Blood transfusions

Question 1

What are the thresholds for RBC transfusions?

Answer 1

1. <=70g/L for most patients

2. <=80g/L for patients with ACS

Question 2

Which patients require CMV -ve RBCs for transfusion?

Answer 2

1. neonates (up to 28/7 post-EDD)
2. elective transfusion during pregnancy
3. intrauterine transfusion

Question 3

Which patients require irradiated RBCs for transfusion?

Answer 3

1. neonates (up to 28/7)
2. intrauterine transfusion
3. Hx of Hodgkin’s lymphoma
4. bone marrow or stem cell transplant
5. immunocompromise: chemotherapy or congenital

Question 4

What are the thresholds for platelet transfusions?

Answer 4

1. no active bleeding or planned invasive procedure:
   - <10 x 10^9 for most patients
   - <20 x 10^9 if infection
2. pre-invasive procedure - aim for plt levels of:
   - >50 x 10^9 f or most procedures
   - 50-75 x 10^9 if high bleeding risk
   - >100 x 10^9 if critical site e.g. eyes or CNS
3. acute bleeding:
   - <30 x 10^9 if clinically significant bleeding (e.g. haematemesis, melaena, prolonged epistaxis)
   - <100 x 10^9 if severe bleeding or bleeding at critical site

Question 5

What is the main complication of platelet transfusions?

Answer 5

bacterial contamination (highest risk compared to other types of blood products, stored at 20-24 degrees)

Question 6

A 36yo woman is receiving 1 unit RBC transfusion over 90 mins. She developed chills halfway through and her obs are checked, temp: 38.2 (baseline: 36.4). All other obs normal.

What is the likely cause and how would you manage?

Answer 6

Febrile non-haemolytic transfusion reaction

1. stop transfusion
2. check ID of recipient, details of unit + crossmatch report form
3. rule out haemolytic reaction
4. PARACETAMOL 500-1000 mg PO
5. restart transfusion at a slower rate + more frequent obs.

Question 7

A 26yo man is receiving 1 unit RBC transfusion over 90 mins. After 5mins he develops widespread pruritic white plaques with surrounding erythematous flare. He feels well otherwise and his obs are stable.

What is the likely cause and how would you manage?

Answer 7

Mild allergic reaction

1. stop transfusion
2. check ID of recipient, details of unit + crossmatch report form
3. rule out angioedema
4. CHLORPHENAMINE 10 mg slow IV injection
5. restart transfusion at a slower rate + more frequent obs

Question 8

A 52 yo man is receiving 1 unit RBC transfusion over 90 mins. At the 15mins obs check he is noted to have developed:

• fever 39.2 (baseline 37.0)
• increased HR 120 (baseline 90)
• decreased BP 90/56 (baseline 132/84)
• SpO2 94%

He also complains of chills, SOB + abdominal pain.

What is the likely cause and how would you investigate + manage?

Answer 8

Acute haemolytic transfusion reaction

1. stop transfusion
2. check ID of recipient, details of unit + crossmatch report form
3. DAT on freshly drawn blood specimen: +ve
   serial FBC: monitor haematocrit
   LDH, bilirubin, haptoglobins: raised
   repeat crossmatch + blood group
4. supportive Mx
   
   • O2 as required
   • 0.9% NaCl IV as required
   • monitor UO and maintain >100 ml/hr
   • FUROSEMIDE if required to maintain UO
   • treat any coagulopathy/DIC with appropriate blood products
5. take down unit and giving set and return to blood bank + inform hospital transfusion department immediately

Question 9

A 26yo man is receiving 1 unit platelet transfusion over 60 mins. Within 2mins he develops SOB + wheeze, swelling of his mouth + lips, abdominal pain + urticarial rash.
His obs are checked:
- HR: 130
- BP: 82/54
- RR: 26

What is the likely cause and how would you investigate + manage?

Answer 9

1. stop transfusion
2. check ID of recipient, details of unit + crossmatch report form
3. O2
4. ADRENALINE 0.5mg IM (repeat after 5mins as required)
5. SALBUTAMOL 2.5-5mg nebs
6. CHLORPHENAMINE 10mg slow IV
7. consider IV adrenaline if severe hypotension

Question 10

Over how long should RBC transfusions be made?

Answer 10

90-120 mins per unit, longer if patient intolerance of increased blood volume

Question 11

A 64yo female received 2 units RBC transfusion post-surgery. After a couple of hours, she complains of SOB, 
Her obs are checked:
- HR: 96
- RR: 26
- BP: 100/60
- temp: 37.9
- SpO2: 72%

What is the likely cause and how would you investigate + manage?

Answer 11

Transfusion-related lung injury

Ix CXR: diffuse lung infiltrates
ABG: monitor
BNP: normal, to rule out TACO

1. 100% O2
2. in severe cases: I + V
3. 0.9% NaCl IV, vasopressors, steroids as required

Question 12

A 72yo male receives 2 units RBC transfusion. Towards the end of the transfusion, he complains of acute SOB + cough. His obs show:

• RR: 26
• SpO2: 89%
• HR: 110
• BP: 152/100
• increased JVP

What is the likely cause and how would you investigate + manage?

Answer 12

Transfusion-associated circulatory overload:

Ix

• CXR: pulmonary oedema
• ABG: monitor
• BNP: raised

1. stop transfusion
2. check ID of recipient, details of unit + crossmatch report form
3. O2 + nurse upright
4. FUROSEMIDE 40-80mg IV