Blood Product Administration

1. Blood Product Administration

2. Background Information Blood products are frequently maintained or initiated during inter-hospital critical care transport. Commonly used blood products Packed Red blood Cells (PRBCs) One unit ( 200 – 225 mls) will increase the hematocrit 3%. Fresh Frozen Plasma (FFP) One unit will increase Fibrinogen 10mg / dl. Platelets One unit (50ml) will increase platelet count 50,000 u/l.

3. Packed Red blood Cells (PRBCs) Also called Packed cells RBC’s Description of Components: Concentrated erythrocytes Citrate anticoagulant Preservative solution / solutions Hct ranges from about 50-65% (e.g., AS-1, AS-3, AS-5) to about 65-80% (e.g., CPDA-1, CPD, CP2D). 50 mL of donor plasma (range 20 mL to 150 mL), 42.5-80 g of hemoglobin or 128-240 mL of pure red cells dependant upon: hemoglobin level of the donor, starting whole blood collection volume, Collection methodology or further processing. leukoreduced

4. Packed Red Blood Cells (PRBCs) Dosing and Response One unit of compatible RBCs increases the hemoglobin level in an average sized adult by approximately 1g/dL or Hct by 3%. Dose Packed cells (mls)= wt (kg) x Hb rise required(g/dL) x 4 Half life of approximately 30 days

5. Packed Red Blood Cells Indications Hemorrhagic hypovolemia Anemia To increase the oxygen carrying capacity of certain subsets of patients with critical illness. Contraindications Anemias that can be corrected with specific medications such as iron, vitamin B12, folic acid, or erythropoietin Coagulation deficiency To improve oncotic pressure, wound healing and sense of well being

6. Packed Red blood Cells (PRBCs) General Recommendations Transfusion is rarely indicated when the hemoglobin level is above 10 g/dL Almost always indicated in patients when the hemoglobin level is below 6 g/dL; For hemoglobin level 6-10 g/dL Ongoing indication of organ ischemia The rate and magnitude of any potential or actual bleeding, The patient’s intravascular volume status Risk of complications due to inadequate oxygenation.

7. Fresh Frozen Plasma (FFP) Separated from whole blood and frozen within 8 hours of collection. It can be obtained from a whole blood donation (approx. 250 ml) or by apheresis (approx. 500 ml). Frozen Plasma must be thawed, usually in a water bath, and infused immediately or stored at 1-6oC for up to 24 hours. Contains a normal concentration of fibrinogen and the labile coagulation factors VIII and V. Fresh frozen plasma contains the clotting factors that are necessary for hemostasis. Plasma also has volume expansion and oncotic properties.

8. Fresh Frozen Plasma (FFP) • Dosing • Multiple coagulation factor deficiency • 10-20 ml/kg • Indications • Active bleeding or risk of bleeding due to deficiency of multiple coagulation factors, • Severe bleeding due to warfarin therapy, or urgent reversal of warfarin effect • Massive transfusion with coagulopathic bleeding. • Bleeding or prophylaxis of bleeding for a known single coagulation factor deficiency for which no concentrate is available. • Thrombotic thrombocytopenic purpura. • Rare specific plasma protein deficiencies, such as C1- inhibitor.

9. Fresh Frozen Plasma (FFP) • Contraindications • Increasing blood volume or albumin concentration • Coagulopathy that can be corrected with administration of vitamin K. • Normalizing abnormal coagulation screen results, in the absence of bleeding.

10. Complications of Blood Product Administration • Hemolytic Transfusion Reaction • Pathogenesis – • Immunologic destruction of transfused red cells, due to antigen antibody reaction. • Mistransfusion of ABO-incompatible blood, resulting from identification errors • Incompatibility unidentified during pre-transfusion testing • Symptoms and signs • an increase in temperature and pulse rate; • chills, • dyspnea, chest or back pain, • Abnormal bleeding, or shock. • Instability of blood pressure • In anesthetized patients, • Hypotension • Evidence of disseminated intravascular coagulopathy (DIC)

11. Complications of Blood Product Administration • Hemolytic Transfusion Reaction • Laboratory findings • hemoglobinemia and/or hemoglobinuria, • elevation of serum bilirubin; • in less catastrophic acute hemolytic reactions, a positive direct antiglobulin test (DAT) • Treatment • transfusion must be stopped • measures to maintain or correct arterial blood pressure; correct coagulopathy, • promote and maintain urine flow.

12. Complications of Blood Product Administration • Febrile nonhemolytic reaction • Symptoms • Fever Shortly after transfusion • No tests available for diagnosis • Treatment • Antipyretics. • Patients who experience repeated,severe febrile reactions may benefit from receiving leukocyte reduced components. • Allergic reactions • urticaria, • wheezing or angioedematous reactions. • Treatment • antihistamines • corticosteroids • epinephrine.

13. Complications of Blood Product Administration • Transmission of Infectious Disease • HIV, HTLV, hepatitis, and syphilis,CMV • Other potential agents • Simian foamy virus (SFV) • HHV-8 • West Nile virus • Chagas • nCJD • Malaria

14. Complications of Blood Product Administration • Transmission of Infectious Disease • Other potential agents • SARS • Influenza • Bartonella spp. • Borrelia spp. • Brucella spp. • Leishmania spp. • Parvovirus spp. • rickettsia • Toxoplasma spp.

15. Complications of Blood Product Administration • Circulatory Overload • Excessive volume at excessive rapid rate • In patients with chronic severe anemia • Transfusion of small volumes in at risk patients • Treatment • Treat for pulmonary edema

16. Complications of Blood Product Administration • Hypothermia • Metabolic complications • Citrate toxicity • Severe liver disease • Inadequate hepatic blood flow • Acidosis • Alkalosis • Hyperkalemia • Hypokalemia

17. Blood Product Administration • Procedure • If blood products are likely to be important to patient transport strategy, request them early or before arrival. • Blood should be stored on ice in a cooler at 4-6C during transport until need for use. Temperature indicators of blood stored in a cooler should not demonstrate that the blood has been stored in a manner outside of what is prescribed. • The transport team may continue or initiate blood products during transport as follows: • Per written or verbal order of the referring physician • Per OLMD order

18. Blood Product Administration • For resuscitation of victims of hemorrhagic shock, when packed red blood cells are available, they may be initiated for persistent shock despite crystalloid resuscitation as follows: • Typed and Crossmatched blood preferred. If typed and crossmatched blood not available, type specific non-crossmatched blood may be transfused. In emergencies, type O blood may be administered. Generally, type O-Negative blood is released emergently for resuscitation, however, transport teams may administer type O-Positive blood in emergencies. • Dose – for resuscitation (after 1-2 isotonic crystalloid fluid boluses [ 40 ml/kg crystalloid in pediatric patients]). After initial blood transfusion, repeat as appropriate to clinical situation with ongoing fluid resuscitation or administration of other blood products (e.g. FFP) • Adults: 1-2 unit PRBC’s • Pediatric: 10 ml/kg

19. Blood Product Administration Both flight crew members should Identify the patient and blood product by checking the patient ID band against the blood product label for name, blood type, unit identifying number, and expiration date. A matching name brand may not be present if using an emergency blood release of uncrossmatched blood. Record this information in the flight record and attach a unit tag, clearly denoting the time of initiating transfusion in the documentation. A blood filter administration set will be used for administration of all blood products. Each blood set should not be used for the administration of more than two units of blood products. Y-type blood tubing should be primed with normal saline only, not lactated ringers. Addition of additives to blood or blood products is prohibited. Blood should be warmed during administration to the extent possible. Packed cells may be mixed with a volume of warm isotonic saline to facilitate warming and more rapid administration.

20. Blood Product Administration Blood and blood products may be administered via infusion pump or with in-line 60 ml syringe, however the blood product must be administered through a blood filter, which may be in the form of standard blood tubing or a pediatric blood filter extension set. If rapid transfusion not indicated for volume resuscitation, initial flow rate should 2-5 ml/min for the first fifteen minutes (if transfusing whole blood or PRBCs) Massive Transfusion – if massive transfusion protocol initiated prior to arrival and a large amount of blood products are being issued for transport, continue to follow the referring center’s massive transfusion protocol to the extent possible. Infuse PRBCs and FFP at the ratio prescribed by the referring physician or OLMD. Citrate is used in banked blood and promotes hypocalcemia. Measure ionized calcium, if possible, and treat per Hypocalcemia CPG.

21. Blood Product Administration • Monitor the patient closely during transfusion. Vital signs, including a temperature should be documented at initiation of transfusion and documented every 15 minutes after initiating blood products. • At conclusion of transfusion, flush tubing with NS until clear. • Observe for signs of untoward response to transfusion. If a transfusion reaction occurs, stop transfusion, save involved blood products, and complete documentation. Notify blood bank providing blood product involved as well as destination facility. • Allergic reaction or anaphylaxis – may occur after only a few ml’s of plasma containing component are administered. Manage per Allergic Reaction/Anaphylaxis protocol. • Hemolytic reaction - clinical manifestation can vary dramatically but may include fever, headache, chest or back pain, hypotension, nausea, pain and infusion site, and coagulopathy. Most common cause is ABO incompatibility. This is potentially life threatening – stop transfusion immediately and administer a crystalloid bolus. • Febrile non-hemolytic reaction – chills and fever without the symptoms described under hemolytic reaction.