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Call Book
Hematology

Transfusion modifications

Leukoreduction: ↓ HLA alloimmunization, ↓ CMV, ↓ febrile non-hemolytic reactions. Standard in most US units.

Eashwar Somasundaram6 min6 questions1 trials

How units are modified

Leukoreduction, irradiation, and washing are not interchangeable. Each prevents a different disaster. Consent is required for every product — name the product, the indication, the benefits and risks, and the alternatives.

Leukoreduction

  • Filters donor leukocytes
  • ↓ HLA sensitization in the chronically transfused, heme malignancy, and marrow / kidney / heart / lung transplant candidates (not liver transplant)
  • ↓ CMV transmission — leukoreduced is CMV-safe for most indications
  • ↓ febrile non-hemolytic reactions
  • Standard on most US units. Does not prevent TA-GVHD

Irradiation

  • Inactivates donor lymphocytes so they cannot engraft
  • Prevents transfusion-associated GVHD (almost uniformly fatal)
  • Indicated: heme malignancy and BMT; Hodgkin lymphoma; purine analogs (fludarabine, cladribine, and some lists include bendamustine); directed-donor first-degree relatives; intrauterine/neonatal transfusion; selected cellular immunodeficiencies
  • Not indicated solely for solid tumor, solid-organ transplant, or HIV
  • A blood-bank step — never 'irradiate' a unit that is already hanging
  • Saline washing removes plasma proteins and anti-IgA. Use for severe anaphylaxis to blood products, with or without IgA deficiency; IgA-deficient donor products are the other path.
  • Frozen/deglycerolized units for rare blood types. Volume-reduced units when TACO risk is high.
  • CMV-seronegative versus leukoreduced: equivalent for most patients; some centers still use CMV-seronegative for intrauterine/neonatal transfusion.
Ordering without a second page
  1. 1

    Prepare

    Prepare RBC (or platelets/FFP/cryo): number of units, indication, modifications.

  2. 2

    Transfuse

    Transfuse order: number of units and rate (usually over 2–4 h).

  3. 3

    Check the increment

    Post-transfusion CBC 15–30 min after completion if the patient is not actively bleeding.

Massive transfusion

Call Book / MGH: call the blood bank (x63623 main; x85280 Lunder). Bring a patient sticker and pick-up slip to Gray/Bigelow 2 for the cooler. Activate MTP when you anticipate replacing one blood volume (70 mL/kg), giving >4 units immediately, seeing ongoing hemorrhage >250 mL/h, or when clinical judgment says so — trauma, GI bleed, cardiac surgery, obstetric catastrophe, ruptured great vessel.

Emergency release versus MTP

  • Emergency-release blood

    4 units of uncrossmatched whole O blood for men and women >50 . For women <50 : 6 units group O RBCs (Rh-negative), 3 units plasma, and one platelet dose. One cooler is enough for most bleeds.

  • MTP coolers

    First cooler: 4 units whole O blood. Then coolers of 6 units O RBCs, 3 units plasma, and 1 platelet dose every 15 minutes until you call it off. A blood-bank sample must be sent before the third cooler or plasma and platelets will not be released.

  • Access: short and stubby — ≤18 g PIV, MAC, or Cordis. Take off the clave and pressure-bag versus a Belmont.
  • No universal ratio. 1:1–2:1 (RBC:FFP, plus 1 platelet dose) is the usual target. One platelet dose ≈ 6 units of whole-blood platelets.
  • Goals: Hb 7–10, INR <2.5 (unless ESLD), platelets >50k, fibrinogen >100–150.
  • Cryoprecipitate is not in the MTP cooler — order it from fibrinogen or empirically (1–2 pooled cryo per 7–8 RBCs).
  • Excess FFP is associated with ARDS in patients who did not need a massive transfusion.
  • Hypothermia: Bair Hugger, blood/fluid warmers.
  • Hypocalcemia from citrate: target iCa 1–3 mM, or empiric 1–2 g CaCl2 per 6 units RBC.
  • Dilutional coagulopathy from crystalloid, metabolic alkalosis (citrate → bicarbonate), hyperkalemia, liver (AST/ALT >800 — extra antifibrinolytic).
  • Women of reproductive age may need RhoGAM after Rh-incompatible resuscitation.

Platelet refractoriness

Refractoriness is failure to achieve an acceptable increment. Normal platelet half-life is ~3 days. Two-thirds of cases are not alloimmune.

Alloimmune

  • Antibody to class I HLA (PRA positive) or platelet-specific antigens
  • Risk: multiple pregnancies, prior non-leukoreduced transfusions, organ transplant ()
  • Drug-associated ITP: heparin, sulfa, vancomycin, linezolid, piperacillin, rifampin, thiazides, GPIIb/IIIa inhibitors
  • Poor recovery: corrected count increment <5k on two occasions, or a rise <10k twice ()

Non-alloimmune

  • Sepsis/DIC, HIT, TTP, CVVH/bypass/IABP, splenomegaly, liver disease, HSCT
  • Viral infection (HIV/HCV) and drugs (amphotericin)
  • Normal recovery at 15 min–1 h, short survival at 18–24 h — consumption, not antibody
Work it up with transfusion medicine, not in silence
  1. 1

    Two post counts

    Draw 15 min–1 h (recovery) and 18–24 h (survival) after two transfusions.

  2. 2

    Call BTS

    Call Book / MGH: Blood Transfusion Service (p21829). HLA studies will not be processed without that conversation.

  3. 3

    PRA

    HLA class I antibody screen. Normal is 0%; range 0–100%.

  4. 4

    Bleeding now

    Tell the blood bank and ask for a Red Cross send-out. Compatible (HLA-antigen-negative or crossmatch-compatible) or ABO/HLA-matched apheresis units take days and last ~3 days on the shelf.

  • Check a post-transfusion CBC within 15–60 min of every subsequent platelet dose.
  • Aminocaproic acid if bleeding (contraindicated in thrombotic DIC). DDAVP if there is uremic platelet dysfunction.

When transfusion is refused

Jehovah's Witnesses vary in what they will accept. Discuss products one by one; a checklist beats a single 'no blood' checkbox ().

Usually acceptable

  • Hematinics: iron, folate, B12, recombinant EPO
  • Non-blood volume expanders (crystalloid)
  • Hemostatic agents: aminocaproic acid, TXA, DDAVP, albumin-free clotting factors

Unacceptable to most

  • Whole blood, packed RBCs, platelets, FFP, cryoprecipitate
  • Preoperative autologous donation transfused later
  • Acceptable to some: intraoperative autotransfusion, HD/apheresis/bypass/ECMO, products with blood fractions (coagulation factors, PCC), plasma-derived albumin/cryo/Ig, products that may contain albumin (rhEPO, vaccines), marrow or organ transplantation.
  • Bleeding or pre-op: IV iron plus rhEPO to accelerate erythropoiesis — onset 2–6 days if iron/folate/B12 are replete.
  • Critical illness: no expert consensus. Some use rhEPO 200–300 U/kg IV q24h or 250–500 U/kg SQ q48h targeting perioperative Hb >10–12, extrapolated to unstable bleeding.

Therapeutic apheresis

Schedule through dialysis if the patient is already on intermittent HD, otherwise through transfusion medicine. Access is a tunneled dialysis catheter or a non-tunneled HD line.

ProcedureWhat is removedClassic indications
Plasmapheresis (PLEX)Plasma, replaced with saline, albumin, or plasma depending on the diseaseTTP (replace ADAMTS13, ), hyperviscosity, cryoglobulinemia, Guillain–Barré, CIDP, myasthenia, ANCA, anti-GBM
LeukapheresisWhite cellsHyperleukocytosis, goal WBC <100k — controversial as a routine
RBC exchangeRed cellsSickle cell with acute decompensation (organ failure, acute chest); severe babesiosis (parasitemia >10%, severe hemolysis, or pulmonary/liver/renal disease)
PlateletpheresisPlateletsRarely used for thrombocytosis; goal <1,000k when it is used