1. Collection and reinfusion of patients own blood for the purpose of volume replacement

2. Four categories of autotransfusion

a. Preoperative autologous blood transfusion

1) Collected before surgery, with the last unit drawn no <72 hours before surgery

2) Provides red cell alloimmunization

3) Provides compatible blood for those with alloantibodies

4) Must be transfused within 4 hours of hanging

b. Perioperative isovolemic hemodilution

1) Collected in OR usually after induction of anesthesia

2) Patient must be able to tolerate rapid blood withdrawal and significant blood loss

3) Up to 2 L of blood are collected immediately before surgery

4) Blood is then replaced with adequate volume of crystalloid or colloid solution to achieve normovolemic hemodilution

5) Blood can be stored at room temperature in OR but should be transfused within 8 hours

6) If surgical procedure is expected to last >8 hours, blood should be refrigerated but must be transfused within 24 hours

7) This process may not prevent or eliminate the need for homologous blood use

c. Intraoperative autotransfusion

1) Cost-effective only if three units of blood can be reinfused

2) Contraindicated when gross bacterial contamination or seeding of malignant cells is a possibility

3) Must be labeled with the patient’s name, hospital identification number, date and time collection begun, and time of expiration; label should indicate “For Autologous Use Only”

4) Must be reinfused within 8 hours

5) Amount collected and reinfused should be documented in the operative procedure note

d. Postoperative blood salvage

1) Collection may begin in the operating room at time of closure

2) Must be reinfused within 6 hours of collection using aseptic technique

3) Must be labeled with the patient’s name, hospital identification number, date and time collection begun, and time of expiration; label should indicate “For Autologous Use Only”

4) Transfusion guidelines and organizational policies and procedures for transfusion therapy must be followed

1. Composition: contains red cells, white cells, platelets, and plasma

2. Volume: approximately 450 to 500 mL/unit plus anticoagulant and preservative in the collection unit

3. Use limited because of advances in the use of blood components

4. Indications

a. Acute massive blood loss manifested by signs and symptoms of hypotension, shortness of breath, tachycardia, pallor, and low hemoglobin/hematocrit

b. Volume expansion required

c. Symptomatic deficit in oxygen-carrying capacity combined with hypovolemia of sufficient degree associated with shock

5. Administration of whole blood is contraindicated when blood loss can be managed with blood components and crystalloid or colloid solutions

6. Disadvantages

a. Volume may lead to potential fluid volume excess

b. Storage considerations

1) Formation of microaggregates

2) Breakdown of cells resulting in increased potassium level

3) Loss of coagulation factors

c. Massive whole blood transfusion may cause calcium deficit in the patient with severely damaged liver

7. Administration considerations

a. Check patient’s serum potassium before administration

b. Number of units administered is determined by the clinical situation

c. Administration of a single unit of whole blood is not appropriate

d. Administer as rapidly as possible to stabilize hemodynamic status

e. For pediatric patients, 20 mL/kg is administered initially, followed by the volume required for hemodynamic stabilization

8. Expected outcome

a. Improved hemodynamic status and resolution of symptoms of hypovolemic shock

b. Hematocrit and hemoglobin may fluctuate because of rapid fluid shifts during active bleeding and result in erroneous laboratory values

9. Compatibility: must be ABO compatible, unless in an emergency situation when type O may be administered to any other blood group

1. Composition: contains red blood cells (RBCs) and has the same cell mass as whole blood; prepared by separating the plasma from the cellular portion of whole blood

2. Volume: contains 250 to 350 mL/unit depending on anticoagulant/preservative used

3. Indications

a. Increase red cell mass when volume expansion is not required

b. Restore or maintain oxygen-carrying capacity of the blood

c. Symptomatic anemia unresponsive to other therapies

d. Hypovolemic shock that can be managed with the administration of RBCs and crystalloid or colloid solutions

e. Acute or chronic blood loss with tachycardia, shortness of breath, pallor, fatigue, and low hemoglobin/hematocrit

4. Administration considerations

a. Number of units administered is determined by the clinical situation

b. Each unit may be infused during a period of 1 to 2 hours but must be infused within 4 hours

c. Red cells with anticoagulant/preservative solution may be viscous and may require dilution with 0.9% sodium chloride

d. For pediatric patients

1) Careful consideration must be given prior to transfusion of RBCs to critically ill pediatric and neonatal patients due to increased morbidity and mortality rates based on the high levels of potassium concentration in RBCs resulting in hyperkalemia

2) Usual dose of PRBCs is 10 to 15 mL/kg

3) Units may be divided into aliquots (smaller amounts) for administration

4) Administer as follows:

a) First 15 minutes of transfusion, administer 5% to 10% of total transfusion volume, and then

b) If no adverse effects, increase administration rate to 2 to 5 mL/kg/hour or as tolerated

5. Expected outcome

a. Resolution of symptoms of anemia

b. Increased hematocrit of 3% and increased hemoglobin of 1 g/dL per unit

6. Compatibility

a. Must be ABO compatible

b. Recipients whose ABO group is unknown may receive group O red cells until ABO type and crossmatching are complete

7. Variations of RBCs

a. Leukocyte-filtered or leukocyte-reduced

1) A unit of leukocyte-reduced RBCs contains fewer than 5 × 10⁸ leukocytes

2) Indications

a) In cases of known febrile, nonhemolytic transfusion reactions caused by donor white cell antigens reacting with recipient white cell antibodies

b) To reduce the incidence of urticarial and anaphylactic reactions

c) To prevent the transmission of cytomegalovirus (CMV) or alloimmunization to HLAs

d) Immunosuppressed patients

3) Reduction methods

a) May be performed before or during transfusion

b) Filtration: may be done during processing or at bedside; removes as much as 99% of leukocytes

4) Compatibility: must be ABO compatible

b. Modified (washed) RBCs

1) Done before transfusion; may reduce number of red cells by 20%; must be used within 24 hours of preparation; the method is more expensive and time-consuming

2) Process to remove platelets, cellular debris, decrease plasma to trace levels, decrease leukocytes

3) Used in patients with recurrent or severe allergic reactions due to one or more plasma proteins and for neonatal and intrauterine transfusions

4) Indications: same as for RBCs

5) Administration: same as for RBCs

6) Compatibility: must be ABO compatible

c. Frozen-deglycerolized RBCs

1) Composition: contains RBCs and glycerol

a) Glycerol is added to the cells before freezing to prevent dehydration and mechanical damage of the cells by ice formation

b) Typically glycerized and frozen within 6 hours of donation

2) Blood frozen for long-term storage; up to 10 years

3) Done for autologous donations and to maintain stores of rare blood types

4) Indications: same as for washed RBCs

5) Administration

a) Must be thawed in water bath or dry warmer

b) Cells are then washed to remove glycerol

c) Must be infused within 24 hours of thawing and washing

6) Compatibility: must be ABO compatible

1. Fresh frozen plasma (FFP)

a. Composition: contains albumin, globulins, antibodies, and clotting factors; prepared by separating plasma from unit of whole blood

b. Volume: 200 to 250 mL/unit

c. Must be frozen within 8 hours of collection

d. Indications

1) Active bleeding with multiple coagulation factor deficiencies

2) Increased level of clotting factors in patients with a demonstrative deficiency

3) Warfarin (Coumadin) reversal

4) Treat disseminated intravascular coagulation (DIC) and evidence of dilutional coagulopathy from large-volume replacement

5) Congenital factor deficiencies for which there are no concentrates (e.g. factors V and XI)

6) Correct acquired deficiency of various coagulation factors due to massive hemorrhage

e. Administration considerations

1) Number of units administered is determined by the clinical situation and underlying disease

2) Administer at 200 mL/hour or more slowly if there is potential for circulatory overload

3) For pediatric patients, the usual dose is 10 to 15 mL/kg at a rate of 1 to 2 mL/minute

4) Transfuse within 24 hours of thawing to avoid loss of clotting factors V and VIII

5) FFP expires in 6 hours at room temperature or in 24 hours if refrigerated

f. Expected outcome: improved coagulation function

g. Compatibility: must be ABO compatible

2. Platelets

a. Composition: prepared from a single unit of whole blood or plasma

1) Random: single units from multiple donors; usually 4 to 8 units obtained

2) Plateletpheresis: multiple units from a single donor; content equivalent to that of 4 to 8 units from random donors

b. Indications: thrombocytopenia or abnormal platelet function

c. Administration considerations

1) Number of units administered is determined by the clinical situation

2) Infusion rate determined by volume tolerance; may be infused as rapidly as 30 minutes but must be infused within 4 hours

3) Pediatric patients

a) Usual dose is 1 unit (50 to 70 mL) per 7 to 10 kg of body weight

b) Administer as IV bolus or IV infusion over 30 minutes to 4 hours

d. Expected outcome

1) Prevention or resolution of bleeding

2) Increased platelet count

e. Compatibility

1) ABO compatibility preferred but not required

2) ABO grouping recommended reducing potential for refractoriness to platelets

f. Special considerations

1) Random donor units may be pooled into a single bag before release from blood bank

2) Plateletpheresis units may reduce the risk of transfusion-transmitted diseases and HLA antibody formation

g. Platelet variations

1) HLA-matched

a) An antigen found on the white cells

b) Collected by apheresis from donor who is HLA-compatible with recipient

c) Decreases premature destruction of transfused platelets by HLA antibodies

d) Frequently used in patients being prepared for tissue/organ transplantation

e) Generally more suitable match obtained from immediate family; less perfect match from non-related donor may be sufficient

2) Leukocyte-reduced/leukocyte-filtered

a) Reduction achieved by filtration, with approximately 99% of leukocytes being removed

b) May occur in the processing phase or by the use of a leukocyte-reduction filter during transfusion

c) Used to decrease the incidence of febrile reaction; helps prevent HLA alloimmunization in patients who require long-term platelet support or may require transplantation

3. Cryoprecipitate

a. Composition: derived from a unit of FFP; rich source of factor VIII (antihemophilia factor), von Willebrand’s factor, factor XIII, fibronectin, and fibrinogen

b. Only source of fibrinogen

c. Volume: each unit contains only 10 to 15 mL of cryoprecipitate and plasma

d. Indications

1) Treatment of deficiencies of factor XIII and fibrinogen

2) May be used in the treatment of hemophilia A and von Willebrand’s disease if factor VIII concentrate is not available

e. Administration considerations

1) Number of units is dependent on the clinical situation

a) Dose may need to be repeated every 8 to 12 hours

b) Laboratory evaluation is required to assess the effectiveness of the treatment

2) Rate of infusion is 1 to 2 mL/min for both adult and pediatric patients

3) Single units must be infused within 6 hours of thawing; pooled units are infused within 4 hours of being pooled

4) 0.9% sodium chloride may be added to the unit to facilitate the recovery of the granulocytes and increase the volume

f. Expected outcome

1) Correction of deficiencies

2) Cessation of bleeding episode

g. Compatibility: ABO and Rh match is preferred when possible; plasma compatibility is also preferred but not required

4. Albumin

a. Composition: commercially extracted from plasma; contains no clotting factors; natural plasma protein

b. Eliminates risk of transfusion-transmitted viruses

c. Role in regulating plasma volume and tissue fluid balance

d. Available in 5% (isotonic) or 25% (hypertonic) solution concentrations

e. Indications

1) Volume expansion when crystalloid solutions are not adequate

2) Treatment of hypoproteinemia

3) 5% concentration is used as the plasma substitute in the treatment of hypovolemic shock and massive hemorrhage

4) 25% concentration is usually used when there are fluid or sodium restrictions

5) Contraindicated in patients with cardiac failure, severe anemia, or known hypersensitivity

f. Administration considerations

1) Amount administered is dependent on the clinical situation

a) 5% solution (50 mg/mL): isotonic solution oncotically equivalent to plasma; available in 50, 250, 500, or 1,000 mL vials

b) 25% solution (250 mg/mL); available in 20, 50, and 100 mL vials