Transfusion Medicine Best Practices:
1.0 Policy Statements 1.1 Regional Health Authorities (RHAs) shall develop policies, processes and procedures for ordering, distribution, storage, transfusion and administration of blood components that comply with Provincial Blood Coordinating Program policies. 1.2 Blood components shall be prescribed by a physician or other authorized health professional. 1.3 Blood components shall be utilized for appropriate indications. 1.4 Red Blood Cells Indications: 1.4.1 Decreased oxygen carrying capacity (e.g. acute blood loss, symptomatic anemia); 1.4.2 Exchange transfusion. 1.5 Platelets Indications: 1.5.1 Deficient platelet count due to production failure and/or dysfunction; 1.5.2 Prophylaxis of bleeding for invasive procedures in thrombocytopenic patients; and 1.5.3 Massive hemorrhage. 1.6 Plasma Indications: 1.6.1 Management of bleeding: 1.6.1.1 In patients with INR > (greater than) 1.7 who require replacement of multiple coagulation factors. 1.6.1.2 In patients with INR > (greater than) 1.7 who are treated with vitamin K antagonist (warfarin) therapy when prothrombin complex concentrates are not indicated or not available. 1.6.2 Reversal of INR > (greater than) 1.7: 1.6.2.1 In preoperative/pre-invasive procedure patients who require replacement of multiple coagulation factors. 1.6.2.2 In preoperative/pre-invasive procedure patients who are treated with vitamin k antagonist therapy (warfarin) when prothrombin complex concentrates are not indicated or not available. Page 2 of 10
1.6.2.3 Operative or invasive procedure must be imminent within six (6) hours due to the labile nature of some coagulation factors in plasma. 1.6.3 Massive transfusion for replacement of coagulation factors; 1.6.4 Therapeutic plasma exchange for thrombotic thrombocytopenic purpura (TTP) or hemolytic uremic syndrome (HUS); and 1.6.5 Management of selected coagulation deficiencies (congenital or acquired) for which no specific coagulation concentrates are available. *Plasma should not be used to correct mildly elevated INR ( 1.7) or aptt prior to an invasive procedure. 1.7 Cryoprecipitate Indications: 1.7.1 Treatment of fibrinogen deficiency; 1.7.2 Factor XIII supplementation if Factor XIII concentrate not available; and 1.7.3 Control of massive bleeding. 1.8 Cryosupernatant Plasma Indications: 2.0 Linkages 1.8.1 Treatment of thrombotic thrombocytopenicpurpura, and hemolytic uremic syndrome undergoing plasma exchange; and 1.8.2 Emergent warfarin reversal when time constraints preclude vitamin K therapy or when PCC is not indicated or not available. Consent or refusal to transfusion of blood components or administration of plasmaderived blood products. Available at: http://www.health.gov.nl.ca/health/bloodservices/pdf/consent_form.pdf Guidelines for appropriate use and administration of frozen plasma components in adults. Available at: http://www.health.gov.nl.ca/health/bloodservices/pdf/guidelines_for_administration_of_f fp.pdf Guidelines for blood component substitution in adults. Available at: http://www.health.gov.nl.ca/health/bloodservices/pdf/guidelines_for_blood_component_s ubstitution_in_adults_ver4.pdf Page 3 of 10
Guidelines for initiation and termination of blood components and blood products. Available at: http://www.health.gov.nl.ca/health/bloodservices/pdf/guidelines_for_initiation_and_termi nation_of_blood_components_and_products_vers1.pdf Policy for blood component and blood product administration. Available at: http://www.health.gov.nl.ca/health/bloodservices/pdf/blood_component_and_blood_prod uct_administration_ver_4.pdf Policy for patient notification of transfusion of blood components or blood products. Available at: http://www.health.gov.nl.ca/health/bloodservices/pdf/patient_notification.pdf 3.0 Scope This policy applies to: 3.1 All health care professionals who prescribe transfusion of blood components. 3.2 All health care professionals who participate in transfusion of blood components. 3.3 All transfusion medicine laboratory technologists. 4.0 General Information 4.1 Whole blood transports oxygen and nutrients throughout the body and removes waste products. It increases oxygen carrying capacity and expands blood volume. Whole blood is broken down into different blood components and then used for specific clinical indications. The main blood components derived from whole blood include red cells, platelets, plasma, cryoprecipitate, and cryosupernatant. 4.2 Red blood cells are primarily responsible for tissue oxygenation. Oxygen is carried on the hemoglobin molecules. 4.3 Red blood cell units that meet special recipient requirements are available. Special requirements include: autologous, phenotyped, directed donor, cytomegalovirus seronegative, irradiated, or washed. 4.4 Platelets facilitate blood clotting at the site of injury to control or prevent bleeding. They are also significant in blood coagulation, wound healing Page 4 of 10
and inflammation. Platelet components contain donor plasma. Each dose of platelets should increase the platelet count by 15x10 9 /L. 4.5 Two types of platelet components are available, pooled (buffy coat) platelets and platelets apheresis. 4.6 Several types of platelet modifications are available to meet special requirements of recipients. These include irradiated, apheresis, HLA matched apheresis, CMV seronegative, plasma reduced, and IgA deficient. 4.7 Plasma is the aqueous protein liquid in which red cells, white cells and platelets are suspended. Plasma proteins support clotting. 4.8 Plasma can be processed to produce cryoprecipitate and cryosupernatant. 4.9 Cryoprecipitate is a plasma component produced by slow thaw of the frozen plasma and removal of the insoluble cryoprecipitate using centrifugation. The cryoprecipitate is then refrozen for later use. 4.10 Cryoprecipitate provides fibrinogen, coagulation factors VIII, XIII and von Willebrand s factor, as well as fibronectin. 4.11 Cryosupernatant provides a source of plasma with reduced levels of vonwillebrand factor. 5.0 Process 5.1 Procedure (N/A) 5.2 Guidelines Red Blood Cells 5.2.1 Red blood cells must be ABO compatible. 5.2.2 Rh negative recipients should receive Rh negative red blood cells except in special circumstances. 5.2.3 Each unit of red blood cells raises the hemoglobin in an average non-bleeding adult by approximately 10 g/l. Platelets 5.2.4 A platelet transfusion is ordered as an adult dose or in ml/kg. 5.2.6 Recipients should receive ABO compatible platelets. Page 5 of 10
5.2.7 If Rh positive platelets are given to Rh negative recipients, Rh immune globulin should be considered. Plasma 5.2.8 Recommended dose is 10-15mL/kg. 5.2.9 ABO compatibility is required. Rh compatibility need not be considered. Cryoprecipitate 6.0 Acronyms 5.2.10 ABO compatibility is preferred. Cryosupernatant Plasma 5.2.11 Cryosupernatant plasma must be ABO compatible. aptt CMV FFPA FP HIT HLA HUS INR ITP PCC TTP vwf Activated partial thromboplastin time Cytomegalovirus Fresh frozen plasma apheresis Frozen plasma Heparin-induced thrombocytopenia Human leukocyte antigen Hemolytic uremic syndrome International normalized ratio Idiopathic thrombocytopenia Prothrombin complex concentrates Thombotic thrombocytopenic purpura vonwillebrand Factor 7.0 Definitions Administration To mete out, dispense; to give as remedy. Page 6 of 10
ABO Compatible ABO Identical Autologous Blood Component Fresh Frozen Plasma Apheresis Frozen Plasma Platelets Red Blood Cells Transfusion Transfusion Medicine Laboratory Donor blood components that are non-identical ABO and Rh group to the recipient ABO and Rh group. Non-identical blood components do not have antibodies against blood group antigens on the recipient s red cells. Donor blood components of the same ABO and Rh group as the recipient. The collection of blood from an individual for the purpose of transfusion back to the individual at a later date. A therapeutic component of blood intended for transfusion. Plasma collected by apheresis from the blood of an individual donor and placed at -18 C within eight hours of collection. It contains all the clotting factors necessary for hemostasis. Plasma separated from the blood of an individual donor and placed at -18 C within 24 hours of collection. It contains all the clotting factors necessary for hemostasis. A blood component prepared by centrifugation of whole blood; consists of a suspension of platelets in plasma or an approved storage solution. A blood component containing red cells concentrated by removal of most of the plasma by centrifugation, sedimentation or cytapheresis of whole blood. Transfer of blood or blood component from one person (donor) to another person (recipient). Hospital Blood Bank. 8.0 Key Words Blood, component, cryoprecipitate, cryosupernatant, cytomegalovirus, indications, plasma, platelets, red cell, Rh 9.0 Supporting Documents 9.1 Process Flow/Algorithm (N/A) Page 7 of 10
9.2 Tables/Charts Quick Reference Blood Components Page 8 of 10
References Callum, J., Lin, Y., Pinkerton, P.H., Karkouti, K., Pendergast, J.M., Robitaille, N Webert, K.E. (2011). Bloody easy 3. Toronto, ON: Ontario Regional Blood Coordinating Network. Clarke, G. & Charge, S. (2013). Canadian Blood Services: Clinical guide to transfusion medicine. Retrieved from www.transfusion medicine.ca Canadian Blood Services. (2013). Circular of Information for the use of human blood components: Red blood cells, leukocyte reduced. Retrieved from http://www.blood.ca/centreapps/internet/uw_v502_mainengine.nsf/resources/ COI/$file/COI-SAGMReduced+RedBloodCellsLeukocytes-April2013.pdf Canadian Blood Services. (2012). Circular of Information for the use of human blood components: Pooled platelets LR CPD, apheresis platelets. Retrieved from http://www.blood.ca/centreapps/internet/uw_v502_mainengine.nsf/resources/ COI/$file/COI-PooledApheresisPlatelets-23Oct12.pdf Canadian Blood Services. (2012). Circular of Information for the use of human blood components: Apheresis fresh frozen plasma, frozen plasma CPD, cryosupernatant plasma, cryoprecipitate. Retrieved from http://www.blood.ca/centreapps/internet/uw_v502_mainengine.nsf/resources/ COI/$file/COI_CPDPlasmaFFPA23Oct12.pdf Canadian Standards Association (2010). Blood and blood components, Z902-10. Mississauga (ON): Author. Canadian Standards Association (2012). Blood and blood components, Z902-10, Amendments. Mississauga (ON): Author. Canadian Society for Transfusion Medicine. (2011). CSTM standards for hospital transfusion service. Version 3. Ottawa: Author. Canadian Society for Transfusion Medicine (2104). Choosing wisely: Five things physicians and patients should question, 3. Retrieved from http://www.choosingwiselycanada.org/recommendations/canadian-society-fortransfusion-medicine-2/ Page 9 of 10
Filardo, T.W. (2006). Stedman s medical dictionary, (28 th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins. Kulkarni, R., Chitlur, M., & Lusher, J. (2011). Treatment of congenital coagulopathies. In P. D. Mintz (Ed.), Transfusion therapy: clinical principles and practice (3 rd ed.), pp.167-207. Bethesda, MD: AABB Press. Menitove, J.E. (2011). Red cell transfusion therapy in anemia. In M. A. Popovsky (Ed.), Transfusion reactions (4 th ed.), pp.37-53. Bethesda, MD: AABB Press. Ortel, T. L., Lockhart, E., & Humphries, J. (2011). Treatments of acquired disorders of hemostasis. In P. D. Mintz (Ed.), Transfusion therapy: clinical principles and practice (3 rd ed.), pp.127-163. Bethesda, MD: AABB Press. Rote, N.S. (2012). Adaptive immunity. In S.E. Heuther & K.L McCance (Eds), Understanding Pathophysiology (5 th ed.), pp.142-164. St Louis MO: Elsevier. Rote, N.S. & McCance, K.L. (2012). Structure and function of the hematologic system. In S.E. Heuther & K.L McCance (Eds), Understanding Pathophysiology (5 th ed.), pp.477-499. St Louis MO: Elsevier. Sesok-Pizzini, D. (2011). Platelet transfusion. In P. D. Mintz (Ed.), Transfusion therapy: clinical principles and practice (3 rd ed.), pp.397-431. Bethesda, MD: AABB Press. Spence, R.K. (2011). Transfusion therapy in surgery. In P. D. Mintz (Ed.), Transfusion therapy: clinical principles and practice (3 rd ed.), pp.265-303. Bethesda, MD: AABB Press. Transfusion Ontario. (2005). About blood transfusion, information for nurses and other health care professionals, (2 nd ed). Toronto ON: Transfusion Ontario Program. Page 10 of 10