Intraoperative Transfusion of Blood Products in Adults - UpToDate
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- Author:
- Full Title: Intraoperative Transfusion of Blood Products in Adults - UpToDate
- Tags transfusion
- Category: #articles
- URL: https://www.uptodate.com/contents/intraoperative-transfusion-of-blood-products-in-adults
Highlights
INDICATIONS AND RISKS FOR SPECIFIC BLOOD PRODUCTS
Red blood cells — We transfuse autologous, salvaged, or allogeneic ../../../Knowledge/Medicine/Red Blood Cell (RBCs) when hemoglobin (Hgb) is <7 to 8 g/dL (approximately equivalent to a hematocrit ≤21 to 24 percent) in most cardiac and noncardiac surgical patients without significant ongoing bleeding. These threshold values are similar to the guidelines of several professional societies . Accurate assessment of a post-transfusion Hgb level can be performed as early as 15 minutes following RBC administration (in the absence of ongoing active bleeding)
We typically use a higher Hgb threshold of <==9 g/dL ==(approximately equivalent to a hematocrit ≤27 percent) in patients who have
- significant ongoing bleeding,
- a known acute coronary syndrome, or
- signs of myocardial or other organ ischemia, particularly during high-risk noncardiac surgery
We administer ../../../Knowledge/Medicine/platelet transfusions as a component of ../../../Knowledge/Medicine/massive transfusion protocol. In surgical patients, we typically maintain platelet count >50,000/microL, or >100,000/microL when central nervous system bleeding is present or likely. We typically avoid prophylactic platelet transfusions in patients with counts below these thresholds (unless they are excessively low) who are not bleeding, unless the risk of even minor bleeding is significant (eg, ophthalmic or neurosurgery) or the planned surgical procedure is likely to result in significant bleeding (eg, major surgery)
Importantly, abnormalities of ../../../Knowledge/Medicine/platelet function affect hemostasis even if platelet count is adequate. Thus, the platelet transfusion threshold may be higher (typically >100,000/microL) in a surgical patient with microvascular bleeding when qualitative platelet defects are strongly suspected or noted on platelet function tests. Qualitative platelet defects may be caused by use of antiplatelet agents that inhibit cyclooxygenase, glycoprotein IIb/IIIa, and/or adenosine diphosphate (ADP), as well as by uraemia, hypothermia, acidosis, or hyperfibrinolysis due to disseminated intravascular coagulation (DIC), trauma, malignancy, liver transplantation or failure, or cardiopulmonary bypass (CPB)
Specific examples of emergency intraoperative situations in which plasma products may be necessary are discussed in other topics: Replacement of deficient coagulation factors – Reversal of warfarin, if a prothrombin complex concentrate (PCC) is not available or cannot be given
- In patients requiring immediate reversal of anticoagulation due to warfarin in preparation for urgent surgery, a four-factor prothrombin complex concentrate (PCC) should be used. However, FFP may be used if neither four-factor nor three-factor PCC products are available (eg, in a resource-limited setting).
- Notably, FFP contains approximately 2 to 3 mg/mL of ../../../Knowledge/Medicine/Fibrinogen
- ../../../Knowledge/Medicine/cryoprecipitate is used to treat hypofibrinogenemia during massive transfusion, especially in a bleeding surgical patient who has known low ../../../Knowledge/Medicine/Fibrinogen concentrations <50 to 100 mg/dL or when fibrinogen cannot be measured in a timely fashion
A single unit of ../../../Knowledge/Medicine/cryoprecipitate contains most of the ../../../Knowledge/Medicine/Fibrinogen (factor I), factor VIII, factor XIII, von Willebrand factor (VWF), and fibronectin derived from one unit of FFP (table 5). Each unit has a small volume of 5 to 20 mL and contains the following protein quantities: - ../../../Knowledge/Medicine/Fibrinogen : >150 mg (range is 150 to 250 mg); half-life is 100 to 150 hours
- Factor VIII : >80 international units (range is 80 to 150 units); half-life is 12 hours
- Factor XIII : 50 to 75 units; half-life is 150 to 300 hours
- von Willebrand factor – 100 to 150 units; half-life is 24 hours
The typical ../../../Knowledge/Medicine/cryoprecipitate transfusion dose, as received from the blood bank, is a pooled product that has been prepared by combining individual ../../../Knowledge/Medicine/cryoprecipitate units derived from 5 to 10 blood donors in a volume of 50 to 200 mL.
# Intraoperative Transfusion of Blood Products in Adults - UpToDate
Metadata
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- Full Title: Intraoperative Transfusion of Blood Products in Adults - UpToDate
- Category: #articles
- URL: https://www.uptodate.com/contents/intraoperative-transfusion-of-blood-products-in-adults
Highlights
- INDICATIONS AND RISKS FOR SPECIFIC BLOOD PRODUCTS Red blood cells — We transfuse autologous, salvaged, or allogeneic red blood cells (RBCs) when hemoglobin (Hgb) is <7 to 8 g/dL (approximately equivalent to a hematocrit ≤21 to 24 percent) in most cardiac and noncardiac surgical patients without significant ongoing bleeding. These threshold values are similar to the guidelines of several professional societies [42,43,70,71]. Accurate assessment of a post-transfusion Hgb level can be performed as early as 15 minutes following RBC administration (in the absence of ongoing active bleeding)
- We typically use a higher Hgb threshold of <9 g/dL (approximately equivalent to a hematocrit ≤27 percent) in patients who have significant ongoing bleeding, a known acute coronary syndrome, or signs of myocardial or other organ ischemia, particularly during high-risk noncardiac surgery
- We administer platelet transfusions as a component of massive transfusion protocols. In surgical patients, we typically maintain platelet count >50,000/microL, or >100,000/microL when central nervous system bleeding is present or likely. We typically avoid prophylactic platelet transfusions in patients with counts below these thresholds (unless they are excessively low) who are not bleeding [100], unless the risk of even minor bleeding is significant (eg, ophthalmic or neurosurgery) or the planned surgical procedure is likely to result in significant bleeding (eg, major surgery)
- Importantly, abnormalities of platelet function affect hemostasis even if platelet count is adequate. Thus, the platelet transfusion threshold may be higher (typically >100,000/microL) in a surgical patient with microvascular bleeding when qualitative platelet defects are strongly suspected or noted on platelet function tests [101]. Qualitative platelet defects may be caused by use of antiplatelet agents that inhibit cyclooxygenase, glycoprotein IIb/IIIa, and/or adenosine diphosphate (ADP), as well as by uremia, hypothermia, acidosis, or hyperfibrinolysis due to disseminated intravascular coagulation (DIC), trauma, malignancy, liver transplantation or failure, or cardiopulmonary bypass (CPB)
- Specific examples of emergency intraoperative situations in which plasma products may be necessary are discussed in other topics: •Replacement of deficient coagulation factors – (See "Clinical use of plasma components", section on 'Overview of indications'.) •Reversal of warfarin, if a prothrombin complex concentrate (PCC) is not available or cannot be given
- In patients requiring immediate reversal of anticoagulation due to warfarin in preparation for urgent surgery, a four-factor prothrombin complex concentrate (PCC) should be used (see "Perioperative blood management: Strategies to minimize transfusions", section on 'Prothrombin complex concentrate'). However, FFP may be used if neither four-factor nor three-factor PCC products are available (eg, in a resource-limited setting).
- Notably, FFP contains approximately 2 to 3 mg/mL of fibrinogen
- Cryoprecipitate is used to treat hypofibrinogenemia during massive transfusion, especially in a bleeding surgical patient who has known low fibrinogen concentrations <50 to 100 mg/dL or when fibrinogen cannot be measured in a timely fashion
- A single unit of Cryoprecipitate contains most of the fibrinogen (factor I), factor VIII, factor XIII, von Willebrand factor (VWF), and fibronectin derived from one unit of FFP (table 5). Each unit has a small volume of 5 to 20 mL and contains the following protein quantities: •Fibrinogen – >150 mg (range is 150 to 250 mg); half-life is 100 to 150 hours •Factor VIII – >80 international units (range is 80 to 150 units); half-life is 12 hours •Factor XIII – 50 to 75 units; half-life is 150 to 300 hours •von Willebrand factor – 100 to 150 units; half-life is 24 hours The typical Cryoprecipitate transfusion dose, as received from the blood bank, is a pooled product that has been prepared by combining individual Cryoprecipitate units derived from 5 to 10 blood donors in a volume of 50 to 200 mL.