Administration of RBCs or whole blood should begin within 30 minutes of issue from the blood bank or 30 minutes from the time it's removed from a blood refrigerator. Once spiked and hung, RBCs should be administered within 2 hours in most patients. Under no circumstances should blood be allowed to hang for more than 4 hours. RBCs can be administered faster if necessary, in as little as minutes for the whole unit in massive bleeding.
Platelets and granulocytes should generally be administered as quickly as the patient can tolerate them. A platelet pool can be given in 20 minutes or so in most patients.
See appendix 5 in paper supplement for component expiration times. RBCs or whole blood left at room temperature for over 30 minutes must be discarded. Alternatively, RBCs whose temperature exceeds 10oC must be discarded. Platelets that have been stored in the refrigerator must be discarded. Platelets that have been pooled and more than 4 hours have elapsed must be discarded. Plasma that has been thawed and stored at 1-6C for more than 24 hours must be discarded. Cryoprecipitate that has been pooled must be discarded if not used within 4 hours.
All blood components must be administered at the bedside through a clot filter (170 µm filter). This filter is present in the standard blood administration set. Blood must be filtered at the bedside even if leukofiltration was performed earlier in the lab. Plasma and cryoprecipitate must also be filtered. Aliquots ofRBCs issued in syringes or bags must also be filtered. A tiny filter that attaches to the tip of the syringe is available from the blood bank for transfusion of neonates.
Microaggregate filters. Microaggregate filters are designed with smaller pore size (20 µm) to retain "micro"-aggregates -- clumps of dead cells and fibrin strands. Significant controversy exists as to the usefulness of these filters. Currently at PMH they are not used except for specific clinical situations; for example, the re-infusion of shed drainage blood where the risk of contamination with such material is high. Microaggregate filters are not currently recommended for routine blood administration, even in high volume, rapid infusion circumstances.
Normal saline is the only intravenous solution universally approved to be administered with RBCs. It can be run simultaneously with the blood via a "Y" set or can actually be injected via sterile technique into the blood bag to dilute concentrated RBCs. NEVER INJECT MEDICATIONS INTO THE BLOOD BAG! They may be non-isotonic and cause hemolysis, or if a transfusion reaction occurs and the blood infusion is stopped, an uncertain dose of the drug will be delivered.
Any solution containing dextrose (e.g. D5W) should not be run with blood because of the risk of hemolysis (the sugar pulls the water out of the RBCs). Even if a sugar solution ran through an IV line prior to the infusion of blood hemolysis can occur, so the line must be rinsed very thoroughly with saline. Any solution containing calcium must not be run with blood because of the risk of clots (it counteracts the citrate anticoagulant). Examples are lactated Ringer's and some formulations of Plasmalyte.
Isotonic formulations of Plasmalyte that do not contain calcium are probably OK to run with blood. However, there are several types of Plasmalyte available in PMH and the hospital staff often don't pay much attention to which one they are using, so be careful. Isotonic (5%) albumin and PPF are probably OK to run with blood also.
What type of premedication to give and when to give it is generally left up to the individual clinician. If they ask for advice, I suggest:
There really is no right or wrong advice. Giving an anti-pyretic will probably not mask the fever of a serious transfusion reaction (hemolysis or sepsis), only the mild fever of a nonhemolytic febrile reaction. Remember that patients can be really uncomfortable during transfusion if they're having symptoms.
The state of Texas requires special informed consent for blood transfusion. PMH, Zale, and CMC have special forms for this -- a separate form for transfusion unrelated to surgery. If transfusion may occur in conjunction with a surgical procedure, a special section of the surgery consent form is used. The state mandates that transfusion consent be documented and that a discussion of specific risks occur: fever, transfusion reaction which may result in kidney failure or anemia, heart failure, AIDS, hepatitis, and other infections.
Informed consent requirements vary between PMH, CMC and ZLUH. In general, informed consent need be obtained only one time during the hospitalization. For outpatient transfusions, only one consent is needed at CMC (for a course of therapy), while PMH and ZLUH require a consent for each transfusion. If in doubt, obtain a consent for the use of any blood component or derivative transfusion. Pathology residents may be asked to obtain a consent from patients undergoing apheresis procedures. See appendix 9 in the call manual paper supplement for a list of possible adverse effects of apheresis.
Informed consent should be obtained by a physician from the patient if they are a competent adult. Adults who are unable to consent may have consent given by their next of kin or an individual with legal right to control their health care decisions. Minors (< 18 years) must have consent from their parent or legal guardian. In an emergency, two doctors may sign the consent if there is not time to wait for next of kin.
Available in the patient care areas; not kept in blood bank. Advised for transfusion in patients with cold agglutinins (although not generally considered mandatory) and patients getting large-volume, rapid transfusions. They also may be used in conjunction with apheresis procedures. Maintenance is performed by hospital, not lab.
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