Chest diseases Hospital Laboratory Hematology Practice guidelines Title RBCs transfusion in Adults SOP Code Policy Owner Hematology Unit Section Hematology Prepared By Dr. Taher Ahmed Abdelhameed Issuing Date 13 April 2015 Reviewed by Dr. Samah E. ElShinnawy First revision 13April 2017 Second revision 13April 2019 Dr.Hanan Elwazan Dr. Ahlam Jeragh Dr. Abdullah Dashty Dr Mohamed El Mutairi Dr Tareq Aleinati Dr Nader Al awadhi Page 1
1.0 Purpose: Implementation of evidence based approach for the use of packed red cell transfusion for adults in Chest Disease Hospital. 2.0 Policy statement(s): The aim of RBCs transfusion is to improve oxygen delivery to the tissues. It is usually indicated in the management of hemorrhage, symptomatic anemia, or intraoperative transfusion during cardiac surgery. 3.0 Responsibility: Hematologists /Cardiologists/Surgeons and Anesthiologists of CDH can use this guidelines. Consultant/ Head of units should assure that ü Hematologists/ Cardiologists /surgeons comply with guidelines. ü Approve and update guidelines. Department Head of the Laboratory/Surgery /Cardiology/ Anaesthesia this guidelines 4.0 Restrictions: This guidelines is to be used only by Medical staff of CDH. 5.0 Definitions: PRBC : Packed Red blood cells Retics : Reticulocytic count TACO: Transfusion Associated Circulatory Overload TRALI: Transfusion Associated Acute Lung Injury GvHD: Graft versus Host Disease MV: Mechanical Ventilator SAGM: Saline Adenine Glucose Mannitol ACS: Acute Coronary Syndrome SEMI : ST- elevation Myocardial infarction : a clinical syndrome defined by characteristic symptoms of myocardial ischemia in association with persistent electrocardiographic (ECG) ST elevation and subsequent release of biomarkers of myocardial necrosis. NSTE-ACS: Non ST elevation Acute Coronary Syndrome can subdivided on the basis of cardiac biomarkers of necrosis (e.g. cardiac troponin). If cardiac Page 2
biomarkers are elevated and the clinical context is appropriate, the patient is considered to have NSTEMI ( non ST elevation Myocardial Infarction), otherwise, the patient is deemed to have UA ( Unstable Angina) 6.0 Basic Principles: ü HB alone is not the only factor that triggers transfusion. ü Patients with HB >10 should not be transfused. 7.0 Procedure: 7.1: Definition of anemia: Definition of anemia (WHO 2011): HB < 13gm/dl in Male HB<12gm/dl in Female 7.2: Precautions: ü RBC transfusion is not routinely indicated for pharmacologically treatable anemia such as: Iron deficiency anemia Vitamin B12 or folate deficiency anemia ü RBC transfusion should not be considered as an absolute method to improve tissue oxygen consumption in critically ill patients or to assist in weaning from Mechanical Ventilation. ü RBC transfusion is an independent risk factor for multi-organ failure and increased mortality. 7.3: RBCs indications & transfusion trigger: -PRBC is used in the management of hemorrhagic shock or to improve tissue oxygen delivery. HB trigger differs according to the clinical condition as follows: ü HB of 7gm/dl should be the target for all critically ill patients (adults and pediatrics). Page 3
ü HB of 8 gm/dl in Patients with pre-existing cardiovascular disease. Transfusion at higher HB level is indicated if the patient experiences any of the following symptoms: Chest pain, orthostatic hypotension, Tachycardia unresponsive to fluid resuscitation, Congestive heart failure. ü HB 8g/dl in a hemodynamically stable Medical or surgical patient. ü HB 8g/dl in ACS ( UA,NSTEMI,STEMI) ü HB 10 g/dl in the first 6 hours of resuscitation in Sepsis when there is evidence of tissue hypoxia. 7.4: RBCs transfusion target: A target HB 9-10g/dl & clinical stability is the aim of transfusion. Patients with HB >10 should not be transfused. 7.5: pre-transfusion testing: Aims to prevent incompatible red cell transfusion. ü Ensures Compatibility of donor red cells with recipient plasma ü Avoid immune hemolytic transfusion reactions in the recipient. 7.6: Special requests: PRBCs provided from Kuwait Central Blood Bank are leukocyte depleted. Each adult unit is about 250 ml, collected on SAGM anticoagulant. Each RBC unit half-life is 35 days. ü Pediatric units are usually 50 ml. 7.7: PRBCs administration: Before starting transfusion, each unit to be transfused should be double checked for ü ABO group of RBC products & it must be compatible with ABO group of recipient. ü RBC product must be serologically compatible with the recipient Rate of transfusion: When transfusion starts it should be slowly for first 15 minutes Complete transfusion within 4 hours maximum (as per FDA) Page 4
7.8: Expected increment: One PRBCs One gm/dl rise in HB or 3% in HCT In children, Transfusion of 5ml/kg rise in HB by 1gm/dl Failure of increment of HB following RBCs transfusion can be caused by: ü Occult bleeding ü Repeated sampling ü Hypersplenism ü Fever ü Hemolysis 7.9: Emergency Release of Blood Products In clinical settings that precludes waiting for completion of pre-transfusion and compatibility testing for example: ü Severe, ongoing, life-threatening hemorrhage ü Presentation with life-threatening anemia The treating physician should ensure the following: ü CDH blood bank should be notified of need for emergency release of PRBC. ü Complete hospital s emergency release form that declares the transfusion emergency. ü Statement of the nature of the emergency (e.g. massive GI hemorrhage ) ü Signature of treating physician. ü A patient blood sample should be sent to blood bank ASAP (before emergency transfusion begins, if possible) ü CDH blood bank should issue the number of requested units, the staff can release either 1- Immediate spin cross matched RBC (ABO group-specific if determined on a current blood specimen) 2- Group O Rh negative PRBC if blood bank has not documented patient s ABO group on a fresh blood sample. ü Blood bank will retrospectively cross match all emergently issued units when it receives the patient s testing samples. Page 5
ü Blood bank will begin issuing type-specific and cross matched products when testing is complete. ü Hematologist should be involved if change of blood group is required or massive transfusion ü 7.10: Hazards of RBCs transfusion: ü Transfusion reactions: Hemolytic transfusion reactions are the most serious. Commonest transfusion reactions are: ü Febrile and allergic transfusion reactions. ü TACO ü TRALI ü Platelet alloimmunization ü Chronic transfusion iron overload ü air embolism ü GvHD ü Transmission of infections ( advances in pathogen detection makes it minimal in recent days) 8.0: References: 1. Transfusion guidelines : when to transfuse : 2013 ; Szczepiorkowski &Dunbar, Transfusion Medicine 638-644 ( ASH Guidelines) 2. Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients : 2013 : Retter et al.,british Journal of Hematology,160,445-464 3.Red Blood cell transfusion : A Clinical Practice guideline from the AABB (2012): Carson et al.,annals of Internal Medicine : 157.No1,49-58 4. Red Blood cell transfusion : A Clinical Practice guidelines from AABB : 2012: Carson et al., Annals of Internal Medicine,49-58 (American College of Physicians). 5. Clinical Practice Guidelines on Red Blood Cell Transfusion 2012 (American Society of Hematology) Page 6
6. Recommendation for the transfusion of red cells :2009: Liumbruno etal., Blood Transfus :7:49-64 7. Red blood cell transfusion in adult trauma and critical Care (American College of Critical Care Medicine) 8.2013 ACCF/AHA guidelines for the management of ST-elevation Myocardial Infarction. 9. ACC/AHA guideline for the management of Non-ST Elevation Acute Coronary Syndrome. Page 7