What supplies are required when administering packed red blood cells?
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Markus M. Müller, Dr.,*,1 Christof Geisen, Dr.,1 Kai Zacharowski, Prof.,2 Torsten Tonn, Prof.,3 and Erhard Seifried, Prof.1 Show
Markus M. Müller1Institute for Transfusion Medicine and Immunohaematology, Goethe University Hospital, Frankfurt/Main Find articles by Markus M. Müller Christof Geisen1Institute for Transfusion Medicine and Immunohaematology, Goethe University Hospital, Frankfurt/Main Find articles by Christof Geisen Kai Zacharowski2Clinic of Anesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Hospital, Frankfurt/Main Find articles by Kai Zacharowski Torsten Tonn3Institute of Transfusion Medicine, University Hospital Carl Gustav Carus, Dresden Find articles by Torsten Tonn Erhard Seifried1Institute for Transfusion Medicine and Immunohaematology, Goethe University Hospital, Frankfurt/Main Find articles by Erhard Seifried Author information Article notes Copyright and License information Disclaimer 1Institute for Transfusion Medicine and Immunohaematology, Goethe University Hospital, Frankfurt/Main 2Clinic of Anesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Hospital, Frankfurt/Main 3Institute of Transfusion Medicine, University Hospital Carl Gustav Carus, Dresden *Institut für Transfusionsmedizin und Immunhämatologie, DRK-Blutspendedienst Baden-Württemberg – Hessen gemeinnützige GmbH, Sandhofstr., 60528 Frankfurt am Main, Germany, [email protected] Received 2014 Jun 13; Accepted 2015 May 6. Copyright notice AbstractBackgroundAbout four million units of packed red cells are transfused in Germany every year. The safety of blood transfusions is further improved by modern production methods and molecular diagnostic techniques. MethodsThis review is based on selected publications, including the German guidelines and regulations and the German Transfusion Act. ResultsPacked red blood cells are transfused to prevent tissue hypoxia. As the clinical manifestations of anemia are nonspecific, the indication for transfusion is based on surrogate parameters, such as the hemoglobin (Hb) concentration, in addition to clinical criteria. For patients with unimpaired cardiopulmonary and vascular function, transfusion is generally indicated at hemoglobin values of 6 g/dL (3.7 mmol/L) or less. Randomized controlled trials have shown that a restrictive transfusion strategy (trigger: Hb 7–8 g/dL) in certain patient groups is as effective as a more liberal strategy (trigger: Hb about 10 g/dL). The most frequent causes for transfusion errors are lack of informed consent, lack of identity checking and/or AB0 identity testing, and the drawing of blood samples in unlabelled tubes. ConclusionOvertransfusion, undertransfusion, as well as other transfusion errors can be markedly reduced by means of appropriate organizational measures and training. The risk of viral transmission via transfusion of packed red blood cells in Germany has reached an all-time low. The reasons comprise the selection of donors and the screening for pathogens such as hepatitis C virus (HCV) or human immunodeficiency virus (HIV) by molecular and serological methods. Transmission of transfusion-relevant viruses via blood products is nowadays a rare event, found only in isolated cases (1). For example, since the introduction of mandatory HCV-PCR (polymerase chain reaction) in Germany in 1999, there has been one single case of transfusion-related HCV transmission in 16 years. At an annual rate of about 4 million units of packed red cells, over 60 million units were transfused in this period (1). Modern production methods using closed blood bag systems and “inline” leukocyte depletion also contribute towards the safety of modern blood products. All steps of production are subject to quality controls to ensure good manufacturing practice (GMP). The use of blood preparations is closely regulated by:
SafetyThe risk of viral transmission via transfusion of packed red cells in Germany has reached an all-time low. Transmission of transfusion-relevant viruses via blood products is nowadays a rare event. Germany as well as other member states of the European Union have carried EU directives over into their own laws and guidelines, so that these regulations and recommendations are largely similar in EU member states. Nevertheless, in English-speaking countries, for example, the bedside test and certain laboratory tests are not mandatory, but there is a compulsory ID check by means of the patient’s wrist band. Learning goalsAfter studying this article, the reader should:
Indications for the transfusion of packed red cellsThe transfusion of packed red cells is carried out to prevent manifest anemia-related tissue hypoxia. The administration of packed red cells is the “ultima ratio” of anemia treatment, employed to achieve the primary treatment goal in cases where causal treatment of the anemia is either not feasible or inadequate. Indications for transfusionThe transfusion of packed red cells is carried out to prevent manifest anemia-related tissue hypoxia. Preoperative anemia is a risk factor for a poor postoperative outcome in a patient (5). With the exception of emergencies and urgent indications for intervention, anemia should be diagnosed and treated before elective surgery. A retrospective analysis showed a fourfold risk of perioperative mortality for patients with mild anemia (hematocrit between 29% and 36% in women and between 29% and 39% in men) compared with those without anemia (30-day mortality: 3.52% for mild preoperative anemia versus 0.78% for hemoglobin/hematocrit in the normal range) (5). The diagnosis and causal treatment of preoperative anemia are not within the scope of this article. Because of the low specificity of clinical symptoms of anemia, surrogate parameters such as hemoglobin (Hb) concentration or hematocrit are used as transfusion triggers in addition to clinical criteria. Box 1 shows the clinical criteria, while Box 2 describes the so-called physiological transfusion triggers. The procedures described here are based not on the results of randomized studies, but on clinical observation and experience. Box 1Assessment of clinical circumstances before transfusion*
*This information can be used in addition to Hb concentration or hematocrit to decide whether or not to transfuse packed red cells (modified from [4]). Here, as in Box 2, we are talking about clinical experience, not the results of randomized studies Box 2Physiological transfusion triggers that may indicate anemic hypoxia*
*Provided anemia confirmed by clinical chemistry and normovolemia present; p02 = partial pressure of oxygen (adapted from [4]) When determining the indications for administration of packed red cells, it is important to distinguish between acute hemorrhage and chronic anemia, e.g., in myelodysplastic syndrome (MLS). In the case of an acute bleeding event, an important treatment goal is the maintenance or restoration of homeostasis, particularly normovolemia by means of volume replacement. Furthermore, along with the surgical treatment, management of coagulation is crucial to stop bleeding. Together with normothermia, physiological pH and ionized Ca2+ within the physiological range, the erythrocytes—particularly in the arterial circulation—contribute to laminar flow and thus to spatial proximity of thrombocytes and von Willebrand factor to the endothelium or endothelial defects, localizing them towards the vessel wall. In acute hemorrhagic shock and in manifest tissue hypoxia, timely administration of packed red cells is a life-saving measure. The dosage depends on the patient’s clinical status and on current and anticipated blood loss (4). The administration of packed red cells has never been systematically investigated in double-blind controlled studies, e.g., in comparison with crystalloid volume replacement. Transfusion triggersIn a patient with normal cardiopulmonary and vascular performance, an Hb level of 6 g/dL or less (Hb <3.7 mmoL/L or hematocrit <18%) is seen as an “absolute“ indication for transfusion (4). In individual cases, particularly in the presence of chronic adaptation to anemia, the transfusion trigger may be lower (e.g., Hb 5.5 g/dL). Acute bleeding or chronic anemia?When determining the indications for administration of packed red cells, it is important to distinguish between acute hemorrhage and chronic anemia, e.g., in myelodysplastic syndrome (MDS). A patient with a stable Hb concentration of over 10 g/dL (Hb >6.2 mmoL/L or hematocrit >30%) without acute blood loss will generally gain no benefit from further administration of packed red cells. Here too, however, exceptions may be justified in individual patients. In such cases, the (physiological) transfusion trigger must be documented in the medical record (Table 1). Table 1Indication for transfusion of packed red cells depending on Hb concentration, medical history, and clinical findings* Hb (g/dL; mmoL/L)Clinical decisionTransfusion indicated?≤ 6 g/dL or ≤ 3.7 mmoL/LIndependent of whether cardiovascular risk factors or signs of anemic hypoxia are presentYes>6 and ≤ 8 g/dL or >3.7 and ≤ 5 mmoL/LNeither cardiovascular risk factors nor signs of anemic hypoxia presentNo>6 and ≤ 8 g/dL or >3.7 and ≤ 5 mmoL/LEither cardiovascular risk factors or signs of anemic hypoxia presentYes>8 and ≤ 10 g/dL or >5 and ≤ 6.2 mmoL/LSigns of anemic hypoxia presentYes (weak evidence!)>10 g/dL or >6.2 mmoL/LIndependent of whether cardiovascular risk factors or signs of anemic hypoxia are presentNo(except in isolated cases) Open in a separate window *Modified from (4) In an adult patient without an increase in red cell destruction, administration of one unit of packed red cells increases the hematocrit or Hb concentration by about 3% or 1 g/dL respectively (4). The standard transfusion rate is one bag per hour. In patients with cardiac or renal insufficiency, transfusion volumes and rates have to be individually adapted or reduced (4, 15). Clinical studies on restrictive versus liberal transfusion triggersJudging by the prospective randomized studies published to date, a restrictive transfusion strategy with transfusion triggers at 7 to 8 g Hb/dL seems to be non-inferior to a liberal treatment strategy with higher triggers—usually around 10 g/dL (6– 11) in the following patient groups:
In special situations, e.g., in upper gastrointestinal bleeding, a restrictive strategy may even be slightly superior (6-week survival rate 95% versus 91% for a liberal strategy) (10). However, a pilot study came to the conclusion that a liberal transfusion strategy achieves a significantly lower 30-day mortality rate in patients with symptomatic coronary heart disease, with a trend towards fewer cardiac events, compared with a restrictive transfusion regimen (12). The findings of a recent study in post cardiac surgery patients are similar (25). Further prospective randomized studies on restrictive transfusion regimens are required to confirm these early results (13), even though some experts already see a transfusion trigger of 7 g/dL as the new standard for almost all groups of patients (14). Transfusion triggerThis is the Hb concentration at which administration of packed red cells is initiated. Patients with cardiac or renal insufficiencyIn patients with cardiac or renal insufficiency, transfusion volumes and rates have to be individually adapted or reduced. Choice of packed red cells and order detailsPacked red cells are usually transfused in an AB0-identical manner. In rare cases, packed cells that are AB0 non-identical but AB0 compatible can be transfused (Table 2). Table 2Compatible transfusion of packed red cells (PRC)* Patient’s blood groupCompatible PRCAA or 0BB or 0ABAB, A, B, or 000 Open in a separate window *Modified from (4, 15) Other blood group characteristics and blood group–specific serological findings have to be taken into account, in particular the following: the Rhesus (Rh) D factor; in certain groups of patients (e.g., regularly transfused patients, patients with known antierythrocytic antibodies, females of child-bearing age) other antigens of the Rh system (C, c, E, e) and the Kell blood group antigen K as well; the results of a recent antibody screening test; relevant data from emergency ID cards and maternity booklets; and the results of serological tolerance testing (cross-matching). With the exceptions of acute emergencies, particular immunohematological constellations, or acute scarcity of resources, AB0-identical and Rh D–identical packed red cells are transfused (3, 4). Deviations from this rule must be documented. In the event of an acute bleeding crisis in a previously unknown person, packed cells of blood group 0 must be transfused until the patient’s blood group has been established by the laboratory. Even in emergencies, blood samples should be taken and sent for blood group determination and an antibody screening test before the transfusion of packed red cells is initiated. As soon as the results are received, transfusion should be switched to packed cells of the patient’s own AB0 blood group. Choice of packed red cells and order detailsPacked red cells are usually transfused in AB0-identical form. In exceptional cases, packed cells that are AB0 non-identical but AB0 compatible can be transfused. Rh D–negative patients should not receive Rh D–positive packed red cells. In an acute bleeding crisis or in the lack of Rh D–negative packed cells, however, Rh D–negative, non-Rh D–sensitized recipients may well have to be given Rh D–positive transfusions. There must be no evidence of Rh D–specific antibodies (anti-D) in the patient’s medical history (emergency ID card, maternity booklet) or in the antibody screening test. In the event that Rh D–positive packed red cells have to be administered to an Rh D–negative recipient, this must be documented in the patient’s medical record, the patient must be informed, and the discharge letter should include the recommendation for antibody screening within the next 2 to 4 months. If antibodies relevant to transfusion are then demonstrated, the patient must be informed and counseled, and an emergency ID card must be issued. For the rest of his/her life, such antibodies must be considered whenever packed red cells have to be transfused. While such antierythrocytic allo-antibodies are rare in the general population (about or less than 1%), they may be found in up to 10% of regularly transfused patients. With the exception of life-threatening situations in which no Rh D–negative blood can be obtained quickly enough, Rh D–negative girls and women of child-bearing age must not receive Rh D–positive packed red cells because of the risk of immunization and the subsequent danger of hemolytic disease of the newborn (HDN) (4). Furthermore, the danger of immunization to principal components of the Rh system such as C, c, D, E, or e and to antigen K with subsequent risk of HDN should always be avoided in girls and women of this age group. Acute bleeding crisisIn the event of an acute bleeding crisis in a previously unknown patient, packed red cells of blood group 0 must be transfused until the patient’s blood group has been established. Administration of packed red cellsBefore the planned administration of packed red cells—with the exception of emergency transfusion—the treating physician must document the recipient’s transfusion history (Box 3). The patient should receive written and oral information about the possible necessity for blood transfusion as early as possible before standard interventions. Standardized information sheets are suitable for this purpose; they are amended to include details discussed between patient and physician, signed by both parties, and the patient receives a copy. The information given to the patient must always include how a transfusion takes place, the risks, potential complications and adverse effects involved, and potential alternatives to transfusion. If the likelihood of perioperative transfusion is estimated as ≥10%—according to local experience—the patient should be informed of the options for autologous hemotherapy, such as preoperative collection of the patient’s own blood for transfusion. Box 3Transfusion history and inspection of packed red cells (PRC) before transfusion
The written agreement of the patient or his/her legal representative—in children, the parent or legal guardian—must be obtained. Early discussion of transfusion gives the patient enough time to come to a decision. If information cannot be given in advance of transfusion, e.g., in an emergency or if the patient is unconscious, it must be provided at the earliest possible time thereafter. If there is a realistic chance that a planned invasive or operative procedure will involve a transfusion, the patient’s blood group must be known and an antibody screening test carried out (no more than 3 days before the procedure). This “type and screen” strategy is particularly helpful if bleeding complications occur. In this event, the blood group and antibody status are known and the patient’s blood is available in the laboratory. If no transfusion-relevant antibodies are currently present or recorded in the patient’s medical history, unmatched packed red cells of the patient’s AB0 blood group can be used in such a case of emergency. This saves the scarce resources of blood group 0 packed red cells for emergencies in which the recipient’s blood group is initially unknown. Pregnancy and HDNRh D-negative girls and women of child-bearing age should not receive Rh D-positive packed red cells because of the risk of immunization and the subsequent danger of hemolytic disease of the newborn (HDN). A positive antibody screening test is followed by identification of the antibodies present. If any transfusion-relevant antibodies are found or were already known, planned interventions must be preceded by allocation of a quantity of compatible, i.e., antigen-negative packed red cells sufficient not only for the anticipated perioperative requirements but also for potential complications. This necessitates close cooperation between the laboratory staff and the treating physicians. If the planned intervention has a high likelihood of perioperative administration of packed red cells (according to local hospital data), the serological compatibility of the patient’s plasma and the packed cells provided should be tested before the intervention (cross-matching). Ordering packed red cellsThe order for packed red cells should generally be placed in writing or electronically. In Germany, blood products require a prescription. This requirement is fulfilled by the physician signing the request form. Requests for emergency transfusions can be made by telephone or fax. The steps involved in an emergency transfusion must be laid down in the local regulations governing transfusion and should be regularly practiced by all parties involved. The following information should be given on the request form or in the blood bank’s electronic module for ordering blood products:
Antibody Screening Test (AST)If there is a realistic probability that a planned invasive or operative procedure will involve a transfusion, the patient’s blood group must be known and an antibody screening test carried out. Preparation and execution of transfusion, with practical tipsThe collection tubes to be filled with blood samples for blood group testing, antibody screening test, and cross-matching must be labeled in advance. Preprinted patient labels can be used for this purpose. The information on each tube must include at least the patient’s family name, given name, and date of birth. Should identification be impossible, another means of labeling must be agreed, e.g., the use of sets of labels with serial numbers. Collection of blood samples in unlabeled tubes is one of the principal causes of error and must be avoided. Cross-matchingIf the planned procedure has a high likelihood of perioperative administration of packed red cells, the serological compatibility of the patient’s plasma and the packed cells provided should be tested preoperatively. The patient’s identity must be clearly established at the bedside before withdrawal of blood. The person taking the samples must ask the patient for identifying details such as date of birth, address, family name, and given name. These data are then compared with the labels on the collection tubes and the request form. After collection of the required samples the date and time of withdrawal is added to the request form and the form is signed. If the person who collects the samples is not the physician ordering the blood products, the latter must also sign the request form. The physician always bears responsibility for the request and for the withdrawal of blood, whether delegated or not, and thus for the identity of the sample. Before the administration of packed red cells the checks detailed in Box 3 must be carried out. Ordering packed red cellsBlood products have to be prescribed; the physician’s signature is required. Transfusion reactionsThese are classified into:
AB0 identity testingAB0 identity testing (bedside testing), important for patient safety, must be carried out and documented by the physician at the patient’s bedside. Checking the recipient’s AB0 blood group is mandatory. The result must be compared with the AB0 blood group of the packed red cells and the blood group recorded in the accompanying documentation. The results of the patient AB0 bedside and identity check must be entered in the medical record with the date, time, and physician’s initials. Only for autologous blood products do the packed red cells also have to be tested; for allogeneic transfusions the AB0 bedside testing of the recipient suffices. The AB0 bedside test must be performed every single time packed red cells are given—even in emergencies. The bedside test should be repeated whenever one of the four crucial parameters—physician, patient, place, time—changes. Febrile, non-hemolytic transfusion reactionThe symptoms are fever or temperature increase >1 °C, sensation of cold, and shivering during transfusion of PRC or up to 4 h thereafter. Practical hintsThe collection tubes for blood group determination, antibody screening, and possibly for cross-matching must be labeled in advance. Preprinted patient labels can be used for this purpose. Administration of packed red cellsTransfusion of packed red cells should always be carried out using a standard transfusion set with a filter (pore diameter 170–230 μm), never with a system that does not include a transfusion filter. Two or more units of packed cells should be given consecutively, not in parallel, with the exception of massive or emergency transfusions. The transfusion should be given via an exclusive venous port; drugs or other infusates should not be mixed with the packed red cells or administered simultaneously through the same port. In the case of transfusion via a central venous catheter, it must be ensured that no other parenteral solution is administered simultaneously via the same lumen. Identity checkThe patient’s identity must be clearly established at the bedside before withdrawal of blood. The person taking the samples must ask the patient for identifying details such as date of birth, address, family name, and given name. The transfusion is initiated by the physician. He/she is responsible for ensuring that the patient is continuously monitored during the administration of packed red cells and thereafter. During and after transfusion a physician must be immediately available for swift intervention should any adverse events occur. Outpatient recipients must be advised of the risk of delayed adverse events. All patients should be observed for about an hour after transfusion. In the rare event that packed red cells have to be heated to body temperature before transfusion, only certified blood heaters may be used for this purpose. The heated packed cells should then be transfused as soon as possible. Opened bags must be used within 6 h. Following transfusion, the transfusion set has to be closed in sterile fashion and retained, together with the empty bag, for 24 h at a temperature of + 1°C to + 10°C. Documentation of packed red cell transfusionThe following information should be documented in the patient’s medical record:
In parallel with the patient-related documentation, product-related documentation is also required. Nowadays this product-associated batch documentation is often accomplished with the aid of an IT system or in the laboratory. These records are to be preserved for 30 years to enable later reconstruction. AdministrationTransfusion of packed red cells should always be carried out using a standard transfusion set with a filter (pore diameter 170–230 μm), never with a system that does not include a transfusion filter. Special productsIrradiated packed red cellsDespite leukocyte depletion, bags of packed red cells may contain a small number of vital donor lymphocytes that can lead to transfusion-associated graft-versus-host disease (ta-GvHD) in immunocompromised recipients (e.g., patients with Non-Hodgkin lymphoma [NHL]). For this reason the packed cells to be used in such circumstances must be irradiated with at least 30 Gy before transfusion. This information has to be included on the request form sent to the blood bank. Because the irradiation elevates the potassium concentration of the packed red cells, irradiated bags have a reduced shelf life and—especially in children and patients with renal insufficiency—should only be ordered from the blood bank when transfusion is scheduled within the ensuing 24 h. The maximum storage time for irradiated packed red cells depends on the terms of licensing for the individual product and is provided in the manufacturer’s product information accompanying every unit of packed cells (eBox 1). eBox 1Indications for irradiation of packed red cells to prevent ta-GvHD*
(For these five situations it is advisable for the transfusion committee to decide the best procedure and write it into the local regulations governing transfusions.) *Modified from (4); ta-GvHD, transfusion-associated graft-versus-host disease Washed packed red cellsWashed packed red cells are rarely indicated. Early contact with the responsible transfusion specialist is recommended. Cryopreserved packed red cellsCryopreserved packed red cells are required in extremely rare cases in patients with multiple transfusion-relevant antibodies or antibodies to high frequent antigens. Particularly early contact with the responsible transfusion specialist is essential. Contraindications, risks, and adverse eventsProvided transfusion is indicated and the transfusion triggers are observed, there are no contraindications to the administration of packed red cells. Serological tolerance should be assured by means of the investigations described above. In patients scheduled for hematopoietic stem cell transplantation, administration of packed red cells donated by blood relatives or potential stem cell donors must be strictly avoided. Members of some religious faiths follow particular rules regarding blood and transfusion, and in such cases the patient’s wishes must be respected. Heating of packed red cellsIn the rare event that packed red cells have to be heated to body temperature before transfusion, only certified blood heaters may be used for this purpose. Transfusion of cellular blood products, seen as transplantation of the fluid organ blood, represents an immunological challenge for the recipient organism. Whether transfusion-related immunomodulation (TRIM) has a negative influence on the postoperative outcome is currently being investigated. The results of these studies will show whether the connection between TRIM and unfavorable outcome postulated from retrospective observation withstands prospective scrutiny. It must be remembered that preoperative anemia represents an independent correlation factor for elevated perioperative morbidity and mortality. This has been shown for coronary bypass surgery (16), major non-cardiosurgical interventions (5), and colorectal surgery (17). Studies from the past 2 years (18– 20) show that both preoperative anemia before coronary bypass surgery and transfusion seem to contribute to the perioperative risk. A meta-analysis of the prospective trials on restrictive transfusion triggers (18) concluded that restrictive transfusion strategies appear to lead to fewer periprocedural infections than liberal transfusion strategies. Acute transfusion reactions can be distinguished from delayed reactions, and immunological from non- immunological reactions (eTable). The estimated frequencies of occurrence of transfusion-related adverse events together with their pathophysiology, treatment, and prophylaxis are given in Table 3a, ,bb. Table 3aPrevalence, pathophysiology, treatment, and prophylaxis of adverse effects of packed red cells (modified from [4, 15])*1 Adverse effectRisk per unit transfusedPathophysiology and treatmentProphylaxisAllergic Open in a separate window *1All figures for risk are estimates. New-variant Creutzfeldt-Jakob disease (vCJD), transfusion-associated parasitosis, post-transfusional purpura, hypothermia, hyperkalemia, and transfusion-associated graft-versus-host disease are not included in this table due to space restrictions. *2Risk declining in Germany owing to use of leukocyte-depleted blood products (since 2001) PRC, packed red cells eTableClassification of adverse drug reactions to packed red cells (from [21]) PathomechanismTime of onsetAcute (<24 h after transfusion)Delayed (>24 h after transfusion)Immunological
Open in a separate window Irradiated packed red cellsDespite leukocyte depletion, bags of packed red cells may contain a small number of vital donor lymphocytes that can lead to transfusion-associated graft-versus-host disease (ta-GvHD). Apart from documentation in the patient’s medical record as described above, the German Transfusion Act requires reporting of adverse effects (2, 3) (eBox 2) in the following circumstances: eBox 2Reporting of adverse events and side effects as stipulated by the German Transfusion Act and prevailing guidelines (2, 3)
*“Severe“ = fatal or life-threatening; requiring or prolonging inpatient treatment; leading to persistent or severe disability; leading to invalidity, congenital anomalies, or birth defects PRC, packed red cells
Washed packed red cellsWashed packed red cells are rarely indicated. Early contact with the responsible transfusion specialist is recommended. Table 3bPrevalence, pathophysiology, treatment, and prophylaxis of adverse effects of packed red cells (PRC) (modified from [4, 15])*1 Adverse effectRisk per unit transfusedPathophysiology and treatmentProphylaxisTransfusion-associated circulatory overload (TACO)On administration of several blood products in risk groups : 1: 12 or less(Excessively) large transfusions in certain groups of patients (cardiac insufficiency, renal insufficiency, etc.)The amount transfused per unit of time should be individually adjusted in vulnerable patients.Transfusion hemosiderosisHigh individual risk with administration of more than 100 units of PRC (lifetime) or more than 20 units/yearAdministration of more than 20 units of PRC/year should be accompanied by regular determination of ferritin. Open in a separate window *1All figures for risk are estimates. New-variant Creutzfeldt-Jakob disease (vCJD), transfusion-associated parasitosis, post-transfusional purpura, hypothermia, hyperkalemia, and transfusion-associated graft-versus-host disease are not included in this table due to space restrictions. *2Calculated risk (1997–2005) for German Red Cross blood donation service: HBV risk: 1 : 360 000 (95% CI: 1 : 190 000–1 : 3 360 000; [24]) *3Calculated risk (1997–2005) for German Red Cross blood donation service: HIV-1 risk: 1 : 4 300 000 (95% CI: 1 : 2 390 000–1 21 370 000; [24]) *4Calculated risk (1997–2005) for German Red Cross blood donation service: HCV risk: 1 10 880 000 (95% CI: 1 7 510 000–1 19 720 000; [24]) PRC: packed red cells; D: figures for Germany; NAT, nucleic acid testing = detection of viral nucleic acid by molecular biological methods such as polymerase chain reaction (PCR); HBV, hepatitis B virus; HCV, hepatitis C virus; HIV, human immunodeficiency virus; GMP, good manufacturing practice Further information on CMEThis article has been certified by the North Rhine Academy for Postgraduate and Continuing Medical Education. Deutsches Ärzteblatt provides certified continuing medical education (CME) in accordance with the requirements of the Medical Associations of the German federal states (Länder). CME points of the Medical Associations can be acquired only through the Internet, not by mail or fax, by the use of the German version of the CME questionnaire. See the following website: cme.aerzteblatt.de Participants in the CME program can manage their CME points with their 15-digit “uniform CME number” (einheitliche Fortbildungsnummer, EFN). The EFN must be entered in the appropriate field in the cme.aerzteblatt.de website under “meine Daten” (“my data”), or upon registration. The EFN appears on each participant’s CME certificate. This CME unit can be accessed until 11 October 2015, and earlier CME units until the dates indicated: –“Mental Disorders in Early Childhood” (Issue 21/2015) until 16 August 2015. –“Animal and Human Bite Wounds“ (Issue 25/2015) until 13 September 2015. Please answer the following questions to participate in our certified Continuing Medical Education program. Only one answer is possible per question. Please select the answer that is most appropriate. Question 1 A patient of unknown blood group needs an emergency transfusion of packed red cells (PRC). What should you give?
Question 2 What do you establish or check in the AB0 identity test (bedside test) before administering packed red cells?
Question 3 Which group of patients must receive Rh (D)-negative packed red cells?
Question 4 What is it crucial to ask about in women scheduled for transfusion?
Question 5 How common are hemolytic transfusion reactions of immediate type without fatal outcome in Germany?
Question 6 Erythema and wheals are found in a female patient after transfusion of packed red cells. Severe complications can be excluded and a renewed identity check is negative. What kind of transfusion reaction does she probably have?
Question 7 In which of the following circumstances is there a clear-cut indication for irradiation of packed red cells with gamma radiation at a dose of at least 30 Gy?
Question 8 In the “type and screen” strategy, which investigations are carried out in the 3-day period preceding a planned intervention?
Question 9 A 28-year-old female patient known to have the blood group B Rh (D) negative suffers a sudden esophageal variceal hemorrhage while in hospital and a transfusion of non–cross-matched packed red cells (PRC) is planned owing to an Hb concentration of 5 g/dL, severe dyspnea, hypotension, and tachycardia. Which of the following products do you choose?
Question 10 In a 55-year-old patient who has undergone major surgery with intraoperative blood loss you find an Hb concentration of 8.4 g/dL with anemia. The patient feels well (BP 135/85 mm Hg, pulse 82/min) and is moving around the ward to the extent allowed by his postoperative status. There are no relevant previous diseases; the postoperative course justifies discharge from hospital; on your pre-discharge examination the patient shows no signs of dyspnea or vertigo and no other clinical abnormalities. How do you proceed?
AcknowledgmentsTranslated from the original German by David Roseveare. FootnotesConflict of interest statement Dr. Müller has received consulting fees from Novartis Pharmaceutical Corporation. He has received payments from Fresenius KABI and Cerus for the preparation of scientific training courses. Furthermore, he has received funding from Cerus for research that he initiated. Prof. Seifried and Dr. Geisen have received funding from Cerus for research that they initiated. Prof. Zacharowski has received consulting fees from Vifor Pharma. He has received reimbursement of travel costs and attendance fees for training courses as well as honoraria for the preparation of scientific training courses from B. Braun, CSL Behring, Fresenius KABI, and Vifor Pharma. He has received funding from Fresenius KABI, B. Braun, Vifor Pharma, and CSL Behring for research that he initiated. How are packed red blood cells administered?It is given by injection into a vein. Bag of packed red blood cells. Side effects include allergic reactions such as anaphylaxis, red blood cell breakdown, infection, volume overload, and lung injury.
What supplies are needed for a blood transfusion?Infusion devices, such as infusion pumps, blood warmers, rapid infusers, and pressure devices, can be used to transfuse blood components. A pressure infusion device may be needed for the rapid transfusion of blood components.
What pre Administration checks are required prior to commencing a transfusion of packed red cells?Temperature, pulse, respirations and blood pressure must be recorded: prior to transfusion along with the presence of any pre-existing rashes. 15 minutes after commencement, and. on completion of each pack (or as otherwise stipulated by the local health service policy).
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