Clinical Practice Guidelines _ Blood Product Prescription

23/05/2016

Clinical Practice Guidelines : Blood Product Prescription

Blood Product Prescription Indications Indications for transf usions: usions: Red Blood Cells Platelets Fresh Frozen Plasma Cryoprecipitate Pre-transfusion assessment Table: Transfusion Volumes and Rates Management of transfusion Complications After transfusion When patients or families refuse a blood product transfusion transfusion RCH Policy Other resources Please read in conjunction with:

Massive transfusion and critical bleeding procedure

Blood transfusion procedure

Background Background Blood and blood product transfusions may be required for acute blood loss, or for failure of production such as bone marrow suppression. marrow suppression. Blood pr oduct oduct therapy should should only be given when the expected benefits to the patient are likely to outweigh the outweigh the potential potential hazards. All blood transfusion activity activity within the RCH must occur in compliance with the relevant policies (needs link) and hospital clinical guidelines (link needed).

Indications for Transfusion Red blood cells Platelets Fresh Frozen Plasma Cryoprecipitate

Indications for Red Blood Cells Hb <70g/L; although <70g/L; although lower thresholds may be acceptable in patients without symptoms and where specific therapy (eg iron) is available.

Transfusion may be indicated at higher thresholds for specific situations: Hb <70-100g/L during <70-100g/L during surgery associated with major blood loss or if evidence of impaired oxygen

http://www.rch.org.au/clinicalguide/guideline_index/Blood_Product_Prescription/

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transport Hb <80g/L; patients on a chronic transfusion regimen or during marrow suppressive therapy (for symptom control and appropriate growth) Hb <100g/L; only for very select populations (eg. neonates)

Indications for Platelets Table 1: Indications for Platelet transfusion ClinicalSituation

Indication for Platelet Transfusion

Bone marrow failure

Plt <10x109/L if no other risk factors for bleeding (see below) Plt <20x109/L if risk factors present (fever, antibiotics, haemostatic failure, risk of intracranial haemorrhage)

Surgery/invasive procedure

Plt <50x109/L. However, higher counts may be needed in surgery with high risk of bleeding eg. neurosurgery

Platelet function Defects

Transfuse if there is bleeding or high risk of bleeding, regardless of actual platelet count

Bleeding/Massive transfusion

Maintain Plt >50x109/L if thrombocytopaenia likely contributing to bleeding Maintain Plt >100x109/L in the presence of diffuse microvascular bleeding (DIC) or CNS trauma

Indications for Fresh Frozen Plasma FFP is appropriate for the following: Warfarin effect, in the presence of life-threatening bleeding in addition to the use of vitamin K and vitamin-k dependent clotting factor concentrates for bleeding with abnormal coagulation Liver disease, if bleeding with abnormal coagulation. Acute DIC when there is bleeding and abnormal coagulation Following massive transfusionor cardiac bypass for bleeding in the presence of abnormal coagulation

Indications for Cryoprecipitate Cryoprecipitate is indicated for: Fibrinogen deficiency, in the setting of clinical bleeding, an invasive procedure, trauma or DIC.

Pre-transfusion Assessment 1. The indication to transfuse (see above) 2. Document reason for transfusion and discussion of consent 3. Collect pre-transfusion sample (except in infants on ASBT protocol). A sample for cross-matching must be collected in a 1.4ml red EDTA tube (NOT bullet tubes). Patients known to have red cell antibodies or haemolytic anaemia will require a larger sample. Correctly identify the patient during the collection of the pre-transfusion sample. Label in accordance with RCH specimen collection policy. 4. Request the appropriate blood component and special requirements: Irradiated blood products should be given to:


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All immuno-compromised patients, including all oncology patients, cardiac neonates and all patients in ICU, to prevent graft-versus host disease. CMV negative products: Leucocyte depleted blood products, are considered an acceptable alternative to CMV seronegative products at RCH 5. Calculate & prescribe the transfusion volume with consideration to pack sizes Unstable patient - See Massive transfusion and critical bleeding procedure Stable patient (see Table 2 below) 6. Prescribe the blood product and rate of administration on the fluid order chart (see Table 2 below) All transfusions must be completed within 4 hours of spiking a pack.

Table 2: Transfusion volumes and rates Blood product

Formula for calculating transfusion volume

Red Blood Cells

Packed cells (mls) = wt (kg) x Hb rise required(g/L) x 0.4

Pack sizes

250-300ml/pack; 50 -60 ml/Pedipack

Rate

Transfusion will be started at a slower rate (eg. Half the rate) for the first 15minutes. If no adverse effects occur, increase the transfusion to a 2-4hourly rate depending on the patient's condition and fluid balance

(eg.10kg child requiring Hb to rise from 60 to 110g/L: 10 x 50 x 0.4=200ml)

Platelets

5 - 20 ml/kg (5 - 10 ml/kg will raise platelet count by 50 100x 109 /L)

Neonatal/ paediatric <40kg patients: Paediatric (single donor) -40 - 60 ml Apheresis (single donor) split into 4 - 8 x 40 - 60 ml packs


3ml/kg/hr over 2-3 hours. (occasionally platelets are given over 30 minutes, but this may contribute to an increased risk of some reactions (fever/chills) and fluid overload)

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Paediatric > 40kg or adult: Apheresis (single donor) >200ml or split into 2 x > 100ml packs Pooled from 4-5 donors >160ml

FFP

10 - 20 ml/Kg

300ml/pack

Start at no more than 5ml/min.

50ml/pack (for neonatal use)

Cryoprecipitate

5-10 ml/kg

30-40 ml/pack

Start at no more than 5ml/min.

Management of Transfusion Administer as per Blood transfusion procedure The key steps include: 1. A formal checking process prior to commencement of transfusion 2. The use of correct equipment (filters, pump, consideration of blood warmer) 3. Correct transfusion documentation including patient observations, start and finish times

Complications during transfusion: The most common immediate adverse reactions to transfusion are fever, chills and urticaria. The most potentially significant reactions include acute haemolytic transfusion reactions, bacterial contamination of blood products and transfusion related acute lung injury. During the early stages of a reaction it may be difficult to ascertain the cause. All suspected transfusion reactions must be reported to the issuing blood bank immediately. The oncall haematologist will contact the clinical area to provide advice regarding investigation and ongoing transfusion support.

After transfusion: Document the effect of transfusion on the patient's condition including Hb if repeated.

Other resources RCH Blood transfusion website


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Clinical Practice Guidelines _ Blood Product Prescription

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