Module 3: Indications for blood/ blood components

Transfusion Training WorkshopKKM 2012

Case 1 – PRBC

Cik SL, 18 year-old lady

Had reconstruction of L mandible

Blood loss 2 L

Hb dropped from 11 to 8.5 g/dL

PR 100 BP 120/70

1 unit packed red blood cell (PRBC) transfused

Case 2 – PRBC

Cik SB, 25 year-old lady

Delivered SVD 1st child

Blood loss 80 mL

Hb 7.5 g/dL MCV 65fL MCH 19 pg

Transfused 2 units PRBC

Case 3 – PRBC

En SM, 35 year-old man

Admitted to ICU for multiple trauma

Hb 8.9 g/dL

Transfused 2 units PRBC

Case 4 – PRBC

En AF, 56 year-old man

Admitted for hernia repair

Known DM with CKD type II

Hb 10.0 g/dL

2 units PRBC requested

Adaptive mechanisms to avoid tissue hypoxia

When Hb falls, cardiac output increases blood viscosity decreases peripheral vasoconstriction occurs

To maintain O2 delivery to tissues

Clinicians underestimate the effectiveness of adaptive mechanisms

Over-reliance on Hb measurements

Using a Hb trigger of 10 g/dL

>> Leading to excessive and inappropriate use of red cell transfusions

Indications for packed red cells Factors to be considered:

Acute vs. chronic anaemia

On-going blood loss

Age of patient

Underlying medical illness

Acute anaemia (due to blood loss)

Acute blood loss(no on-going loss)

% blood volume loss

Blood volume mL

Need for PRBC transfusion

15 750 No*

15 – 30 800 – 1500 No*

30 – 40 1500 – 2000 Probably

>40 > 2000 Yes

* Except for patients who tolerate anaemia poorly eg. pre-existing anaemia, severe cardiac or respiratory disease, age >65 years

BJH guidelines 2001

Acute blood loss(no on-going loss)

% blood volume loss

Blood volume mL

Need for PRBC transfusion

15 750 No*

15 – 30 800 – 1500 No*

30 – 40 1500 – 2000 Probably

>40 > 2000 Yes

* Except for patients who tolerate anaemia poorly eg. pre-existing anaemia, severe cardiac or respiratory disease, age >65 years

BJH guidelines 2001

Acute blood loss(no on-going loss)

% blood volume loss

Blood volume mL

Need for PRBC transfusion

15 750 No*

15 – 30 800 – 1500 No*

30 – 40 1500 – 2000 Probably

>40 > 2000 Yes

BJH guidelines 2001

Acute blood loss(no on-going loss)

% blood volume loss

Blood volume mL

Need for PRBC transfusion

15 750 No*

15 – 30 800 – 1500 No*

30 – 40 1500 – 2000 Probably

>40 > 2000 Yes

BJH guidelines 2001

Acute blood loss(no on-going loss)

% blood volume loss

Blood volume mL

Need for PRBC transfusion

15 750 No*

15 – 30 800 – 1500 No*

30 – 40 1500 – 2000 Probably

>40 > 2000 Yes

BJH guidelines 2001

* Except for patients who tolerate anaemia poorly eg. pre-existing anaemia, severe cardiac or respiratory disease, age >65 years

Acute blood loss(no on-going loss)

Hb level g/dL Need for PRBC transfusion

< 7 Yes

7 – 10 No*

> 10 No •Except for patients who tolerate anaemia poorly eg. severe cardiac or respiratory disease, age >65 years

BJH guidelines 2001

Case 1 – PRBC

Acute blood loss of 2L = 40% loss of blood volume

Need for transfusion: probably

But in view of young age and Hb >8.0 with no ongoing blood loss

Decision: not to transfuse

Chronic anaemia

Chronic anaemia

Chronic anaemia is better tolerated

Better O2 delivery due to the increase in 2,3 DPG and a shift in the O2 dissociation curve

Cardiac output at rest does not usually increase until Hb falls <7 g/dL

Chronic anaemia

The cause of anaemia should be established

Correct the anaemia eg. iron deficiency anaemia with iron Rx

Usually asymptomatic with Hb >7 g/dL

Transfuse only if life-threatening

BJH guidelines 2001

Case 2 – PRBC

1st pregnancy Minimal blood loss post-partum Hb 7.5 g/dL Hypochromic microcytic indices Most likely iron deficiency anaemia Treat with iron supplements while

investigating No indication for transfusion

Anaemia in Critical Care

Anaemia in critical care

Same target apply as for acute blood loss

Over-transfusion may increase mortality in this group

Herbert et al, NEJM 1999

0 5 10 15 20 25 30

Days

Surv

ival %

Restrictive-transfusionstrategy (trigger Hb <7)

Liberal-transfusion strategy (trigger Hb <10)

P= 0.10

50

60

70

80

90

100

Herbert et al, NEJM 1999

30-day mortality no worse: all patients

0 5 10 15 20 25 30

Days

Surv

ival %

Restrictive-transfusionstrategy (trigger Hb <7)

Liberal-transfusion strategy (trigger Hb <10)

P= 0.02

50

60

70

80

90

100

Herbert et al, NEJM 1999

30-day mortality lower in patients with APACHE II score <20

Anaemia in critical care

Hb level g/dL Need for PRBC transfusion

< 7 Yes

7- 10 No*

> 10 No •Except for patients who tolerate anaemia poorly eg. severe cardiac or respiratory disease, age >65 years

BJH guidelines 2001

Case 3 – PRBC

Multiple trauma

Hb 8.9

Age 35 years

No case for transfusion

Pre-operative Assessment

Peri-operative transfusion

Objective is to manage the patient so that transfusion is not needed

Investigate and treat anaemia prior to op

Discontinue anti-platelet drugs or anticoagulants if possible

Consider erythropoeitin or autologous transfusion

Management of acute haemorrhage during surgery is the same approach as for acute blood loss

BJH guidelines 2001

Case 4 – PRBC

Hernia repair

Hb 10 g/dL

No indication for transfusion

Case 1 – Whole blood

51 year-old lady

c/o: fever x 5 days Myalgia Haematemesis x 1

cupful

Hb 10.7 Hct 31 Plt 42

Dengue IgM pos (D7)

O/E: Pink

BP 115/66 PR 110

T 37.5

Case 1 – WB

Chest: dull both bases

Abd: tender RHC and ascites

Diagnosis: DHF or severe dengue

2 pints whole blood (WB) requested

Whole blood

Made into components

Contain 1 unit red cell, 1 unit plasma and 1 unit platelet

Kept at 4oC

Labile clotting factors are lost

Platelets are non-functional

Case 1 – WB

Plasma in WB will leak in DHF

Higher risk of TRALI with WB

PRBC stays in vessels, less leak (indicated only if signs of occult bleeding)

Monitor clinically

Indications for WB

Most indications for WB transfusion are now well managed exclusively with blood component therapy

Storage of WB precludes the production of components and is highly inefficient

WB is thus unavailable in most blood banks in the United States

AABB circular 2009

Case 1 – FFP

Pn SA, 60 year-old lady

h/o Hypertension and IHD

Atrial fibrillation on warfarin

Case 1 – FFP

c/o severe headache

O/E: R hemiparesis GCS 12/15

CT scan: L parietal haemorrhage

INR 9.0

Case 1 – FFP

Urgent 4 units FFP requested

IV vitamin K 10 mg bolus

FFP transfused 1½ hour later (6h after admission)

Case 1 – FFP

GCS deteriorated

Intubated and ventilated

Referred neurosurgical

Conservative Mx

Indications for FFP

1. For warfarin reversal in a bleeding patient ONLY if prothrombin complex concentrate (PCC) is not available

BJH guidelines 2001

Warfarin reversal

INR and discontinuation of Warfarin

White 1995

Reversing Warfarin Effect

Stop warfarin

Give Vitamin K

PCC or FFP

Prothrombin Complex Concentrate (PCC) Lyophilised powder

Reconstituted within 1 minute

Kept at pharmacy (like albumin and ivIg)

INR reversal by PCC

Yasaka 20037-27u/kg

Pre Post

100

90

30

60

80

40

50

20

70

10

0Pre Post

100

90

30

60

80

40

50

20

70

10

0

Reversal of Warfarin800 mL FFP 25-30 U/kg PCC

FII

Makris 1997Median 3 17 15 65

Warfarin and ICH

6x risk of hematoma expansion after admission

Expansion is associated with poor outcome

3x mortality risk than non-warfarin ICH

Flibotte 2004

PCC vs FFP

PCC gives more rapid and complete correction of warfarin-induced coagulation defect than FFP

Rapid correction of INR prevents ICH enlargement

Must combine with Vitamin K for sustained reversal

Yasaka 2003

Fredriksson 1992

FFPTime to thaw

15 mL/kg: large volume

Slow to administer

Effect on levels is small

Multiple donors, ±

untreated

Blood group required

Generally available

PCCRapid reconstitutionMinimal volume Rapid

administrationReliable correction Prothrombotic riskPooledViral inactivation Limited availability

Rapid reversal of warfarin

PCC

Prothrombinex

Octaplex

Beriplex

PCC for warfarin reversal

4- factor PCC contains factors II, IX and X + factor VII

Beriplex Octaplex

3- factor PCC contains factors II, IX and X (little factor

VII) Prothrombinex

Warfarin reversal: guidelines

BJH guidelines 2011

Non-emergency

INR 5 – 8, no bleeding Stop warfarin

INR >8, or <8 + bleeding IV Vit K 2 – 5 mg

BJH guidelines 2011

Management of emergency or life-threatening bleeding

Stop warfarin Give IV Vitamin K 5 mg Give 4-factor PCC:

INR Dose< 5.0 15 IU/kg

≥ 5.0 30 IU/kg pending 30 IU/kg

Makris 2005

Safe INR for surgery

INR <1.5

Corresponds to factor levels >50%

Safe for most surgeries

INR <1.2

Corresponds to factor levels >80%

Surgeries in critical sites eg. neurosurgery

Ansell J, Chest 2001White RH, Ann Intern Med 1999

Case 2 – FFP

DI, 64 year-old man

h/o Forest 2a ulcer and UGIB

Elective OGDS planned

2 units FFP requested

Hb 14 g/dL

PT 14s APTT 28s

Case 2 – FFP

Not sure the reason for requesting FFP

Why was PT and APTT testing done?

If you took a good history, the UGIB must be due to the ulcer (and not due to a

bleeding disorder)

This practice of simply requesting FFP before a procedure MUST STOP

PT and APTT

Puetz J, JTH 2013

FFP use

Puetz J, JTH 2013

Pre-operative coagulation screening tests BCSH guideline 2008

PPV of abnormal tests 0.03 – 0.23 No significant increase in bleeding

associated with abnormal tests

Routine pre-op screening is NOT RECOMMENDED

Chee, BCSH guidelines 2008

Case 3 – FFP

En SY, 48 year-old man

Alcoholic liver disease

Elective OGDS planned

PT 15s APTT 30s

2 units FFP transfused

Indications of FFP

2. Liver disease in the PRESENCE of coagulopathy AND life-threatening bleeding

BCSH guidelines 2001

FFP and liver disease

The response to FFP in liver disease is unpredictable

Other factors like dysfibrinogenaemia, thrombocytopenia and hyperfibrinolysis need to be considered

There is no evidence to substantiate the use of FFP to prevent bleeding in patients with liver disease and prolong PT

BCSH guidelines 2001

Case 3 – FFP

Yes, patient has liver disease but definitely no coagulopathy

So why transfuse FFP?

This is an INAPPROPRIATE & UNNECESSARY TRANSFUSION – a practice which has to STOP

Other indications for FFP

3. Massive transfusion with excessive bleeding, guided by timely tests of coagulation

4. Plasma exchange for Thrombotic Thrombocytopenic Purpura (TTP)

5. Multiple coagulation factor deficiencies or DIC with bleeding

6. FV deficiency where no clotting factor concentrate is available

BCSH guidelines 2001

ICU patients

Many patients in ICU have a prolong PT due to inadequate vitamin K intake

ICU patients should routinely receive vitamin K; 10 mg thrice weekly for adults and 0.3 mg/kg for children

FFP is not the treatment of choice for correcting inadequate vitamin K intake, even if clotting times are prolonged and an invasive procedure such as liver biopsy is being contemplated

BCSH guidelines 2001

In other words

Please don’t use FFP to correct clotting times (or to shrink haematomas!)

Treat the patient as a whole; NOT as a number

Requesting FFP

2 units?

4 units?

Dose calculation is 15 mL/kg per dose

1 unit FFP ≅ 200 mL

Eg. for a 50 kg patient = 750 mL = 4 units

What’s in FFP?

All the coagulation factors

1 unit FFP increases most factors by about 5% (in a 50-kg patient)

4 units FFP will increase to 20%

But will also depend on the size of the patient

Case 4 – FFP

45 year-old man

Chronic hepatitis B with hepatocellular carcinoma

Portal vein thrombosis

c/o abdominal pain and vomiting

Referred to H. Selayang

Case 4 – FFP

Hb 10.7 TW 10.5 Plt 134

ALT 668 T. Bil 14.5

APTT 36.6 s PT 18.5 s

Was informed by liver team to transfuse 4 FFP before transferring patient and

Another 4 FFP to be transported together with patient to hospital

Case 4 – FFP

No indication for FFP (no bleeding, instead has thrombosis!)

Once thawed, coagulation factors in FFP decay with transport time and are destroyed by heat

Once thawed, FFP must be transfused immediately

Puetz J, JTH 2013

Case 6 – (accompanying) PRBC

49 year-old man, alcoholic

Subdural haematoma

Hb 13.5 PT 12s APTT 36s

Referred to neurosurgery

Neurosurgeon requests patient to be transferred along with 2 PRBC

The practice of transporting blood and blood components with patients is strongly discouraged

This will result in wastage or unnecessary transfusion

Case 1 – platelet

MC, 60 year-old lady

Admitted with acute myocardial infarction

Platelet count 38 x 109/L

Streptokinase and LMWH not given

Request platelet transfusion prior to antiplatelet therapy

Patient succumbed from CCF 1 week later

Platelet clumping

Pseudo-thrombocytopenia

Case 1 – platelet

Again, trying to correct a number

Patient was not bleeding BUT clotting!

Case 2 – platelet

Madam LNY, 60 year-old lady

Known chronic renal failure

Admitted for UGIB

Platelet count 90 x 109/L Urea 48

Approx 30 cc of hematemesis documented

Request platelet transfusion prior to HD therapy

Indications for platelet transfusion- treatment Thrombocytopenia* and life-threatening

bleeding (cause of thrombocytopenia needs to be established)

DIC or massive transfusion with excessive bleeding

Platelet dysfunction Uraemia with life-threatening bleeding not controlled

with DDAVP or cryoprecipitate Post-cardiac bypass with bleeding not due to surgical

causes or heparin effect Inherited platelet dysfunction with life-threatening

bleeding

Indications for platelet transfusion- prophylaxis

Platelet count <10 x 109/L in patients with BM failure

To keep platelet count >50 x 109/L prior to lumbar puncture or surgery

Requesting platelets

Paediatric dose: 1 unit/ 10kg or 15mL/kg

A rise of 50 x 109/L is expected

Adult dose: 4 – 6 units or 1 apheresis

A rise of 45 x 109/L is expected for a 70kg patient

Case 1 – cryoprecipitate

ER, 33 yr old man Brought in by passer-by in a hit & run

accident Suspected pelvic fracture Alert GCS – full BP 100/60 PR 106 Hb 12.8 PT/APTT – normal Request for cryoppt in view of possible

massive internal bleed

No role for prophylactic cryoprecipitate

What’s in cryoprecipitate?

Fibrinogen

Factor VIII

von Willebrand factor

Factor XIII

Indications for cryoprecipitate

Hypofibrinogenemic states with bleeding DIC – disseminated intravascular coagulation APML – acute promyelocytic leukaemia

No longer used for haemophilia A, von Willebrand disease or factor XIII deficiency where concentrates are now available

Dosing for cryoprecipitate

1 unit contains 350 mg fibrinogen

Paediatric dose: 1 unit/10 kg or 5ml/kg will increase fibrinogen by 60 – 100 mg/dL

Adult dose: 1 pool = 6 units 1 pool cryoprecipitate increases fibrinogen

by 45 mg/dL in a 70kg patient

The next time you decide to transfuse

Stop, think and ask yourself …

Is it really necessary?

The end