Transfusion

Last updated: July 21, 2022

Summarytoggle arrow icon

Transfusion of whole blood or fractionated blood components is a widely used method for managing numerous conditions. Packed red blood cells (pRBCs), the most commonly transfused products, are primarily used for the treatment of acute and chronic blood loss. RBC transfusion elevates hemoglobin (Hb) levels and helps maintain organ perfusion and tissue oxygenation. The decision to transfuse RBCs is based on the patient's Hb level, hemodynamic status, and comorbidities (e.g., cardiovascular disease). Fresh frozen plasma (FFP), cryoprecipitate, platelet, and clotting factor transfusions are also available. Pretransfusion testing must be performed, unless in an emergency situation, to minimize the risk of transfusing incompatible RBCs and subsequent transfusion reactions. Testing involves blood typing (ABO and Rhesus) of the recipient's blood, RBC antibody screening of the recipient's serum or plasma, and compatibility testing (crossmatching recipient serum or plasma and donor RBCs).

See also “Transfusion reactions.”

There are more than 250 antigens on the RBC surface, which are classified into several antigen-antibody systems or blood groups. Blood type is most commonly communicated as a combination of ABO blood type and Rhesus blood type (e.g., O- for blood type O Rh-negative blood products and AB+ for blood type AB Rh-positive blood products). [1]

ABO blood type system [1]

ABO blood types [2]
Type Blood type O Blood type A Blood type B Blood type AB
Prevalence ∼ 45% ∼ 40% ∼ 10% ∼ 5%
Antigens on RBCs No antigens A antigen B antigen A and B antigens
Antibodies in plasma Anti-A and anti-B antibodies Anti-B antibodies Anti-A antibodies No antibodies
Can receive RBCs from O A, O B, O AB, A, B, O (universal RBC recipients)
Can donate RBCs to O, A, B, AB (universal RBC donors) A, AB B, AB AB
Can receive FFP from O, A, B, AB (universal FFP recipients) A, AB B, AB AB
Can donate FFP to O A, O B, O AB, A, B, O (universal FFP donors)

Individuals with blood type O can only receive RBCs from other blood type O donors. RBCs from donors of any other type (e.g., A, B, or AB) can cause acute hemolytic transfusion reactions.

Rhesus blood type system [1]

Rh blood types [2]
Type Rh-negative Rh-positive
Prevalence 1–15% [2] 85–99% [2]
Rh(D) antigen on RBCs Absent Present
Antibodies in plasma Anti-Rh antibodies can form after sensitization No anti-Rh antibodies
Can receive RBCs from

Rh negative (preferably)

Rh positive, Rh negative
Can donate RBCs to Rh negative, Rh positive Rh positive

In Rh-negative women of childbearing age, exposure to Rh-positive RBCs (e.g., by transfusion or fetomaternal hemorrhage) can trigger maternal Rh alloimmunization, which can cause HDFN in subsequent pregnancies. Rh-negative donor blood is therefore preferred in these patients, however, Rh-positive blood is acceptable if an emergency transfusion is required.

FFP transfusions do not need to be Rh-compatible as the risk of transfusion reactions and/or subsequent alloimmunization is low. [3]

Extended RBC antigen systems [4]

Several other antigen groups can trigger antibody formation in antigen-negative individuals after exposure to antigen-positive RBCs. Only some cause clinically significant hemolytic anemias and/or transfusion reactions.

Blood bank measures

  • Blood products for transfusion can be allogeneic (i.e., from a donor) or autologous.
  • Systemic measures are taken by blood banks and blood donation services prior to release for transfusion to reduce risks associated with individual donor units.
    • Allogeneic donor blood is tested to determine blood type, screened for common infectious diseases, and then leukoreduced.
    • Some blood donations undergo additional processing to further reduce the risk of complications in high-risk groups.
    • Blood for autologous transfusion typically undergoes minimal processing intraoperatively prior to retransfusion. [8]
  • All prospective blood donors in the United States undergo screening via a donor history questionnaire (DHQ), e.g., to identify infectious risk (see “Blood donation infection screening”) and high-risk medications (e.g., antiplatelet agents) and/or noninfectious conditions (e.g., cancer). [9][10][11]

Infection control

Additional processing

Blood products for patients with certain preexisting conditions may require further processing to reduce the risk of complications.

Pretransfusion safety practices [17][21]

  • Consider transfusion therapy when benefits outweigh the risks and alternatives to blood transfusion have been excluded.
  • Choose condition-specific transfusion thresholds and indications tailored to individual patient needs, for example:
    • Preexisting conditions (e.g., heart disease, hematological malignancy)
    • Specific clinical circumstances (e.g., trauma, critical illness)
    • Functional status and desired level of care
  • Whenever possible:
  • Ensure that the right blood product is being transfused to the right patient at the right time.
  • Do not delay life-saving transfusions.
  • Only defer life-saving blood transfusions if a clear and valid advance directive prohibits their use or an individual with decision-making capacity declines transfusion after an informed discussion.

Emergency-issued blood products (e.g., uncrossmatched RBCs) can be given under implied consent and without pretransfusion testing in life-threatening situations.

Patients who do not wish to accept blood transfusions (e.g., Jehovah's witnesses) are advised to carry an advance directive card. However, in life-threatening situations, if the patient cannot be consulted and clear advance directives are not available, blood products should be given.

Pretransfusion checklist

Ensure the following whenever possible:

Requests and prescriptions

Ensure the following are appropriately labeled, documented, and communicated:

  • Two independent patient identifiers (e.g., full name and unique medical record number)
  • Reasons for transfusion
  • Type and number of units of the blood product to be transfused
  • Rate or duration of transfusion
  • Special requirements (e.g., washed or irritated products)
  • Name and contact details of the requesting clinician

Safety check prior to administration [17]

  • Confirm the patient's identity.
  • Check if the correct blood products have been issued.
  • Ensure blood product containers are undamaged and contents appear normal.

Compare patient and blood product identifiers immediately prior to transfusion. Do not transfuse if there is any discrepancy!

Transfusion administration [17]

See “Fractionated blood components” for component-specific administration instructions.

  • Equipment
    • Give blood component transfusions through a standard blood infusion set.
    • Use blood-warming devices in patients with cold agglutinins or those requiring multiple transfusions.
  • Rate of administration
    • When possible, transfuse at a slower rate for the first 15 minutes.
    • Complete all transfusions within 4 hours of removing the blood product from temperature-controlled storage. [23]
  • Cautions

Diuretics are often used in clinical practice to help maintain a normal volume status in patients requiring multiple transfusions but have not been shown to reduce the risk of transfusion-associated circulatory overload. [24]

Monitoring [17][22]

  • Check clinical status and vital signs for every unit transfused:
    • Before initiation
    • 15 minutes after starting the transfusion
    • Within 60 minutes of completion
    • If any symptoms or signs of a possible transfusion reaction (e.g., dyspnea, chills, pruritus) develop
  • Monitor for signs of fluid overload, especially in patients requiring multiple transfusions.
  • Observe inpatients for 24 hours after transfusion.

Follow the initial management of acute transfusion reactions for any patient who has a change in vital signs or becomes acutely unwell during or in the hours following a transfusion.

Transfuse blood products with complete pretransfusion testing whenever possible. If life-saving transfusion is required before pretransfusion testing is complete, use emergency-issued blood products until fully tested blood products are available.

Overview of pretransfusion testing [25][26][28]
Objectives Method Results
1. Type and screen [25][28] Blood typing
  • Forward typing: Recipient RBCs are mixed with commercially available anti-A, anti-B, and anti-Rh(D) antibodies to identify A, B, and Rh(D) antigens.
  • Reverse typing: Recipient plasma is mixed with commercially available type A and type B RBCs to identify anti-A and/or anti-B antibodies.
  • Type is determined by the presence or absence of hemagglutination between recipient RBCs and test antibodies OR recipient plasma and test RBCs.
  • Considered valid for up to 3 days in inpatient settings [26]
RBC antibody screen
2. Crossmatching [25][28] Electronic crossmatch
  • Match donor units to the recipient
  • Donor units are selected by a specialized computer system without mixing donor and recipient samples (turnaround time: ∼ 5 minutes).
Serologic crossmatch
  • Match donor units to the recipient
  • Confirm donor-recipient compatibility
  • Detects reactions missed by type and screen

Recommendations in this article are consistent with the American Association of Blood Banks (AABB) guidelines for transfusing red blood cells (2016), platelets (2015), and plasma (2010). [29][30][31]

Whole blood [32]

Whole blood is rarely used, as most patients require just one blood component, e.g., pRBCs to treat anemia.

Fractionated blood components

Fractionated blood components are prepared by separating whole blood into its constituent elements and storing each under ideal conditions.

Recommendations in this section are consistent with the 2015 AABB guideline for red cell transfusion. [17][24][30][33]

Content

  • RBCs
  • A preservative, typically citrate-based [34]
  • Unit volume: ∼200–350 mL [22]

Compatibility requirements

See “ABO blood type system” and “Rhesus blood type system.”

Common indications for pRBC transfusion

The decision to transfuse should be made on a case-by-case basis. [17][24][30]

Indications for RBC transfusion are not determined solely by Hb value, but rather by an assessment of the clinical circumstances and the patient's overall condition.

Restrictive transfusion thresholds (i.e., Hb 7–8 g/dL) in hemodynamically stable patients are associated with similar clinical outcomes and less blood use and adverse effects compared to liberal thresholds (9–10 g/dL) [30]

Administration

  • Dose [24]
    • Give the minimum number of units required to relieve symptoms and/or restore Hb to above transfusion thresholds.
    • In the absence of active bleeding, reassess the patient clinically after each unit and check their CBC.
  • Usual rate: 90–120 minutes per unit [33]

Effect

  • Hb and oxygen-carrying capacity of the blood
  • 1 unit of pRBCs increases Hb value by ∼ 1 g/dL.
  • Intravascular volume expansion roughly equivalent to unit volume

Complications

Recommendations in this section are consistent with the 2015 AABB guideline for platelet transfusion. [17][24][29][33]

Content [22][35]

  • Platelets suspended in plasma or platelet additive solution [35]
  • Typically provided as either of the following: [35]
    • Single donor apheresis platelets (SDAP) unit: derived from 1 unit of whole blood from a single donor and contains ∼ 310 X 109 platelets in ∼300 mL
    • Random donor pooled platelets (RDP) pack: derived from 4–6 units of whole blood from various donors and contains ∼ 280 X 109 platelets in ∼200 mL

Compatibility requirements [17][35]

Compatible donor platelets may not be available due to limited supply. The risks of incompatible platelet transfusion are lower than those of incompatible pRBCs. [36]

  • ABO compatibility: preferred but not required for routine transfusions [1][36]
  • Rh(D) matching: Rh(D)-negative platelets are preferred in Rh(D)-negative recipients to prevent alloimmunization. [22]
  • Consider donor plasma compatibility when transfusing multiple units. [37]

Indications for platelet transfusion [24][29][35]

Cautions [24][35]

Platelet transfusion is usually not recommended to treat idiopathic or autoimmune thrombocytopenia in nonbleeding patients, e.g.:

Platelet transfusion in patients with HIT or TTP is associated with higher rates of arterial thrombosis and mortality compared to no transfusion. [42]

Administration

Effect

Complications [24]

Do not use platelet transfusions to treat severe thrombocytopenia due to ITP, TTP, HUS, or HIT unless there is major bleeding.

Fresh frozen plasma [17][24][31][33]

Recommendations in this section are consistent with the 2010 AABB guideline for plasma transfusion. [31]

4-factor PCC is preferred over FFP for the immediate reversal of vitamin K antagonists. [24]

Cryoprecipitate [17][24]

Cryoprecipitate is primarily used to treat bleeding associated with fibrinogen deficiency.

Only consider cryoprecipitate in the management of vWD, hemophilia A, or factor XIII deficiency if single-factor concentrates and recombinant synthetic factors are unavailable. [17]

Clotting factors

Prothrombin complex concentrate (PCC) [45]

Do not use PCC or FFP to reverse vitamin K antagonists unless there is an emergency indication (e.g., life-threatening bleeding, emergency surgery). [24]

Single-factor concentrates [22]

When possible, use recombinant synthetic factors over blood-derived clotting factors, as they are not associated with any risk of infection transmission. [22]

Antithrombin III

Albumin

General principles [1]

Pretransfusion testing takes up to 120 minutes; emergency transfusion can occur prior to pretransfusion testing using uncrossmatched products. [1]

Blood product selection [1][26][35]

Definition

  • The replacement of a large volume of blood in response to massive hemorrhage
  • There is no universal threshold for a massive transfusion; proposed values include: [54][55]
    • Complete replacement of a patient's blood volume (∼ 10 units of RBCs) within 24 hours
    • Replacement of ≥ 50% of a patient's blood volume (∼ 5 units of RBCs) within 3 hours
    • Blood loss replacement at a rate of > 150 mL/minute
    • Transfusion of ≥ 3 units of pRBCs within 1 hour

Risks [56]

Giving patients large volumes of blood products, especially if unbalanced or given rapidly, risks the following massive transfusion-associated complications:

Judicious use of blood products to avoid overtransfusion is the best way to prevent massive transfusion-associated complications!

Massive transfusion protocols (MTP) [58]

  • Goal: mitigate the risks of massive transfusion [59][60]
  • Clinical application: activated for patients with large volume transfusion requirements, e.g., due to trauma, major surgery, obstetric complications, GI bleeding
  • Protocol components
  • Initial approaches: Consider a fixed ratio approach or whole blood approach for patients with ongoing hemorrhage prior to laboratory results.
  • Subsequent approach: Consider targeted transfusion regimen once laboratory results become available and/or hemostatic control is achieved.

The optimal approach to blood component transfusion for massive hemorrhage remains unknown. Follow local hospital protocol under specialist guidance.

Fixed ratio approach [22][59]

Whole blood approach [32]

Targeted transfusion regimen [59][61]

  • Requires frequent laboratory monitoring (e.g., every 1–2 hours)
  • Thresholds and dosing vary by local protocols
  • Consult transfusion services if available.
Suggested thresholds for targeted transfusion in massive hemorrhage [22]
Blood components Indications Dosage
RBCs
  • Falling Hb
  • Ongoing hemorrhage
  • Hemodynamic instability
  • One unit of pRBCs, repeated as needed [62]
FFP
  • FFP 15–20 mL/kg
Platelets
Cryoprecipitate

Massive transfusion protocol checklist [59]

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