelet Ct B. Post-tranfusion Platelet Ct (w/ in 1 hr of Transfusion)

Approved by the Transfusion Committee MMC May 1998