Blood Products and Transfusion Indications
Red Blood Cells
- Hgb <7 (NEJM 2014;371:1381, NEJM 2013;368:11)
- Hgb <8 if CAD/ACS, ortho/cardiac surgery
- AIHA and MDS (no specific Hgb threshold)
- Sickle cell disease (see Anemia: Sickle Cell Disease)
• response: 1U ↑Hgb~1
• pRBCs will not exert same oncotic effect as hyperoncotic colloid (25% albumin) (Hct ~55% diluted in saline)
- Low platelets or functionally abnormal platelets
- <10,000: PPX spont bleeding. Consider antifibrinolytics in refractory thrombocytopenia in CA
- <50,000: major bleed, intra- or post-op surgical bleed, ppx prior to invasive operative procedures (no data)
- <100,000: post-bypass bleed, ICH/ophthalmic (no data)
- ITP: if life-threatening CNS/GI/GU bleed; fatal hemorrhage is often preceded by wet purpura (mucus membrane bleeding). Otherwise plts not beneficial.
- HIT/TTP: avoid PLTs unless bleeding
- Assess response at 30-
60m: 1U ↑ PLT ~ 30K.
• No evidence that apheresis platelets > whole blood derived platelets.
• No evidence that platelets reverse antiplatelet agents
Fresh Frozen Plasma
- Active bleed d/t deficiency in multi coag. factors or isolated coag factors for which concentrate is not available
- Cirrhosis: consider anti-fibrinolytics instead. Treating INR with FFP will likely ↑ bleeding due to ↑ portal pressures.
- ALF: Consider for ↓Plt or ↑ PT only if bleed or pre-op
- VKA reversal: IV Vitamin K first. PCC if life-threatening.
- Trauma, DIC in presence of bleeding, congenital TTP
• Effect < 6H due to short t1/2 of FVII
• Assess response: 1U ↑ coagulation activity ~10%
- Fibrinogen <100: 50-100mg/dL, give 10U; <50, give 20U
- Advanced liver disease (consider antifibrinolytics instead)
- Massive transfusion w/ ↓ fibrinogen or abnl ROTEM/TEG
- Complex cardiac surgery (JAMA 2017;217:738)
- Postpartum hemorrhage (Br J Anaesth 2015; 114:623)
- FVIII deficiency, VWD, uremia
• Fibrinogen replacement: 0.2 bag/kg → 100 mg/dL fibrinogen w/ t1/2 3-5d
• FVIII or vWF replacement: cryo is last resort therapy
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