Journal Presentation

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Dr. Jerin Sultana Mukty

Resident (Phase A)

Department of Haematology

BSMMU

Blood Transfusion Guidelines From the AABB & ASH:RBC,Platelet & Plasma Transfusion

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Jeffrey L. Carson, MD; Gordon Guyatt, MD; Nancy M. Heddle, MSc; Brenda J. Grossman, MD, MPH; Claudia S. Cohn, MD, PhD; Mark K. Fung, MD, PhD; Terry Gernsheimer, MD; John B. Holcomb, MD; Lewis J. Kaplan, MD; Louis M. Katz, MD; Nikki Peterson, BA; Glenn Ramsey, MD; Sunil V. Rao, MD; John D. Roback, MD, PhD; Aryeh Shander, MD; Aaron A. R. Tobian, MD, PhD����

1st Published on October 12,2016�Volume 316, Number 19, page: 2025 - 2035

Blood transfusion guidelines :

• Transfusion of blood and blood component is one of the most common medical procedure performed in the world.��.Transfusion based on well-designed & appropriately powered RCTs is the 1'st step in optimizing transfusion practices. ��.Systematic reviews provide the 2'nd step by building the knowledge base necessary to assess the impact of transfusion practice on pt outcomes.

Contd :

• Third step is the development of clinical practice guidelines which occur when systematic reviews interpreted by individual with expertise in transfusion medicine.��Objectives :��-To minimize risks of transfusion through more sophisticated donor testing,pretransfusion testing,recipient identification & multiple improvement in blood component characteristics & quality.

• This guidelines support optimization of patient outcomes & appropriate utilization of limited & costly resources & allow for transfusion medicine physician to become a part of treatment team.

RBC Transfusion Guidelines :

• Red blood cell transfusion practices should be designed to optimize clinical outcomes & to avoid transfusion that are not clinically indicated.��.Despite the risk of transfusion-transmitted infections & noninfectious adverse event RBC transfusion is relatively safe.��.Approximately 85 million units of RBC transfuse worldwide annually.

• Liberal RBC transfusion strategies are not necessarily associated with superior outcomes & may expose pts to unnecessary risks.

Objectives:

• The AABB guidelines recommends target Hb level for RBC transfusion among hospitalized adult patients who are hemodynamically stable & the length of time RBCs should be stored prior to transfusion.��.RBC transfusion should be based on clinical assessment of the patient in addition to laboratory testing.

Normal RBC values:

• Adult Male: 4.7-6.1 million / mm³�Adult Female: 4.0-5.0 million / mm³���Function of RBC:�
• Gas exchange Between lungs,blood & tissue(oxygen,carbondioxide).
• Determining blood type

Major Goals of RBC Transfusion Therapy:

• Use of donor erythrocyte with an optimal recovery & half-life in the recipient.

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• Achievement of appropriate Hb level�
• Avoidance of adverse reaction including transmission of infectious agent

Pretransfusion testing:

• Pretransfusion testing is mandatory for any transfusion procedures. ��.It prevents incompatible red cell transfusion �-compatibility of donor red cells & recipient plasma.�-Avoid immune hemolytic transfusion reactions in the recipient.

Indication of RBC transfusion :

• Treatment of symptomatic anaemia � �-Prophylaxis in life-threatening anaemia��-Restoration of oxygen-carrying capacity in case of haemorrage��-RBCs are also indicated for exchange transfusion : Sickle cell disease� . Severe parasitic infection (malaria, babesiosis) �

• Severe methemoglobinemia�.severe hyperbilirubinemia of newborn���Dosage:� . 1unit of RBC will raise the Hb of an average size adult by-1g/dl(or raise HCT-3%)��Administration :Transfuse slowly for first 15min.� . Complete transfusion within 4hrs

Contraindication of RBC transfusion :

• ��.RBC transfusion is not routinely indicated for pharmacologically treated anaemia such as��-Iron deficiency anaemia��-VitB12 deficiency or folate deficiency anaemia��.chronic steady state asymptotic anaemia� �.uncomplicated pregnancy� �.minor surgery that doesn’t require general anesthesia. �

Storage duration of RBCs:

• RBCs can be stored in refrigerator at 6°c for upto 42 days.

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• Average duration of RBC storage in the United states is 17.9 days it differs among hospitals & patient populations.�
• Among 13 trials, 2 primary trials involving neonates the mean storage duration of RBC were 1.6 days & 5.1 days for fresher RBCs compared with 9 days & 14.1 days for standard issue RBCs.

Contd:

• The storage duration of transfused RBCs in the trials of adults ranged from a median of 4 days for fresher RBCs compared with a median of 19 days for standard issue RBCs.

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• No evidence suggest that fresher RBCs transfusion is superior to standard issue RBCs for the outcome of mortality with similar estimates in both adults & infants. �

Contd:

• The absolute difference in 30-day mortality was 4 more Deaths per 1000 with fresher blood (95% Cl, 5 fewer death to 14 more deaths per 1000)

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• There was no evidence that patient had more adverse effects by receiving standard issue RBCs.

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Contd:

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• For nosocomial infection, there was higher risk among patient receiving fresher RBCs with an absolute difference of 43 more nosocomial infection per 1000 patients transfused (95%Cl, 1 more nosocomial infection to 86 more nosocomial infections per 1000). however the quality of evidence was low.

Hb Thresholds for RBC Transfusion in RCTs:

Method:�

• Reference librarians conducted a literature search for RCTs evaluating Hb threshold for RBC transfusion & storage duration.�
• For RBC transfusion threshold, 31 RCTs included 12587 participants & compared restrictive threshold (transfusion not indicated untill the Hb level is 7-8gm/dl) with liberal threshold (transfusion not indicated untill the Hb level is 9-10gm/dl).� �

Result :

• This trials demonstrated that restrictive RBC transfusion thresholds were not associated with higher rates of adverse clinical outcomes, including 30-day mortality, myocardial infarction, cerebrovascular accident, rebleeding, pneumonia or thromboembolism.

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• The RCTs also demonstrated that fresher blood did not improve clinical outcomes.

Guidelines for Platelet transfusion :

• Platelet transfusion can be administered either as a prophylactic to minimize the risk of bleeding or as a therapeutic to control bleeding ��.It decrease the bleeding risk in pts with hypoproliferative thrombocytopenia.��.Initial guidelines recommended transfusion of nonbleeding patients at the level of 20000/microL.

• Several studies of different patients population shows that there is no difference in bleeding risk between a platelet count of 10000/microL & a count of 20000/microL. ��.Observed that 7100/microL/d is necessary for interaction with the endothelium.��.These studies also shows that bleeding in hypoproliferative thrombocytopenia is common & decreases with age.

Contd:

• Patients with a temperature >38°c or with recent haemorrage can receive platelet with platelet count <10000/microL.��.Procedures such as central line placement, lumber puncture & BM biopsy,the threshold is provider & service dependent & falls between 20000 & 50000/microL.��.Platelet concentrates are ordered by using an electronic order entry system.

Selected multicenter RCTs Informing PLT guidelines :

Recommendation for platelet transfusion :

• Platelet should not be transfused in patients with Thrombotic thrombocytopenic purpura or Heparin-induced thrombocytopenia unless a life-threatening haemorrage has occurred. �.This is a consensus & disease oriented evidence rating

Guidelines for Plasma transfusion :

• Plasma are transfused using a weight-based dosing of 10-20mL/kg of recipient weight.��.It must be transfused within 24hrs or be relabeled as "thawed plasma" to allow for refrigerator storagestorage for upto 5days.��.Although degradation of clotting factors v & 8 observed during storage, overall maintenance of clotting factors at sufficient levels for therapeutic use.

• There is lacking of RCTs evidence to guide plasma transfusion.�.Recently plasma is used to normalize elevated INR before a planned surgery or invasive procedure.��.studies demonstrated that plasma transfusion shows no significant improvement in mild prolongation of INR(1.1-1.85)

Contd:

• Patients with hemorrhagic shock or active bleeding leading to hemodynamic instability are transfused with plasma to optimize Laboratory values. Laboratory testing must be performed to assess the response. ��.If plasma is indicated to correct elevated INR,a posttransfusion INR must be obtained before ordering additional plasma.��

Contd:

• Patients with an INR >=2(>1.5 for neurosurgical pts)are appropriate candidates for plasma transfusion. ��.Risks with plasma transfusion include allergic reaction, transfusion related circulatory overload,transfusion related acute lung injury& transfusion transmitted infection.

Recommendation for plasma transfusion :

• Transfusion of plasma should be considered in a patient who has a INR greater than 1.6 with active bleeding or in a patient receiving anticoagulant therapy before invasive procedure.

Indication of Fresh frozen plasma:

Contraindication of Fresh Frozen plasma:

Complications of Blood Transfusion :

• Blood transfusion has infectious & noninfectious complications which further devided into:��-Acute�-Delayed