CMC Medical Staff Transfusion Guidelines. Table of Contents edition INTRODUCTION:

Transcription

1 CMC Medical Staff Transfusion Guidelines 2014 edition INTRODUCTION: The CMC Blood Component and Transfusion Guidelines have been approved by the multidisciplinary Transfusion Committee. These are based on current evidence and recently published expert guidelines. These transfusion guidelines are not intended to be proscriptive rules, but they are applicable to many common clinical circumstances in which transfusion is considered. Table of Contents BLOOD PRODUCTS... 2 I. RED BLOOD CELLS (RBC)... 2 II. PLATELETS (PLT)... 3 III. PLASMA (FFP)... 5 IV. CRYOPRECIPITATE (CRYO)... 6 V. GRANULOCYTES... 7 NEONATAL TRANSFUSION GUIDELINES - INFANTS < 4 MONTHS... 8 I. RED BLOOD CELLS (RBC) - INFANTS < 4 MONTHS... 8 II. PLATELETS (PLT) - INFANTS < 4 MONTHS... 8 III. PLASMA (FFP) AND CRYOPRECIPITATE (CRYO) - INFANTS < 4 MONTHS... 8 SPECIAL BLOOD PRODUCT/COMPONENT MODIFICATIONS... 9 I. IRRADIATION OF CELLULAR BLOOD COMPONENTS... 9 II. CYTOMEGALOVIRUS (CMV)-NEGATIVE COMPONENTS III. SICKLE CELL-NEGATIVE RED BLOOD CELLS (RBC) IV. SPECIAL PLATELET ORDERS FOR REFRACTORY PATIENTS (CROSSMATCHED/HLA MATCHED) V. PRE-OPERATIVE AUTOLOGOUS BLOOD DONATION (PAD) BLOOD PRODUCTS--SPECIAL TRANSFUSION ORDER GUIDANCE I. BLOOD WARMING II. PREMEDICATION TO PREVENT TRANSFUSION REACTIONS Transfusion Guidelines, Revised 7/2014, Approved MEC 8/2014 Page 1

2 BLOOD PRODUCTS I. RED BLOOD CELLS (RBC) How Supplied: All Red Blood Cell products issued at CMC facilities are leukocyte-reduced. Volume of one unit is ml. Cost: CMC acquisition cost per RBC unit is $245. Cost inclusive of staff time and infusion supplies is estimated at $500. Utilization Review Guidelines: Red cell transfusion may be appropriate to improve oxygen carrying capacity. Documentation of the indication(s) for transfusion and special circumstances for transfusions ordered outside these guidelines is required. Indications: 1) Acute Blood Loss: Maintain circulating blood volume with fluid resuscitation. If timely hemoglobin and hematocrit testing is available, consider transfusion if hemoglobin is less than 7 g/dl in otherwise healthy patients; less than 8g/dL in elderly patients and those with known ischemic cardiac or respiratory disease. If decision is based on blood loss: a) 15-30% loss of blood volume: RBC transfusion likely not required b) 30-40% loss of blood volume: RBC transfusion probably required c) Greater than 40% loss of blood volume: RBC transfusion almost certainly required. 2) Massive transfusion protocol (MTP) includes 5 RBC, 5 plasma, and 1 pheresis platelet in each MTP pack. 3) Anemia in the absence of acute blood loss. NOTE: Single RBC unit orders are recommended for most situations, with clinical re-assessment prior to additional RBC transfusion. a) Hemoglobin less than 7g/dL: Stable hospitalized patients including critical care unit. (target: up to 9 g/dl). NOTE: Many younger patients safely tolerate lower hemoglobin if normovolemic. b) Hemoglobin less than 8 g/dl: Patients with co-morbid conditions such as acute coronary disease, pulmonary disease, or acute septic shock: (target: up to 10 g/dl). c) Hemoglobin less than 10 g/dl: Significantly symptomatic patient with normal volume status (single RBC unit order is recommended). 4) Post-operative transfusion: a) Hemoglobin less than 7 g/dl (insure adequate volume status prior to RBC transfusion). b) Hemoglobin less than 10 g/dl: RBC transfusion may be appropriate if any of the following are present: organ hypoxia, increased potential for or ongoing blood loss, volume status and risk factors for complications of inadequate oxygenation 5) Hemoglobin less than 10 g/dl and burn patient - at least 10% TBSA burn. A lower transfusion threshold may be appropriate depending on the clinical situation. 6) Other-Specify reason. Outcome Indicators: Improvement in clinical status of patient (relief of symptoms of decreased oxygen carrying capacity) Transfusion Guidelines, Revised 7/2014, Approved MEC 8/2014 Page 2

3 Improvement in Hgb/Hct (one unit of red cells should raise the Hgb on average 1g/dL or 3% Hct in an adult). Post-transfusion Hgb can be drawn after 1 hour of transfusion if there is no ongoing blood loss in a normovolemic patient. Dosing (adults and children at least 35 kg): RBCs should be transfused based on clinical need. Avoid transfusions based solely on Hgb or Hct value. In the absence of acute hemorrhage, RBC transfusion should be given as single unit. RBC dose in each Massive Transfusion Pack (MTP) is 5 RBC units. Dosing (children less than 35 kg): RBC ml/kg will raise hemoglobin by 2 to 3 g/dl depending on body size (in the absence of acute blood loss). Administration: Non-emergent infusion rate for adults and children 35 kg or above: ml/hr for the first 15 min then ml/hr if well tolerated. Infusion must be complete within 4 hours after issue time. Non-emergent infusion rate for children less than 35 kg: Must be based on patient s clinical status and needs. Transfusion is generally completed within 1-2 hours and must be completed within 4 hours. II. PLATELETS (PLT) How Supplied: All platelets at CMC are leukocyte-reduced single donor apheresis. A unit has at least 3 x platelets. Units are stored at room temperature for up to 5 days after donation. Volume is ml. Cost: CMC acquisition cost per platelet unit is $645. Cost inclusive of staff time and infusion supplies is estimated at $1300. Utilization Review Guidelines: Platelets are administered for the prevention and treatment of bleeding in patients with thrombocytopenia or platelet function defects. Indications: 1) Prophylaxis in hematology/oncology and other patients with bone marrow suppression: a) Platelet count less than 10,000/μL: Stable patient. b) Platelet count less than 20,000/μL: Risk factors for bleeding (h/o bleeding, infection, fever, sepsis, disseminated intravascular coagulopathy, qualitative function defect). 2) Prophylaxis for Interventional Radiology (IR) Procedures: a) No platelet count requirement: Fine needle and bone marrow aspiration. b) Platelet count less than 25,000/ μl: Paracentesis, thoracentesis, central lines, PICC lines, percutaneous drains, superficial organ biopsy. c) Platelet count less than 35,000/μL: Deep organ core biopsy (e.g., lung and liver), angiogram. d) Platelet count less than 50,000/ μl: Highest risk IR procedures (eg, renal core biopsy, neuraxis procedures such as LP, epidurals). Transfusion Guidelines, Revised 7/2014, Approved MEC 8/2014 Page 3

4 3) Platelet count less than 50,000/ μl: Active bleeding or prophylaxis for most OR procedures and higher risk endoscopy procedures with significant bleeding risk. 4) Platelet count less than 100,000/μl: Neurosurgical, ophthalmologic or other procedures where microvascular bleeding is high risk. 5) Cardiac Surgery with: a) Platelet count less than 100,000/μL and microvascular bleeding. b) Microvascular bleeding and qualitative Platelet function defect c) Microvascular bleeding and current ROTEM findings indicating isolated or combined defect of platelet function. d) Post-op microvascular bleeding 6) Documented qualitative platelet dysfunction (e.g., drug-induced, uremia, hereditary). 7) Massive transfusion protocol (MTP) includes 5 RBC, 5 plasma, and 1 pheresis platelet in each MTP pack. ROTEM monitoring is recommended to guide therapy. 8) Other-Specify reason. Outcome Indicators: Cessation or reduction of bleeding Rise in platelet count by 20,000-60,000/μl in a 70 kg recipient after transfusion of a single apheresis platelet unit (if measured min post-transfusion). Dosing (adults and children at least 35 kg): Standard dose is one unit. In some cases such as large body size with large platelet count gap from goal, an order for two platelet units is reasonable. Orders above two units will generally require pathologist approval. Dosing (children less than 35 kg): Platelets 5 to 10 ml/kg will raise platelet count by at least 50,000/uL depending on body size of the child. Administration: Non-emergent infusion rate for adults and large children: ml/hr x 15 min, then ml/hr if well tolerated). Infusion must be complete within 4 hours of issue time. Non-emergent infusion rate for children < 35 kg: Must be based on patient s clinical status and needs. Transfusion is generally completed within 1-2 hours and must be completed within 4 hours. Comments: Platelet function defect should be documented by laboratory assessment of platelet function; or presumed due to hypothermia or mechanical devices that affect platelet function. Tests available include: o ROTEM : Assess both overall platelet function and coagulation factor functionality (Note: available at CRMC) o VerifyNow-P2Y12: Assess P2Y12 inhibitors such as clopidogrel (PLAVIX) and ticagrelor (BRILINTA). o VerifyNow-Aspirin: Asses aspirin effect on platelet function. Not for use in patients also taking other anti-platelet agents. o PFA-100: Assess intrinsic defects such as von Willebrand disease and aspirin medications. o Note: IV GPIIb/IIIa inhibitors may or may not cause abnormal ROTEM, PFA-100 or VerifyNow results. Transfusion Guidelines, Revised 7/2014, Approved MEC 8/2014 Page 4

5 Recommendations for stopping medication prior to invasive procedures vary with the medication and clinical situation. Platelet function tests may help assess level of platelet inhibition and safe timing of surgical procedure. Consider DDAVP in addition to administration of platelets to control bleeding. III. PLASMA (FFP) How Supplied: Fresh Frozen Plasma (FFP) or Fresh Plasma 24 (FP24): Plasma prepared from either a whole blood or apheresis collection and frozen either within 8 hours or 24 hours of collection. o Can be used interchangeably all are referred to as Plasma o Contains similar levels of clotting factors Thawed plasma: Unit of FFP or FP24 that was thawed and stored at 1-6 C for 1-5 days o Considered therapeutically equivalent to FFP/FP24 for most indications. Cryo-poor plasma: Prepared from FFP after cryoprecipitate is removed. o Contains limited or no factor VIII and XIII, vwf, fibrinogen, or fibronectin o Used solely in the treatment of thrombotic thrombocytopenic purpura Volume per unit is ml Cost: CMC acquisition cost per FFP unit is $75. Cost inclusive of staff time and infusion supplies is estimated at $150. Utilization Review Guidelines: Plasma transfusion therapy is indicated for treatment of documented coagulopathy, where the mechanism for coagulation defect is known, understood and attributable to coagulation factor deficiency, and it is expected that replacement with plasma transfusion is the most efficient way to correct that deficiency. PT/INR, PTT, and ROTEM analysis are indicative of the severity of coagulation defect. Indications: 1) Active Bleeding: a) INR greater than 1.7. b) ROTEM showing significantly abnormal INTEM, EXTEM CT, CFT, alpha angle 2) Prophylaxis for Interventional Radiology procedures: a) INR greater than 1.5: Highest risk IR procedures (e.g., renal core biopsy, neuraxis procedures such as LP, epidurals). b) INR greater than 1.7: Deep organ core biopsy (e.g., lung and liver) and angiogram. c) INR greater than 2.0: Thoracentesis, central lines, PICC lines, percutaneous drains, superficial organ biopsy. d) INR greater than 3.0: Paracentesis, bone marrow biopsy. e) No coagulation testing required: Fine needle aspiration 3) Prophylaxis for moderate to high risk operating room and endoscopy procedures: a) INR greater than 1.7. b) ROTEM showing abnormal INTEM, EXTEM CT, CFT, alpha angle (ROTEM may also enter into pre-ir transfusion decisions). 4) Prophylaxis for lower risk surgical procedures, endoscopy with biopsy, a) INR greater than 2.0 b) ROTEM showing significantly abnormal INTEM, EXTEM CT, CFT, alpha angle. 5) INR greater than 1.5: Intracranial or spinal bleeding or planned neurosurgical procedure. Transfusion Guidelines, Revised 7/2014, Approved MEC 8/2014 Page 5

6 6) Massive transfusion protocol (MTP) includes 5 RBC, 5 plasma, and 1 pheresis platelet in each MTP pack. ROTEM monitoring is recommended to guide therapy. 7) Emergent reversal of warfarin in a patient with active bleeding or when bleeding could be catastrophic (e.g. intracranial hemorrhage). a) For non-urgent surgical procedures, Vitamin K should be used to reverse warfarin effect unless therapeutic anticoagulation is again rapidly needed post-procedure. b) Instead of plasma consider Prothrombin complex concentrate (FEIBA) for lifethreatening bleed (e.g. intracranial hemorrhage) see U2010/PRL 10 (Hemostatic medications for trauma/anticoagulated patients presenting with life-threatening hemorrhage). 8) Disseminated Intravascular Coagulopathy (DIC) with active bleeding. Consider administration of cryoprecipitate if fibrinogen or ROTEM FIBTEM is low. 9) Replacement fluid for plasma exchange (therapeutic apheresis) procedure. 10) Replacement of single factor deficiencies for which no single factor concentrate product is available (e.g. factor XI, V deficiency). This is very rare. 11) Other-Specify reason. Outcome Indicators: Cessation or reduction of coagulopathic bleeding. Reduction of INR or improved ROTEM Dosing (adults and children at least 35 kg): ml/kg (typically 2-4 units for adults). Dosing (children less than 35 kg): ml/kg (whole units are issued from which specific volume can be infused) Administration: Non-emergent infusion rate for adults and children at least 35 kg: ml/hr x 15 min, then ml/hr if well tolerated. Infusion must be complete within 4 hours of issue time. Non-emergent infusion rate for children less than 35 kg: Must be based on patient s clinical status and needs. Transfusion is generally completed within 1-2 hours and must be completed within 4 hours. IV. CRYOPRECIPITATE (CRYO) How Supplied: Cryoprecipitate is distributed as a pool of 5 units or as single units. Cryoprecipitate contains factor VIII, von Willebrand factor, fibrinogen and factor XIII. Cryoprecipitate must have at least 150 mg fibrinogen/unit (on average at CMC it has at least 200 mg fibrinogen/unit). Volume of a 5-unit pool is about 100 ml. Cost: CMC acquisition cost per two 5-packs units (10 unit order) is $650. Cost inclusive of staff time and infusion supplies is estimated at $1600. Utilization Review Guidelines: Cryoprecipitate transfusion therapy is indicated for treatment of documented coagulopathy where the mechanism for coagulation defect is known, understood and attributable to fibrinogen, factor VIII or XIII, or von Willebrand factor deficiency, and it is expected that replacement with Transfusion Guidelines, Revised 7/2014, Approved MEC 8/2014 Page 6

7 cryoprecipitate transfusion is the most efficient way to correct that deficiency. Fibrinogen level and ROTEM FIBTEM analysis measure severity of coagulation defect for common scenarios. Indications: 1) Active bleeding, peripartum, or prior to moderate-to high-risk invasive procedure: a) And fibrinogen less than 100 mg/dl. b) Or ROTEM showing significantly low FIBTEM. c) Assess also the need for plasma and platelets. 2) Massive transfusion protocol: Cryoprecipitate is not routinely supplied, but should be considered after the patient has received 1 to 2 MTP boxes. ROTEM tubes are supplied with 2 nd box to encourage monitoring. 3) Liver disease with dysfibrinogenemia and active bleeding 4) Factor XIII deficiency and active bleeding; specific factor concentrate is preferred. 5) Uremic bleeding; DDAVP is preferred. 6) Other-Specify reason. Outcome Indicators: Fibrinogen level increases to at least 100 mg/dl. Cessation of coagulopathic bleeding. Dosing (adults and children t least 35 kg): Choices are 5 units or 10 units in an adult (to best approximate one unit per 7-10 kg). Due to high fibrinogen content of our cryo, 10 units is maximum single order dose. 10 units will raise fibrinogen by 50 to 100 mg/dl in an average size adult. Dosing (children less than 35 kg): 1 to 2 single units per 10 kg will raise fibrinogen by 60 to 100 mg/dl. Administration: As rapidly as tolerated. Comments: Fibrinogen threshold of less than 100 mg/dl is often stated, however, this value has not been rigorously defined in clinical trials. Similarly, the precise ROTEM FIBTEM value for decision point is not defined. When there is coagulopathic bleeding, cryo may be efficacious even if FIBTEM is in low normal range, but also consider plasma and/or platelets. Not indicated in hemophilia A or von Willebrand Disease (vwd). In patients with congenital fibrinogen deficiency (afibrinogenemia, hypofibrinogenemia) with acute bleeding or surgery, use fibrinogen concentrate if available. V. GRANULOCYTES Comments 1) Data for some clinical indications are inconclusive. Granulocytes are rarely transfused in the modern era of powerful marrow stimulants such as G-CSF. Some clinical utility may exist in neonatal patients with sepsis. 2) All requests for granulocyte transfusion must be discussed with the Transfusion Service Medical Director or another Pathologist. Because of the rarity of this component it may not be available in a timely manner. 3) All Granulocyte products are irradiated. Transfusion Guidelines, Revised 7/2014, Approved MEC 8/2014 Page 7

8 NEONATAL TRANSFUSION GUIDELINES - INFANTS < 4 MONTHS I. RED BLOOD CELLS (RBC) - INFANTS < 4 MONTHS Indications: 1) Blood loss that totals > 10% of blood volume in the critically ill, extremely low birth weight (<1000 grams) infant that is a relative indication depending on hemodynamic stability, need for vasopressor infusions (ie, dopamine), renal function, pulmonary function (ie, need for mechanical ventilation), and disease prosesses (ie, sepsis) associated with increased oxygen consumption. Blood loss > 10% is not an absolute indication for transfusion of red blood cells. 2) Symptomatic anemia, indicating primarily by persistence tachycardia (HR > 170). Symptoms may also include difficulty feeding, poor weight gain, and/or excessive apnea/bradycardia. Generally, if such symptoms are related to anemia, one would expect the hematocrit to be below 25% in infants not on supplemental oxygen and below 30% in infants requiring supplemental oxygen. 3) Anemia (hematocrit < 30%) in the presence of conditions that increase tissue oxygen consumption (ie, sepsis). 4) Heart disease in which transfusion is given to decrease cardiac workload or improve tissue oxygen delivery. 5) Intraoperative requirement clinically determined by anesthesiologist and/or surgeon. 6) Postoperative to restor hemodynamic stability when other types of fluid replacement have been inadequate or when the hemodynamic instability is sufficiently life-threatening. II. III. PLATELETS (PLT) - INFANTS < 4 MONTHS Indications 1) Thrombocytopenia (platelet count < 30,000/μL) in the presence of bleeding or disseminated intravascular coagulation. 2) Intraoperative requirement clinically determined by anesthesiologist and/or surgeon. 3) Postoperative hemorrhage that is not reasonable attributed to a discrete anatomic bleeding source or to coagulopathy. 4) Profoundly low platelet count (< 20,000/ μl), even in absence of active bleeding. PLASMA (FFP) AND CRYOPRECIPITATE (CRYO) - INFANTS < 4 MONTHS Indications 1) Documented disseminated intravascular coagulation. Fibrinogen < 150 mg/dl and elevated FDPs. 2) A clinical condition (ie, sepsis, necrotizing enterocolitis, significant blood loss) strongly associated with disseminated intravascular coagulation. 3) A clinical condition strongly associated with capillary leak syndrome. 4) Intraoperative requirement clinically determined by anesthesiologist and/or surgeon. 5) Postoperative hemorrhage. 6) Replacement therapy. Transfusion Guidelines, Revised 7/2014, Approved MEC 8/2014 Page 8

9 SPECIAL BLOOD PRODUCT/COMPONENT MODIFICATIONS I. IRRADIATION OF CELLULAR BLOOD COMPONENTS Include request as part of RBC and Platelet Orders. There may be a several hour delay in availability. Irradiation of cellular blood components (RBC and platelets) is highly effective in preventing the lymphocyte proliferation that rarely causes graft-versus-host disease (GVHD) in immunosuppressed transfusion recipients. Leukocyte reduction alone is not effective in the prevention of GVHD. In general, the risk of GVHD is proportional to the severity of immune deficiency. Given the rarity of GVHD, risks associated with some of the factors below are not well characterized, and expert opinions vary about some of these indications. 1) Absolute and Probable Indications (Neonatal/Pediatric): NOTE: ALL RBC and platelets issued for infants less than 4 months of age at CRMC and CCMC are irradiated whether or not ordered in EPIC. The same is true for intrauterine cellular transfusions. a) Intra-uterine transfusion recipients. b) Highly premature newborns (less than 1200 gm). c) Recipients of neonatal exchange transfusion. d) Term newborns on extracorporeal membrane oxygenators. e) Congenital cellular immunodeficiency syndrome patients. 2) Absolute and Probable Indications (Hematologic/Oncologic/Transplant): a) Recipients of autologous or allogeneic hematopoietic stem cell transplants. b) Recipients of solid organ transplants (this is controversial). c) Patients with active or past history of Hodgkin lymphoma or non-hodgkin lymphoma, whether or not currently under treatment. d) Patients with hematologic malignancies such as acute leukemia and myelodysplasia treated with cytotoxic agents, whether or not currently under treatment. e) Patients with certain solid tumors such as neuroblastoma, rhabdomyosarcoma and glioblastoma under treatment. f) Patients receiving high dose chemotherapy, radiation therapy and/or aggressive immunotherapy, including all patients with current or past exposure to fludarabine, other purine analogues, alemtuzumab (Campath), or anti-thymocyte globulin therapy. 3) Absolute and Probable Indications (Related to transfusion of certain components): a) Granulocyte transfusions. b) HLA-matched components or any cellular components from biologic relatives. c) Crossmatch-compatible platelets. 4) No established indications: a) Patients with AIDS or HIV, unless one of the above indications applies. b) c) Patients with aplastic anemia not receiving immuno-suppressive therapy. Transfusion Guidelines, Revised 7/2014, Approved MEC 8/2014 Page 9

10 d) Patients without malignancy (such as those with autoimmune diseases) receiving immunosuppressive medications other than fludarabine or other purine analogues. e) Elderly and pregnant patients, unless one of the above indications applies. II. CYTOMEGALOVIRUS (CMV)-NEGATIVE COMPONENTS While there is not universal agreement, some data and standard practice support the clinical equivalence of pre-storage leukocyte-reduced RBC and platelets to CMV negative blood components. Pre-storage leukocyte-reduced blood components are used for all transfusions in Community Medical Centers (CMC) facilities. CMV transmission is generally not thought to be a factor with non-cellular components such as plasma and cryoprecipitate. NOTE: Granulocyte transfusions to CMV negative or CMV untested patients should be from a CMV negative donor, if feasible. EXCEPTION: By agreement with CMC hematologist-oncologist physicians the following patients should receive RBC and platelets that test CMV negative (in addition to being leukoreduced). Any substitution with CMV untested components requires the approval of the ordering physician. 1) Newly diagnosed leukemia/lymphoma/myeloma/aplasia/myelodysplasia patients, whose CMV status is not yet known. 2) Patients who may be allogeneic stem cell transplant candidates and whose CMV status is not yet known. 3) Patients known to be CMV negative, who are potential candidates for allogeneic stem cell transplant or have previously undergone allogeneic transplant. III. SICKLE CELL-NEGATIVE RED BLOOD CELLS (RBC) It is CMC Laboratory policy to automatically provide sickle cell hemoglobin negative RBC products for all neonatal and intrauterine transfusions including exchange and replacement transfusions. The ordering provider should also request screened, sickle cell negative RBCs for patients known clinically to have a sickle hemoglobin disorder (ie, SS, SC, S-thalassemia, including heterozygous sickle trait patients). Initial identification of sickle cell negative RBCs usually relies on communication from the ordering provider. Once the blood bank is aware of the need, this documentation will be included in the patient blood bank for future reference. IV. SPECIAL PLATELET ORDERS FOR REFRACTORY PATIENTS (CROSSMATCHED/HLA MATCHED) 1) General Comments: a) Crossmatched and/or HLA Matched platelets may be beneficial for the patient who is immunologically refractory to platelets. The usual definition of platelet refractoriness is two consecutive 60 minute post-transfusion platelet count increments of less-than 5,000 /ul. The 60-minute post-transfusion platelet count is very important to the assessment of immunologic refractoriness. If the 60 minute increment is above this value but the count drops off after that, the refractoriness is likely to be due to a non-immune factor such as medications, infection, splenomegaly. b) Once immune refractoriness has been documented, start the process for crossmatched platelets. If the patient does not respond, request HLA-matched platelets. Transfusion Guidelines, Revised 7/2014, Approved MEC 8/2014 Page 10

11 c) Orders for Crossmatched and/or HLA matched Platelets must be coordinated with the Transfusion Service Laboratory. It takes at least one day to obtain them, as they are not sourced locally. d) Crossmatched and/or HLA Matched Platelet products are irradiated. 2) Crossmatched platelets a) Crossmatched platelets are more convenient and economical than HLA matched ones. b) If HLA typing cannot be done due to leukopenia, this is only choice for the refractory patient. 3) HLA Matched Platelets. a) The HLA type of all patients who will receive long-term platelet support should be performed before they are rendered pancytopenic by therapy. WBC count must be >1.0x103/ul for typing. b) HLA Matched Platelets may be required if most of the attempted crossmatched Platelet products are positive. V. PRE-OPERATIVE AUTOLOGOUS BLOOD DONATION (PAD) 1) Interest in PAD has declined dramatically in recent years. High wastage rates (unused autologous blood cannot be given to other patients), higher risk of coming to surgery significantly anemic, along with improved safety of the blood supply (with respect to infectious disease transmission) have all contributed to its lower use. 2) PAD may be a reasonable option for patients with rare blood types or multiple antibodies, or who refuse donor blood. 3) PAD requires advance planning, with collection ideally 4-6 weeks before anticipated need, to mitigate the anemia induced by it. 4) NOTE: The State of California does require that physicians discuss alternatives to allogeneic transfusion (including autologous donation and the largely discredited idea of directed donations from chosen donors), with patients for whom it may be an option. This does not mean that the surgeon should recommend autologous donation to the patient. This is the Paul Gann Blood Safety Act (Health and Safety Code Section1645). The mandated patient handout, A Patient s Guide to Blood Transfusion is stocked in CMC hospitals and is available at the Medical Board of California web site. Transfusion Guidelines, Revised 7/2014, Approved MEC 8/2014 Page 11

12 BLOOD PRODUCTS--SPECIAL TRANSFUSION ORDER GUIDANCE I. BLOOD WARMING 1) General Blood Warmer Notes: a) A physician must order use of a blood warmer unless it is routinely part of operating room protocol (eg, trauma and cardiac cases). b) Blood warming is not needed or recommended for platelets or cryoprecipitate. Avoid infusion through the blood warming device, when feasible. 2) American Association of Blood Banks (AABB) recommends the following indications: a) Massive transfusions. b) Trauma situations in which core-rewarming measures are indicated. c) Administration rate of PRBC and/or plasma greater than 50 ml/min for 30 min or more (adults) or greater than 15 ml/min/kg/hour (children). d) Exchange transfusion of a newborn. e) Patient rewarming phase during cardiopulmonary by-pass surgery. 3) AABB guidelines recommend consideration of blood warming in the following situations: a) Packed RBC transfusion in the presence of potent high-titered cold agglutinins reactive at body temperature and capable of binding complement thereby causing hemolysis. b) Raynaud's syndrome. c) Neonatal and pediatric transfusions. d) Warming is definitely indicated for RBC exchange transfusion of newborns. e) Therapeutic apheresis procedures. II. PREMEDICATION TO PREVENT TRANSFUSION REACTIONS Simple (non-hemolytic, non-septic) febrile reactions and allergic reactions (the large majority of which are cutaneous only) may complicate at least 1% of transfusions. With the exception of IgA and haptoglobin deficiency it is not usually possible to define antigen(s) to which patient is reacting. Most expert guidance is to premedicate only if a patient has experienced more than one bona fide such reaction. Routine use of premedication for all patients is not advocated by experts or supported by evidence. 1) Febrile reaction: Recommend acetaminophen at least 30 min prior to transfusion. 2) Allergic reaction: a) Premedication with antihistamine (eg, mg diphenhydramine) 30 min prior to transfusion may be helpful in patients with history of either severe or multiple non-severe allergic reactions. b) Routine premedication may be considered in patients undergoing multiple high volume plasma exposures, eg, therapeutic plasmapheresis, but is not otherwise indicated. c) If antihistamines are not sufficient prednisone (20-50 mg orally) or parenteral steroid may be used. d) Patients with current or history of severe allergic reactions should be discussed with the blood bank. Additional testing (eg, to explore possible IgA or haptoglobin deficiency) or plasma volume reduction, may be indicated. Transfusion Guidelines, Revised 7/2014, Approved MEC 8/2014 Page 12