Cryoprecipitate is used in cases of hypofibrinogenemia, which most often occurs in the setting of massive hemorrhage or consumptive coagulopathy. Transfusion-related infections are less common than noninfectious complications. All noninfectious complications of transfusion are classified as noninfectious serious hazards of transfusion. Acute complications occur within minutes to 24 hours of the transfusion, whereas delayed complications may develop days, months, or even years later.
Blood transfusion can be a lifesaving procedure, but it has risks, including infectious and noninfectious complications. There is debate in the medical literature concerning the appropriate use of blood and blood products. Clinical trials investigating their use suggest that waiting to transfuse at lower hemoglobin levels is beneficial.
Enlarge Print. The threshold for transfusion of red blood cells should be a hemoglobin level of 7 g per dL 70 g per L in adults and most children. A restrictive transfusion strategy hemoglobin level of 7 to 9 g per dL [70 to 90 g per L] should not be used in preterm infants or children with cyanotic heart disease, severe hypoxemia, active blood loss, or hemodynamic instability.
Transfusion of plasma should be considered in a patient who has an International Normalized Ratio greater than 1. Platelets should not be transfused in patients with thrombotic thrombocytopenic purpura or heparin-induced thrombocytopenia unless a life-threatening hemorrhage has occurred. Packed red blood cells RBCs are prepared from whole blood by removing approximately mL of plasma. One unit of packed RBCs should increase levels of hemoglobin by 1 g per dL 10 g per L and hematocrit by 3 percent.
In most areas, packed RBC units are filtered to reduce leukocytes before storage, which limits febrile nonhemolytic transfusion reactions FNHTRs , and are considered cytomegalovirus safe. RBC transfusions are used to treat hemorrhage and to improve oxygen delivery to tissues. Transfusion of RBCs should be based on the patient's clinical condition.
In , a randomized, multicenter, controlled clinical trial evaluated a restrictive transfusion trigger hemoglobin level of 7 to 9 g per dL [70 to 90 g per L] versus a liberal transfusion trigger hemoglobin level of 10 to 12 g per dL [ to g per L] in patients who were critically ill. The authors recommended transfusion when hemoglobin is less than 7 g per dL, and maintenance of a hemoglobin level between 7 to 9 g per dL.
A similar study was carried out in critically ill children. The liberal transfusion trigger was a hemoglobin level of 9. Patients in the restrictive group received 44 percent fewer blood transfusions, with no difference in rates of multiple organ dysfunction syndrome or death. The restrictive transfusion strategy is useful for children who are stable patients in intensive care. It should not be used in preterm neonates or in children with severe hypoxemia, active blood loss, hemodynamic instability, or cyanotic heart disease.
Plasma products available in the United States include fresh frozen plasma and thawed plasma that may be stored at Plasma contains all of the coagulation factors.
Thawed plasma has lower levels of factors V and VIII and is not indicated in patients with consumption coagulopathy diffuse intravascular coagulation. Plasma transfusion is recommended in patients with active bleeding and an International Normalized Ratio INR greater than 1. Supportive care can decrease high-normal to slightly elevated INRs 1. Table 1 gives indications for plasma transfusion.
Inherited deficiency of single clotting factors with no virus-safe or recombinant factor available—anticoagulant factors II, V, X, or XI. When C1 esterase inhibitor is unavailable 9. Information from references 7 through 9. Platelet transfusion may be indicated to prevent hemorrhage in patients with thrombocytopenia or platelet function defects.
Contraindications to platelet transfusion include thrombotic thrombocytopenic purpura and heparin-induced thrombocytopenia. Transfusion of platelets in these conditions can result in further thrombosis. Patients in the lower trigger group received Gastrointestinal bleeding was more common in the lower trigger group; however, there was no difference in blood transfusions between groups. Tables 2 9 and 3 9 — 12 give indications for platelet transfusion in adults and neonates, respectively.
Information from reference 9. Consider transfusion; transfuse for clinical reasons e. Transfuse if any of the following indications exist:. Intraventricular or intraparenchymal cerebral hemorrhage. Coagulation disorder. Sepsis or fluctuating arterial venous pressures. Invasive procedure. If the mother's platelets are used, unit must be washed, irradiated, and resuspended in plasma that is ABO compatible with the neonate.
Information from references 9 through Cryoprecipitate is prepared by thawing fresh frozen plasma and collecting the precipitate. Cryoprecipitate contains high concentrations of factor VIII and fibrinogen. Indications for cryoprecipitate transfusion are listed in Table 4. Congenital dysfibrinogenemia Information from references 12 and Transfusion-related complications can be categorized as acute or delayed, which can be divided further into the categories of noninfectious Table 5 16 and infectious Table 6 16 , Therefore, patients are far more likely to experience a noninfectious serious hazard of transfusion than an infectious complication.
Mistransfusion transfusion of the incorrect product to the incorrect recipient. Noninfectious serious hazards of transfusion. Anesth Analg.
I nformation from references 16 and Hemolytic transfusion reactions are caused by immune destruction of transfused RBCs, which are attacked by the recipient's antibodies. The antibodies to the antigens of the ABO blood group or alloantibodies to other RBC antigens are produced after immunization through a previous transfusion or pregnancy. There are two categories of hemolytic transfusion reactions: acute and delayed. Nonimmune causes of acute reactions include bacterial overgrowth, improper storing, infusion with incompatible medications, and infusion of blood through lines containing hypotonic solutions or small-bore intravenous tubes.
In acute hemolytic transfusion reactions, there is a destruction of the donor's RBCs within 24 hours of transfusion. Hemolysis may be intravascular or extravascular. The most common type is extravascular hemolysis, which occurs when donor RBCs coated with immunoglobulin G IgG or complement are attacked in the liver or spleen. Symptoms of acute hemolytic transfusion reactions include fever, chills, rigors, nausea, vomiting, dyspnea, hypotension, diffuse bleeding, hemoglobinuria, oliguria, anuria, pain at the infusion site; and chest, back, and abdominal pain.
The incidence of acute hemolytic reactions is approximately one to five per 50, transfusions. Allergic reactions range from mild urticarial to life threatening anaphylactic.
Urticarial allergic reactions are defined by hives or pruritus. These antigens are soluble, and the associated reaction is dose-dependent. Allergic transfusion reactions occur in 1 to 3 percent of transfusions. Patients with anaphylactic transfusion reactions, like those with urticarial reactions, may present with hives, but they are distinct in that they also develop hypotension, bronchospasm, stridor, and gastrointestinal symptoms.
For example, anaphylaxis occurs because of donor IgA being infused into a recipient who is IgA deficient and has preexisting circulating anti-IgA. Prevention of anaphylactic transfusion reactions includes avoiding plasma transfusions with IgA in patients known to be IgA deficient. After the expiration date, rare or valuable packed RBC units can be "rejuvenated" with a biochemical solution that restores much of the original biochemical environment of the RBCs.
The "rejuvenated" units are "washed" with isotonic saline in an automated device and then can be transfused as a saline-red blood cell suspension within 2 to 4 hours, or these units can be stored, glycerolized and frozen for up to 10 years. The thawed units are washed of the glycerol, and by doing so are depleted of plasma and leukocytes. Cryopreserved blood can help to maintain stores of Rh negative blood, to provide units for persons with antibodies to high-incidence antigens or persons difficult to cross-match because of multiple alloantibodies and to provide plasma-free blood to persons with IgA deficiency.
Each unit is to mL in volume. FFP contains about mg of fibrinogen per unit. Once thawed, FFP should be used immediately. Platelets are stored with agitation at 22 degrees C for up to 5 days. Since platelets are stored at room temperature, there is risk for bacterial contamination with bacterial growth that increases with storage time. Blood transfusion is used to try to solve life- and health-threatening conditions on a short-term basis. Packed red blood cells are most often used for blood transfusion.
Sometimes blood is transfused after prolonged storage of these cells but there is continuing debate as to whether transfusion of 'older' blood is as beneficial as transfusion of 'fresher' blood.
The results of the studies for the outcome death from any cause were uncertain due to the small number of participants who contributed information. We could not exclude an effect on death with either longer or shorter storage.
None of the trials considered the other outcomes of interest in this review, namely transfusion-related acute lung injury, postoperative infections, and adverse events. The safety profiles of the two approaches are unknown. The level of confidence in the results of this review is very low. The studies have limitations in the way they were designed and executed.
Moreover, the limited number of people included in the studies led to imprecise results. We are aware of four large ongoing trials in this area which will help us to better understand the effects of storage on red blood cells in relation to outcomes for patients. These results are based on three small single centre trials with high risks of bias.
There is insufficient evidence to determine the effects of fresh or older packed red blood cells for blood transfusion. Therefore, we urge readers to interpret the trial results with caution.
The results from four large ongoing trials will help to inform future updates of this review.
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