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Guidelines for the Judicious Use of Blood Products: Recommendations for Transfusion Medicine

This presentation outlines essential guidelines for the judicious use of blood products in clinical settings. It details recommendations for the usage of red blood cells, platelets, fresh frozen plasma (FFP), and cryoprecipitate, emphasizing the importance of avoiding unnecessary complications and managing workload and costs. The guidelines are based on professional associations' standards and consensus conferences, advocating for a standardized framework to optimize patient outcomes. Implementation strategies include forming a multidisciplinary transfusion committee, developing local SOPs, and continuous education for healthcare professionals.

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Guidelines for the Judicious Use of Blood Products: Recommendations for Transfusion Medicine

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  1. Recommendations for Judicious Use of Blood ProductsForum for Transfusion Medicine:O. Ben-Tal, N. Rachimi-Levene, E. Shinar, J. Orlin,V. Yahalom, D. Attias and N. Manny

  2. Outline of Presentation • Guidelines-Why?! • Recommendations for product usage. • Implementation-Suggetions. • Guidelines for use of irradiated, filtered and washed blood.

  3. Guidelines for Transfusion-Why?! • Provide a standardizedframeworkfor the use of critical products with a limited supply. • Avoid unnecessary complications: Primum non nocere. • Advise other disciplines using our professional expertise. • Manage workload and costs.

  4. Sources of Recommendations: • Guidelines published by professional associations 1990-2005: AMA, AABB, ASCO, BAA etc. • Consensus conferences/Task Forces. • Original Grade I manuscripts (NEJM): e.g. TRAP, RBC in ICU.

  5. General Rule of Thumb: • Blood products replace a specific deficiency/dysfunction: • RBC: Oxygen - carrying capacity. • Platelets:Reduced number or function. • FFP: Deficiency of Vitamin-K dependent and/or FXI (FXIII) deficiency. • Cryoprecipitate: Fibrinogen, (FXIII).

  6. Red Cells-Recommendations • Hb <7g/dL in a stable patient. • Hb between 7-10g/dL in patients with: • Asymptomatic Cardiac, Vascular, Hematological, Oncological disease. • Symptomatic anemia in a normovolemic patient. • Acute blood loss of>15% blood volume or 2g/dL Hb. • Pre-operative Hb <8g/dL and expected blood loss of >15% (~1000ml).

  7. Red Cells-Recommendations • RBC should not be transfused for: • Volume replacement • Correction of iron, folic acid or B12 deficiency. • Treatment of anemia of cancer.

  8. Red Cells-Suggestion for Surgical Orders Goal: to decrease unnecessary issuing and outdating of RBC: • Compose local “surgical blood order” for procedures requiring transfusion in 80-90% of cases. • Establish a local “Type & Screen” (T&S) policy for procedures requiring blood in <20% of cases.

  9. Surgical Blood Order

  10. Platelets:Transfusion Recommendations * Controversial

  11. FFP-Recommendations • 10-15ml/kg should be given to reduce active bleeding: • Warfarin overdose (5-10ml/kg may suffice) • FVII/XI deficiency. • DIC/microvascular bleeding with PT/PTT > x 1.5 mean normal. 4. Massive transfusion: if PT/PTT > x1.5 Normal.

  12. FFP-Recommendations • FFP given to prevent bleeding in patients with: • Known clotting-factor deficiency before surgical procedures; after Hem. Consult. • FFP should not be given: • For volume depletion. • For hypo-proteinemia/albuminemia.

  13. Cryoprecipitate-Recommendations • 1-1.5 bag/10 kg (~10 units to an ‘average’ patient) cryoprecipitate should be given to: • A bleeding patient with Fibrinogen level <100 mg/dL. • Severe DIC or dilutional coagulopathy after massive transfusion. • Patients with vWD unresponsive to DDAVP, therapeutically or as prophylaxis, after coagulation consult. • Patients with Hemophilia A when no FVIII is available, after coagulation Consult.

  14. Implementation Steps • Transfusion Committee-multidisciplinary • Devise local guidelines • Decide upon local specific SOP’s (see below) • Help educate and implement • Card/Forms? • Educate physicians & nurses. • Audit- continually…..

  15. A ‘guideline card’

  16. NEW FORMS Note: T&S form separated from order form

  17. Special Blood Products: Irradiation See Health Ministry specifications on how to mark products. • Absolute indications cellular products: • Congenital immune deficiency. • Recipients of products from blood-related donors. • BM/PBSC autologous/allogeneic transplant. • Patients treated with Purine analogs. • Patients with Hodgkin’s lymphoma. • Recipients of granulocyte transfusions. • Intra-uterine transfusion.

  18. Special Blood Products: Irradiation • Relative Indications: • Hem. Patients with leukemia, NHL etc. • Patients with solid tumors. • Exchange transfusion. • Premature newborns. • Organ - transplant recipients. Unproven Indications: • AIDS patients. • Term newborns.

  19. Leukofiltration of Cellular Products: • Reduce to <5x106/bag: • To prevent transfusion reactionsand reduce exposure to foreign HLA (alloimmunization) : • Previous repeated Febrile non-hemolytic transfusion reaction (FNHTR). • Hem./Onc. patients receiving many transfusions. • For CMV prevention in: • Renal transplant recipients. • Premature newborns. • Exchange transfusion.

  20. Special Blood Products:Washing • Remove Plasma of RBC / Platelet concentrates and replace with with normal saline: • Anaphylactic shock in IgA deficiency. • Repeated mild allergic reaction. • ABO-incompatible BM/PBSC transplant recipients. • TRALI, PTP.

  21. Thank You

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