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CHR Guidelines for Transfusion

These guidelines were developed by the CHR Regional Transfusion Committee and were approved by the Medical Advisory Board on December 10, 1998.  They are reviewed and updated with each revision of the Guide To Laboratory Services.

Safety of allogeneic transfusion is a concern both for physicians and patients.  Although the risk of transfusion remains low, physicians need to use blood and blood products judiciously to ensure that any attendant risk can be justified by the potential for clinical benefit to the patient.  As a matter of policy the use of allogeneic transfusion should be minimized without compromising patient care by under-transfusing.   Strategies that should be considered to reduce allogeneic blood use in appropriate cases include blood conservation techniques in surgery, autologous transfusion, acute normovolemic hemodilution and the use of a Cell Saver.  Recombinant human erythropoietin may be appropriate in some cases (e.g. to increase pre-operative hemoglobin to acceptable levels in those unwilling to accept transfusion for religious reasons).   The purpose of the guidelines is to promote a consistent and scientifically based pattern of blood use in the Region.  The guidelines will also be used as a basis for transfusion audit.  It is recognized that the guidelines will not necessarily be appropriate in all clinical circumstances and that it is a matter of clinical judgement to ensure that each patient receives the most appropriate treatment.

In 1997, the CMA published guidelines that refer specifically to red blood cell and plasma transfusions only.  Guidelines based on current literature, for the use of other components and plasma protein (fractionation) products have been developed by the Transfusion Committee.  The following CMA Guidelines are endorsed by the Transfusion Committee and form the basis for good transfusion practice.  Italicized script indicates direct quotation from the CMA recommendations.

General

1. Patients should be informed that transfusion of red blood cells, plasma or both is a possible element of the planned medical or surgical intervention and provided with information about the risks, benefits and available alternatives.

2. When feasible, the patient’s consent to a transfusion of red blood cells, plasma or both, should be obtained and recorded in the patient’s medical chart.

3. The physician overseeing the care of the patient should be responsible for obtaining informed consent for red blood cell or plasma administration.

4. Patients should be informed that they have received a red blood cell or plasma transfusion subsequent to its administration.  A Regional policy is pending.

5. A physician prescribing transfusion of red blood cells or plasma should be familiar with the indications for and benefits and risk from the use of these fractions.

6. Documentation that supports the administration of the red blood cells or plasma should be found in the patient's chart.

Red Blood Cell Transfusion

7. Red blood cell transfusions should be administered primarily to prevent or alleviate symptoms, signs or morbidity due to inadequate tissue oxygen delivery (resulting from a low red blood cell mass).

8. There is no single value of hemoglobin concentration that justifies or requires transfusion; an evaluation of the patient's clinical situation should also be a factor in the decision.

9. In the setting of acute blood loss, red blood cell transfusion should not be used to expand vascular volume when oxygen carrying capacity is adequate.

10. Anemia should not be treated with red blood cell transfusion if alternative therapies with fewer potential risks are available and appropriate.

11. Pre-donation of autologous blood should be considered a therapeutic option for adolescents and adults undergoing elective surgery in which the likelihood of transfusion is substantial (i.e. 10% or more).

12. Autologous transfusion is not risk free and the decision to transfuse should be a carefully considered one after weighing the risks against the potential benefits.

Additional Recommendations for Red Cell Transfusions

• Correct hypovolemia with crystalloids.
• Administer on a unit by unit basis.
• Recognize that patients with myocardial ischemia, congestive heart failure, transient ischemic attacks or previous thrombotic stroke are at particular risk from reduced oxygen carrying capacity.

Plasma Transfusion

13. Plasma transfusion should be considered for patients with acquired multiple coagulation factor deficiencies under the following circumstances:

a. Plasma is recommended when serious bleeding has occurred or when preparing for an emergency surgical or invasive procedure in patients with vitamin K deficiency or on warfarin therapy with significantly increased PT, INR or PTT.

b. Plasma is recommended when there is actual bleeding in patients with liver disease and increased PT, INR or PTT. Plasma may be administered to prepare for surgery or liver biopsy when the results of PT, INR or PTT or other appropriate coagulation assays are deemed sufficiently abnormal. Prophylactic plasma transfusion is not indicated for certain invasive procedures (e.g., percutaneous liver biopsy, paracentesis, thoracentesis) in patients with liver disease if their INR is 2.0 or less.

c. Plasma is recommended in patients with acute disseminated intravascular coagulation with active bleeding associated with increased PT, INR or PTT, provided that the triggering condition can also be treated effectively.

d. Plasma should be administered in the context of massive transfusion (more than 1 blood volume) if there is microvascular bleeding associated with a significantly increased PT, INR or a PTT. If the PT, INR or PTT cannot be measured quickly, plasma may be transfused in an attempt to stop diffuse nonsurgical bleeding.

14. Plasma should be used in the treatment of TTP or adult HUS, followed as soon as possible by daily plasmapheresis with either cryosupernatant plasma or plasma as replacement fluid. Plasma transfusion or exchange is not recommended in the classic form of pediatric HUS.

15. Plasma should be used in patients with acquired deficiencies of a single coagulation factor only when DDAVP or appropriate factor concentrates are ineffective or unavailable. Plasma should be used in these patients only when bleeding has occurred or is reasonably expected to occur from surgery or other invasive procedures. Plasma may be used depending on the specific factor involved.

16.Frozen plasma can be derived from two donor sources:

• Random donor (from whole blood donation)- usually about 250 mL
• Apheresis donor- usually about 500 mL.

Note that the actual volume may vary. Frozen plasma contains at least 100 mL of plasma that has been separated from a single whole blood donation. Apheresis fresh frozen plasma contains 200-600 mL of plasma.

            a. The recommended pediatric dose is 10- 15 mL/ kg body weight.

            b. The recommended adult dose is 750- 1000 mL.