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Recommendations for Judicious Use of Blood Products Forum for Transfusion Medicine: O. Ben-Tal, N. Rachimi-Levene, E. Shinar, J. Orlin,V. Yahalom, D. Attias and N. Manny. Outline of Presentation. Guidelines-Why?! Recommendations for product usage. Implementation-Suggetions.

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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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