HOW I DO – Transfusion of Blood Products PART – 4

HOW I DO – Transfusion of Blood Products PART – 4

(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)

Question: In last part, we covered some important points related to cut off for RBC transfusion. I was very surprised to know that 1. Whole blood has no advantage whatsoever over PCV (also known as RCC i.e. red cell concentrate). But has some important disadvantages. 2. Stable outpatients with chronic anemia, and no heart issues, can be maintained at Hb level that they are fairly comfortable i.e. up to even 4 g. 3. For cardiac patients, cut off is about 8 g, and not 10 which many people try to maintain. 4. Even for most patients admitted with active bleeding, a cut off of 8-9 is sufficient. 5. For most other admitted patients, including those in ICU, cut off of 7 is sufficient, as found in multiple trials. No advantage of improving oxygenation by increasing Hb to 9 or 10 or higher. 6. Even for cardiac surgery, preoperative Hb of 7-8 is sufficient.

In fact, this means that most of us have been doing over transfusion, especially for patients with cardiac disease, where we felt Hb should be maintained over 10 or so. Also felt same for ICU patients, especially if on ventilator or respiratory disorders. But your review will help many of us and patients to reduce number of transfusions and associated burden of finding donors, and cost.

Answer: Yes, and in fact, lower Hb cut off as above is associated with better outcomes as well. Not just cost saving. Hope our readers will use these cut offs in practice for both Hb, and earlier described for platelet.

Que: Certainly. And we will spread the message to other clinicians as well. What are other important points that we should know about red cell transfusion?

Ans: 1. For most patients with chronic anemia, don’t transfuse more than one or two units in a day, for the first time. They have compensatory hyperdynamic circulation, and more blood transfusion or fluids can precipitate heart failure. Most common such scenario is in nutritional anemia e.g. iron or B12 def.  Ideally, of course these patients should be treated without any transfusion. Supplementation alone is sufficient in vast majority.

For those on regular blood transfusions, two units can be given easily on the same day e.g. MDS, PRCA…

2. Overall, for most patients 1-2 units is sufficient. There is no need to completely correct anemia by transfusion. And as we have seen last time, Hb cut off for transfusion is generally around 7-8 for most indications. Further improvement in Hb should be achieved by treatment of underlying process.
3. MOST IMPORTANT STEP before transfusion is to ensure that RIGHT BLOOD is given to the RIGHT PATIENT. By ensuring matching of all identifiers on blood unit with patient. Name alone is not sufficient, as two patients can have exactly same names, even when name is unusual. Unique ID used in most large hospitals are best additional identifiers. But in smaller hospitals, where unique ID system may not be available, doctor and hospital staff should be very careful to ensure that multiple identifiers are used for confirmation before transfusion of any blood product.

LARGE MAJORITY OF ABO INCOMPATIBLE BLOOD TRANSFUSIONS ARE IN FACT DUE TO WRONG IDENTIFICATION, rather than mistakes at the level of testing. These are rare nowadays. Wrong identifications are much more of a concern in emergency situations, operation theaters. Elective blood transfusions for any product should preferably be done in day time.

4. Warming of the blood is generally not required. Very specific situations only require blood warming. Warming is unfortunately a common practice howerver. Warming the blood is done in several different ways and that is unsafe. In those rare situations where blood warming is indicated, this should be done using official blood warmers to ensure blood is not heated too much. Otherwise there is risk of hemolysis. Uncontrolled heating of blood using water etc are dangerous with risk of hemolysis, and contamination both.
5. For the large majority of patients, two units red cell can be easily given on the same day. I still see the practice of one unit per day transfusion very frequently. This is unnecessary burden for patient and family where they have to come for two days, instead of one day.

Routine use of pre medications is not required before blood transfusion.

6. Time to transfuse each unit is about 1-2 hours for most adults. There is no need to prolong it for 3-4 hours. In fact, more than 4 hours is certainly not recommended, as there is higher risk of infections. Blood is stored at very low temperatures, hence bacterial growth does not happen. Once at room temperature, bacteria can grow rapidly. In emergency situations like hypotension, active bleeding, it can be transfused much faster as well.
7. First about 10 minutes should be slow transfusion (at about 50-100 ml per hour) to ensure no incompatible blood. However after that, it should be given at about 250 ml per hour – to complete whole unit within 1-2 hours.
8. RCC/PCV should not be given concurrently with other fluids, medicines using same line. It can be given however with normal saline, fresh frozen plasma, or albumin. Not with ringer lactate, dextrose solutions etc. With a multi lumen catheter, such as CVP line, different lumens can be used for other medicines. Preferably first 15 minutes however should be only blood. In case there is any reaction, this helps differentiate source of reaction as blood versus other medicines.                                                                                                                                                                                                                                                                          August 19^th, 2024 Dr Chirag A. Shah; M.D. Oncology/Hematology (USA), 9998084001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com www.shyamhemoncclinic.com