SIMPLE TRANSFUSION GUIDELINES FOR PRACTIONERS

Blood and blood products are indispensable commodities in medical practice. The availability of blood products are always in short supply in spite of huge donor pool available in our country.

That is why every one of us should endeavour to optimize the use of blood and blood products to the maximal benefit for our patients. Still, in most parts of our country blood components are not available, even in some of the tertiary centres like medical college hospitals.

The transfusion guidelines are enumerated not only to list the indications of blood components but also to stress the need to avoid using blood and blood components wherever they are not indicated. This is necessary not only to conserve blood products but also to avoid innumerable blood transfusion related adverse events. Transfusion related HIV still remains a major problem in our country, in spite of routine screening.

The use of whole blood (or fresh whole blood) is obsolete in clinical practice. Even though in many centres, due to non-availability the transfusion of whole blood is inevitable, this can be avoided in centres where component facilities are available. Even in major trauma or conditions with acute bleed, the replacement of lost blood with fresh or stored blood is no more a valid concept. There are also situations in which due to financial constraints, a whole blood would be an option instead of components.

However, outside the logistic and social issues, the clinicians are requested to minimize the use whole blood.

The major blood components are packed cells, Fresh Frozen Plasma, Platelets and Cryoprecipitate.

Before going into the indications, one must clearly understand the fact that the indications are based on the diagnosis and the clinical condition of the patient, RATHER THAN ON THE NUMBERS ALONE.

Packed Cells:

The commonest indication being anemia, the decision to transfuse will depend on the diagnosis and clinical condition as stated above.

  • In patient with cardio respiratory compromise and in pre-operative patients with very high risk of bleeding, a target Hb of 10g/dl is acceptable whereas in others a transfusion target of 8g/dl is sufficient.
  • In patients with severe anemia of nutritional cause such as iron deficiency or B12 deficiency, transfusion is usually not indicated even at Hb levels of 5g/dl, unless they are pregnant or have system compromise due to low Hb. These patients respond rapidly to proper therapy. Proper diagnosis and appropriate treatment is the clue
  • In patients with known auto-immune hemolytic anemia, other than to tide over the acute condition, it is better to avoid transfusions as these patients will form more allo antibodies to transfused red cells, which makes the condition worse.
  • Patients with chronic anemia due to bone marrow failure syndromes can be maintained at a lower target level depending on the clinical status.
  • Anemia due to acute or chronic infections or anemia in ICU settings does not need transfusions except if the anemia is severe enough to cause cardo respiratory compromise. Randomised studies have shown that unwarranted transfusion simply to improve Hb levels do not benefit or even can cause transient immunosuppression.

Platelets:

  • Platelets are strictly not indicated just to improve the numbers. Unlike Hb, one fifth of normal levels of platelets (30,000/cumm) are sufficient for normal livelihood, unless any interventional procedure is done. Also, if the patient has immune thrombocytopenia transfusion of platelets are not indicated even with a very low platelet count of less than 10,000, as transfused platelets are rapidly consumed and does not have any prophylactic value to prevent any major bleed.
  • Hence, one should know the cause of thrombocytopenia, before attempting to transfuse. They are not indicated in Immune thrombocytopenias, unless the patient has active bleeding or signs of internal bleeding
  • Also in microangiopathic disorders like HUS (Hemolyic uremic syndrome) and TTP (Thrombotic thrombocytopenic pupuras) platelet transfusions are contra-indicated unless in the presence of bleeding.
  • Platelets are not indicated in bone marrow failures or post chemotherapy situations in which the platelet count is more than 20,000 and patient is not bleeding.
  • Indications for prophylactic platelet transfusions:
  • Platelet count of less than 10,000 in a stable patient
  • Platelet count of less than 20,000 in a patient with fever, sepsis, chemotherapy, drugs which consume platelets (such as amphotericin)
  • In neonates, with allo immune or other causes of thrombocytopenia, prophylactic platelet transfusion should aim at a platelet count of more than 50,000
  • Indications for therapeutic platelet transfusions
  • Any actively bleeding patient with thrombocytopenia, platelets can be transfused to keep the count above 50,000. Simple mucosal bleed or venepucture site bleeding are not indications for transfusions. They can be controlled with local pressure, ice, cyclopakpron tablets etc.
  • Any patient who need any invasive procedures will need platelet transfusions to keep the platelets above 50,000 during the procedure. In major procedures, a target of 75,000 is desirable, whereas CNS and ophthalmic surgeries, the target should be above 1,00,000/cumm.
  • The amount of platelets required may depend on the patient’s weight, clinical condition, diagnosis and the prior platelet exposure. Please contact your blood bank or hematology dept. for further advice in this regard. In multiple transfused patients, platelets are consumed rapidly and hence these patients should receive platelets during the procedure. Transfusing the platelets and waiting for an increment after 1 hour may not be feasible in many of these patients.
  • There is no contra-indication to major procedures, if it is deemed clinically indicated and done in the tertiary centres with hematology support.
  • Platelet function disorders can be congential, drug induced or secondary to cardiac surgery in which cases platelet transfusions are indicated even with a normal platelet count.
  • N.B: In a thrombocytopenic patient with active bleeding, always rule out the possibility of coagulation defect (such as DIC). The patients with associated coagulation defect should receive adequate necessary supplements first, before platelet transfusions.
  • Fresh Frozen Plasma:
  • To correct coagulation defects associated with DIC or vit k deficiency with active bleeding of impending bleeding:
  • To correct very prolonged INR associated with warfarin therapy esp. if associated with bleeding
  • To treat hemophiliacs, if specific factors are not available
  • To replace fibrinogen in conditions of low fibrinogen associated with conditions such as DIC
  • As a replacement for albumin
  • Bleeding due to causes other than coagulation deficiency
  • It is a product prepared from FFP and is a rich source of fibrinogen and Factor VIII. Since each bag comes in a small volume (~50ml), it can be used whenever sudden and massive replacements are needed esp. in cases of DIC.
  • To correct coagulation defects in Hemophilia A and in Von willebrand disease in the absence of specific factors
  • To rapidly correct coagulation abnormality in cases of DIVC or massive hypofibrinogenemia after thrombolytic therapy.
 
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