LifeBridge Health Transfusion Service Sinai Hospital of Baltimore Northwest Hospital Center BQA 1011.02 Transfusion Criteria Version#2 Department POLICY NO. PAGE NO. Blood Bank Quality Assurance Manual 4287 1 OF 5 Printed copies are for reference only. Please refer to the electronic copy for the latest version. 1. Purpose 1.1. In order to monitor and address transfusion practices for all categories of blood and blood components, a peer-review program is designed to monitor appropriateness of use using the following Sinai Transfusion Criteria. 2. Procedure 2.1. Indications for Appropriate Ordering and Use - Adult 2.1.1. Red Cells/Leukoreduced Red Cells 2.1.1.1. Anticipated Blood Loss 2.1.1.1.1. Blood loss >1500 ml 2.1.1.1.2. >500 ml adult with prior Hct <24% 2.1.1.1.3. >500 ml obstetrical patient 2.1.1.1.4. Systolic pressure < 100 mm Hg; Pulse rate >100/minute or decrease in systolic pressure by 30%, or other symptoms of hemoragic shock. 2.1.1.2. Anemia or Abnormal O 2 Transport 2.1.1.2.1. Symptomatic Anemia unresponsive to medical management. Documentation of clinical reason for transfusion is in medical record. 2.1.1.2.2 Hgb < 7g/dL (Hct 21%) in an asymptomatic hemodynamically stable patient 2.1.1.2.3. Hgb < 8g/dL (Hct 24%) in an asymptomatic hemodynamically stable patient with established cardiovascular disease. 2.1.1.2.4. Hgb <8g/dL (Hct 24%) in an asymptomatic hemodynamically stable post-operative patient. 2.1.1.2.5. Hgb 7-10g/dL (Hct 21-30%) in an operative or preoperative patient with potential/actual blood loss, organ Effective Date: 09/10/2013 1
ischemia, risk of inadequate oxygenation (e.g. low cardiopulmonary reserve, high oxygen consumption). Documentation of clinical reasons for transfusion is in medical record. 2.1.1.2.6. Acute Coronary Syndrome Note: According to the American Red Cross In general RBC transfusion may be beneficial in patients with acute coronary syndromes who have a Hgb level <8g/dL on hospital admission, and a transfusion should be considered in critically ill patients with stable cardiac disease and a Hgb level <7g/dL. Due to the lack of randomized controlled trials, the AABB does not make recommendations for either liberal or restrictive transfusion criteria in the setting of acute coronary syndrome. Observational studies have shown a benefit of transfusion at Hct <24 in patients with NON- ST segment acute coronary syndrome and have seen a relative increase in mortality seen in patients transfused with Hct >27% (Am Heart J 2008;155:1047-53). 2.1.1.2.7. Acute cerebrovascular accident 2.1.1.2.8. Sickle Cell Disease 2.1.1.2.9. Hypoplastic bone marrow 2.1.2. Washed Red Cells 2.1.2.1. Evidence that premedication for allergic reactions will not avoid reaction 2.1.2.2 Documentation of IgA deficiency 2.1.2.3. Evidence of severe or atypical reactions using leukoreduced cells or antihistamines pretransfusion 2.1.2.4. Exchange transfusion of newborn or adult 2.1.2.5. Units in which donor has antibody (documented) to recipient antigen. 2.1.3 Irradiated Red Cells 2.1.3.1 All pediatric aliquots for neonates / patients < 1 year old. 2.1.3.2 Fetuses receiving intrauterine transfusion 2.1.3.3 Directed donations from blood relatives 2.1.3.4 Donor units selected for HLA matching transfusion 2.1.3.5 Status post stem cell or bone marrow transplantation (allogeneic) 2.1.3.6 Patient at risk for Graft vs Host disease 2.1.3.7 Patients with genetic diseases: 2.1.3.7.1 SCID 2.1.3.7.2 Wiskott- Aldrich 2.1.3.7.3 T-cell defects 2.1.3.8 Physician request for patients whom have received chemo or irradiation therapy for cancer: 2.1.3.8.1 Acute lymphoblastic leukemia 2.1.3.8.2 Acute myeloblastic leukemia 2.1.3.8.3 Hodgkins disease 2.1.3.8.4 Non-Hodgkins disease Effective Date: 09/10/2013 2
2.1.3.8.5 Neuroblastoma 2.1.3.8.6 Glioblastoma 2.1.3.9 Patients receiving fludaribine, cladaribine, or nucleoside analog Rx 2.1.4. Apheresis Platelets 2.1.4.1. Platelet count of less than 20K/ul; i.e. prophylactic transfusions in oncology patients 2.1.4.2. Acute bleeding in patients with platelet counts less than 30K/ul 2.1.4.3. Post-operative cardiac by-pass patient bleeding 2.1.4.4. Treatment of patients with qualitative platelet abnormalities who are bleeding or are having surgery 2.1.4.5. Less than 10,000 platelets per cubic millimeter 2.1.4.6 See Criteria listed in 2.1.3 for Irradiated Platelets. 2.1.5. Frozen Plasma 2.1.5.1. Severe liver disease 2.1.5.2. Documented congenital coagulation factor deficiencies (including factors II, V, VII, IX, XI, von Willebrand) 2.1.5.3. Coagulation values above PT 14 or APTT 40 2.1.5.4. Patients with thrombotic thrombocytopenia purpura (TTP), sometimes in conjunction with plasma exchange 2.1.5.5. Patients with suspected combined coagulation defects documented in the chart, (e.g., prothrombin complex disorders with coagulopathy or DIC) plus active bleeding. 2.1.5.6. In massive transfusions (e.g., trauma) when patient shows clinical microvascular bleeding (oozing) plus fibrinogen is less than 100 mg/dl. 2.1.5.6.1 1:1 ratio (red blood cells: plasma) is recommended during massive transfusion events to maintain balance of blood volume 2.1.6. Cryoprecipitate 2.1.6.1. Factor VIII deficiency if recombinant and other viral-safer products are unavailable 2.1.6.2. Factor XIII deficiency 2.1.6.3.Von Willebrand s disease (vwd) if other viral-safer products are unavailable 2.1.6.4. Fibrinogenopenia (<100mg/dL) or dysfibrinogenemia 2.1.6.5 Fibrin Glue (tissue sealant mfgr.) 2.1.6.6. Massive transfusion (bleeding with replacement of >10 units RBCs/ 24 hr) 2.1.6.7. Uremic bleeding 2.1.6.8. TPA-related life-threatening bleeding (or Reteplase) 2.2 Indications for Appropriate Order and Use Pediatrics 2.2.1 Red Blood Cells / Leukoreduced / Irradiated/ CMV Negative 2.2.1.1. Neonatal (<24 hrs.) 2.2.1.1.1 Hgb < 13g/dL 2.2.1.1.2 Persistent hypotension unresponsive to 20-30ml/Kg Plasmanate and pressor support 2.2.1.2. Neonatal (<4 mos.): Effective Date: 09/10/2013 3
2.2.1.2.1 Hgb < 13g/dL and heart or lung disease 2.2.1.2.2 Blood loss >10% of blood volume (including phlebotomy) 2.2.1.2.3 Hgb <8g/dL with clinical signs of anemia 2.2.1.3. Pediatrics (>4 mos.) 2.2.1.3.1 Acute blood loss >15% of blood volume 2.2.1.3.2 Hgb <8g/dL with clinical signs of anemia 2.2.1.3.3 Hgb <13g/dL with cardiac or pulmonary disease 2.2.1.3.4 Chronic anemia with Hgb <8g/dL and poor response to treatments 2.2.1.3.5 Chronic anemia with Hgb <10g/dL and clinical signs or anemia 2.2.1.3.6 Chronic anemia with hypertransfusion therapy (Sickle diseases, thalassemias) 2.2.1.3.7 Irradiated Red Cells in Pediatrics > 4 months old. 2.2.2. Whole Blood 2.2.2 1. Neonatal (only): Exchange transfusion (reconstituted RBC + FP: 2 donor exposures) 2.2.3. Platelets: 2.2.3.1. Platelet count <20K/uL in a stable, nonbleeding patient 2.2.3.2. Platelet count <50K/uL in a bleeding patient 2.2.3.3. Platelet count <50/uL in a preoperative patient or a patient at risk for IVH 2.2.3.4. Platelet count <300K/uL in DIC or unknown reason for bleeding 2.2.3.5. Platelet dysfunction by history (e.g., ASA), aggregation or bleeding time studies 2.2.3.6. Less than 10,000 platelets per cubic millimeter 2.2.3.7 Irradiated Platelets see criteria in 2.1.3 above. 2.2.4. Frozen Plasma 2.2.4.1 PT and/or APTT prolonged to >1.5 times upper normal limit 2.2.4.2 Known diagnosis of coagulant deficiency with no other product available 2.2.4.3 Known or suspected acute ATIII, protein C or protein S deficiency bleeding 2.2.4.4Plasma exchange in hemolytic uremic syndrome (or TTP) 2.2.5. Cryoprecipitate 2.2.5.1 Acutely preop or bleeding with diagnosis of von Willebrand disease 2.3 Indications for Appropriate Administration 2.3.1 In the absence of acute hemorrhage, RBC transfusion should be ordered as single units. Criteria for red cell transfusion are the same for both allogenic and autologous units. 2.3.2 Laboratory results upon which a transfusion is based (Hct, PT, PTT, platelet count) should be drawn no more than 24 hours prior to transfusion. 2.3.3 It is acceptable to premedicate a patient with a history of urticarial reactions with antihistamines prior to transfusion. Simple urticarial reactions do not require stopping a transfusion. Effective Date: 09/10/2013 4
2.3.4 See the Nursing Departments Blood and/or Blood Component Transfusion procedure. 3 References 3.1. BQA.1002.05 Peer Review Program 3.2. AABB (2012) Standards for Blood Banks and Transfusion Services. 28 th ed Bethesda, MD. 3.3. AABB. (2001). Guidelines for Blood Utilization Review. Bethesda, MD. 3.4. Annals of Internal Medicine.(March 2012) Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB. Departments: Blood Bank Effective Date: 09/10/2013 5