Article

Blood Product Selection and Administration

Although some patient presentations requiring transfusion of blood products may be minor in etiology, other conditions can be life-threatening, necessitating rapid identification and administration of the appropriate product to prevent morbidity and mortality.


The authors review blood components, transfusion indications, and associated complications.


 

References

Overview

Emergency physicians (EPs) frequently encounter patients requiring blood-product transfusions. Anemia from acute bleeding, emergent reversal of warfarin therapy, and correction of thrombocytopenia are just a few indications for transfusion in the ED. Rapid physician assessment and the timely administration of blood products, including packed red blood cells (PRBCs), platelets, fresh frozen plasma (FFP), cryoprecipitate, and other factors are crucial in resuscitation, and are life-saving in some instances. This article describes the different types of blood products, transfusion indications, complications, and medical decision-making involved.

In 2011, nearly 14 million units of whole blood and RBCs were transfused in US hospitals according to the 2011 National Blood Collection and Utilization Survey Report. In the United States, United Kingdom, Western Europe, and Canada, approximately 40% of critically ill patients received a mean of 5 U of PRBC per hospitalization.1,2

In the ED, hemodynamic instability due to acute hemorrhage is the most common indication for transfusion of PRBCs. Common emergent sources include gastrointestinal (GI) bleeding, dysfunctional uterine bleeding, and bleeding secondary to trauma. For every unit of PRBCs transfused, the typical result in the average adult is an increase in hemoglobin (Hgb) by 1 g/dL and hematocrit by 3%. In the pediatric population, a 3 mL/kg intravenous (IV) dose achieves equivalent results.3

Blood Components and Type Compatibility

After donated blood is collected, blood banks divide the blood into type and components, including red cell concentrate, FFP, cryoprecipitates, and platelets.

Packed Red Blood Cells

After RBCs are separated from whole blood, they can be further processed through leukoreduction, which removes most white blood cells at the expense of a 10% to 15% loss of RBCs. Leukoreduced RBCs (LRBCs) are used in patients with a history of two or more febrile nonhemolytic transfusion reactions (FNHTR). In addition to preventing FNHTR, LRBCs may also be effective in preventing cytomegalovirus (CMV) transmission or human leukocyte antigen (HLA) alloimmunization.4

Cytomegalovirus negative PRBCs and blood components are indicated for the following patients: premature and all infants younger than age 4 weeks; intrauterine transfusions; bone marrow or organ transplant recipients (including transplant candidates); immunocompromised and asplenic patients; and pregnant women.

Irradiated PRBCs and blood products are exposed to 2,500 rad of gamma radiation to destroy lymphoproliferative processes. This irradiation prevents transfusion-associated graft-versus-host disease (TA-GVHD) in susceptible patients. Absolute indications for irradiated blood products include bone marrow transplant recipients and donors, stem-cell donors, T-cell immunodeficiency, intrauterine transfusion, and HLA-matched platelet transfusions. Relative indications include patients with leukemia, Hodgkin disease, non-Hodgkin lymphoma, neonatal exchange transfusion, premature infants, neuroblastoma, and glioblastoma.3

Divided RBC units or “pedi-packs” are derived from dividing single units of PRBCs into 4 units. Pedi-packs are type O irradiated, leukoreduced, and Hgb S negative PRBCs; however, they are not necessarily CMV negative. Pedi-packs minimize blood wasting and donor exposure when a small volume transfusion is indicated.5

Type O

Often, cross-matched blood is not immediately available. If PRBCs are needed within the first 15 minutes of resuscitation and the patient’s condition cannot be stabilized with 2 L of crystalloid fluids, type O blood is warranted. In general, women of childbearing age should be transfused with type O Rh-negative blood.6

Of 4,241 trauma patients who received uncrossmatched PRBCs (URBCs) or type O transfusions in a retrospective study at a level 1 trauma center, those receiving URBCs had a 39.6% mortality compared to 11.9% of those with crossmatched PRBCs (P<.001). In general, the use of URBCs is an independent predictor of mortality after adjusting for gender, mechanism, age, hypotension, intubation, initial Hgb, abbreviated injury scale, Glasgow coma scale, injury severity score, and the amount of blood products received. Crossmatched blood should be used whenever available, and a request for uncrossmatched blood products should trigger the blood bank to release crossmatched blood in anticipation of massive transfusion.7

Platelets

Platelets are separated and concentrated through serial centrifugation, then re-suspended in residual plasma. A therapeutic adult dose is comprised of four to six platelet concentrates of the same blood type. This raises platelet counts by 5,000 mL/U. Even though hemostasis may be maintained at platelet counts of 5,000/mL, it is acceptable to transfuse for platelet counts below 10,000/mL. Patients who are bleeding due to platelet dysfunction, and/or thrombocytopenia require platelets. Platelet transfusion is generally ineffective in the case of immune-mediated platelet consumption such as thrombotic thrombocytopenic purpura (TTP).8

ABO Compatible Platelets

Infants and small children require ABO compatible or volume-reduced platelets.9 Type ABO compatibility is less clinically significant in adults; however, Rh sensitization may occur. Conditions refractory to platelet therapy include fever, sepsis disseminated intravascular coagulation (DIC), splenomegaly, idiopathic thrombocytopenic purpura, and platelet alloimmunization. Patients frequently transfused with platelets or those with platelet alloimmunization require leukoreduced and HLA-matched products to minimize HLA antibody-induced immune destruction.10

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