What are the critical considerations for blood transfusion?

From the Guidelines

Blood transfusions should only be performed when clinically necessary, as they carry risks including allergic reactions, infections, and transfusion-related acute lung injury. The decision to transfuse should be based on the patient's clinical condition rather than arbitrary hemoglobin thresholds. Generally, transfusion is considered when hemoglobin falls below 7 g/dL in stable patients, or below 8-10 g/dL in patients with cardiac disease or active bleeding, as recommended by the AABB 1 and supported by other guidelines 1. Before transfusion, proper blood typing and cross-matching must be performed to prevent potentially fatal transfusion reactions. During the procedure, patients should be monitored for signs of adverse reactions including fever, chills, rash, back pain, or respiratory distress. If these occur, the transfusion should be stopped immediately and appropriate treatment initiated. Each unit of packed red blood cells typically raises hemoglobin by approximately 1 g/dL in an average-sized adult. Transfusions should be administered at a rate of 2-4 hours per unit unless rapid replacement is needed in emergency situations. This cautious approach to transfusion therapy balances the benefits of improved oxygen delivery against the significant risks associated with allogeneic blood products, as emphasized in guidelines from critical care medicine 1. Key considerations include:

• The use of a restrictive strategy for RBC transfusion, where transfusion occurs when hemoglobin concentration decreases to < 7.0 g/dL in adults in the absence of extenuating circumstances 1.
• Avoiding the use of erythropoietin for treatment of anemia associated with sepsis 1.
• Prophylactic platelet transfusion when counts are < 10,000/mm3 (10 × 10^9/L) in the absence of apparent bleeding and when counts are < 20,000/mm3 (20 × 10^9/L) if the patient has a significant risk of bleeding 1.
• Decision for RBC transfusion should be based on an individual patient’s intravascular volume status, evidence of shock, duration and extent of anemia, and cardiopulmonary physiologic parameters 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Blood Transfusion Overview

• Blood transfusion is a medical procedure that involves transferring blood or blood components from a donor to a recipient 2.
• The management of hemotherapy is regulated by laws and guidelines, and the transfusing physician is responsible for correct implementation at the bedside 2.

Indications for Blood Products

• Indications for blood products, such as packed red blood cell concentrates (RBC), platelet concentrates (PC), and fresh frozen plasma (FFP), have to be carefully adapted to the patient's current clinical situation and pre-existing diseases 2.
• RBC are indicated for most perioperative elective surgeries, and evidence-based transfusion thresholds have been defined 2.
• PC are indicated for bleeding patients with thrombocytopenia or -pathy, and prophylactically in clinically stable, not bleeding patients with a platelet trough count of less than 10/nl 2.
• FFP is indicated for balanced substitution of coagulation factors, coagulation inhibitors, and fibrinolysis factors in massive transfusion settings 2.

Adverse Transfusion Reactions

• Adverse transfusion reactions are rare, but hemolytic and allergic reactions can occur 2.
• Severe hemolytic transfusion reactions are often caused by wrong blood in tube (WBIT) at the diagnostic bedside blood withdrawal or a mix-up of blood components before transfusion 2.

Massive Transfusion Situations

• Massive transfusion situations require proactive management, including RBC, FFP, and potentially PC and coagulation factor concentrates 2.
• The optimal composition and timing for the administration of blood supplements during massive transfusion have been studied, and the use of RBC, FFP, and PC in appropriate proportions can correct blood coagulation dysfunction and anemia 3.

Risks Associated with Blood Transfusion

• Transfusion of red blood cells, fresh frozen plasma, or platelets is associated with an increased risk of mortality and infection after cardiac surgery in a dose-dependent manner 4.
• Each of the three blood products is independently associated with an increase in mortality per unit transfused 4.
• Prediction models based on preoperative variables can facilitate blood component management for patients undergoing elective coronary artery bypass graft surgery 5.