Blood Product Transfusion in Adults: Indications, Adverse Reactions, and Modifications

 

Am Fam Physician. 2020 Jul 1;102(1):30-38.

Author disclosure: Dr. Raval is involved in research in the field of therapeutic apheresis, in particular optimizing the use of therapeutic plasma exchange, red cell exchange, and extracorporeal photopheresis. He has received funding to serve as a medical advisor and speaker for Terumo BCT, Alexion, and Sanofi Genzyme on these topics. This manuscript addresses practical blood banking and transfusion medicine and is unrelated to the areas of therapeutic apheresis for which Dr. Raval has received funding; the other authors have no relevant financial affiliations.

Millions of units of blood products are transfused annually to patients in the United States. Red blood cells are transfused to improve oxygen-carrying capacity in patients with or at high risk of developing symptomatic anemia. Restrictive transfusion thresholds with lower hemoglobin levels are typically clinically equivalent to more liberal thresholds. Transfusion of plasma corrects clinically significant coagulopathy in patients with or at high risk of bleeding. Mildly abnormal laboratory coagulation values are not predictive of clinical bleeding and should not be corrected with plasma. Transfused platelets prevent or treat bleeding in patients with thrombocytopenia or platelet dysfunction. Cryoprecipitate is transfused to treat hypofibrinogenemia. Many adverse reactions can occur during or after blood product transfusion. Transfusion-associated circulatory overload (i.e., volume overload) is the most common cause of mortality associated with blood products. Modifications to blood products can prevent or decrease the risks of transfusion-related adverse reactions. It is critical to quickly recognize when a reaction is occurring, stop the transfusion, assess, and support the patient. Reporting a reaction to the blood bank is part of ensuring patient safety and supporting hemovigilance efforts.

The transfusion of blood products is a common medical procedure, with more than 16 million units transfused annually in the United States.1 However, there are associated hazards. When considering transfusion of any blood product, it is good practice to consider the patient's relevant laboratory data, overall clinical circumstances, feasible alternatives, and adjuncts to transfusion.2 These factors should be part of the informed consent process.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

The transfusion threshold of red blood cells for most adults should be a hemoglobin level ≤ 7 to 8 g per dL (70 to 80 g per L) in patients with asymptomatic anemia.2,3

A

Systematic reviews of RCTs evaluating red blood cell transfusion thresholds demonstrate identical outcomes in patients transfused via restrictive vs. liberal strategies

The transfusion threshold of plasma for most adults should be an international normalized ratio > 1.5 to 1.6 in patients with active bleeding or at high risk of bleeding.48,11

C

Consensus recommendations for plasma transfusion based on weak evidence from RCTs, clinical trials, and observational studies

The transfusion threshold of platelets for most adults should be a platelet count ≤ 10,000 per μL (10 × 109 per L) in patients prophylactically to prevent spontaneous bleeding in hypoproliferative thrombocytopenia.1416

A

Systematic reviews of RCTs and observational studies evaluating platelet transfusion thresholds

The transfusion threshold of platelets for most adults before surgery or childbirth should be a platelet count < 50,000 per μL (50 × 109 per L).4,68,1418

C

Consensus recommendations for platelet transfusion based on poor evidence from observational studies

Do not routinely administer pretransfusion antipyretics or antihistamines to prevent transfusion reactions.19,20,22,23

A

Systematic reviews of RCTs evaluating pretransfusion medication strategies


RCT = randomized controlled trial.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

The transfusion threshold of red blood cells for most adults should be a hemoglobin level ≤ 7 to 8 g per dL (70 to 80 g per L) in patients with asymptomatic anemia.2,3

A

Systematic reviews of RCTs evaluating red blood cell transfusion thresholds demonstrate identical outcomes in patients transfused via restrictive vs. liberal strategies

The transfusion threshold of plasma for most adults should be an international normalized ratio > 1.5 to 1.6 in patients with active bleeding or at high risk of bleeding.48,11

C

Consensus recommendations for plasma transfusion based on weak evidence from RCTs, clinical trials, and observational studies

The transfusion threshold of platelets for most adults should be a platelet count ≤ 10,000 per μL (10 × 109 per L) in patients prophylactically to prevent spontaneous bleeding in hypoproliferative thrombocytopenia.1416

A

Systematic reviews of RCTs and observational studies evaluating platelet transfusion thresholds

The transfusion threshold of platelets for most adults before surgery or childbirth should be a platelet count < 50,000 per μL (50 × 109 per L).4,68,1418

C

Consensus recommendations for platelet transfusion based on poor evidence

The Authors

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JAY S. RAVAL, MD, is senior director of transfusion medicine and therapeutic pathology and an associate professor in the Department of Pathology at the University of New Mexico School of Medicine (Albuquerque), and an adjunct associate professor in the Department of Pathology and Laboratory Medicine at the University of North Carolina School of Medicine (Chapel Hill)....

JOSEPH R. GRIGGS, DO, is director of the University of New Mexico Sandoval Regional Medical Center Blood Bank and an assistant professor in the Department of Pathology at the University of New Mexico School of Medicine.

ANTHONY FLEG, MD, MPH, is director of the University of New Mexico School of Medicine Preceptorship Program and an associate professor in the Department of Family and Community Medicine at the University of New Mexico School of Medicine.

Address correspondence to Jay S. Raval, MD, MSC08 4640, 1 University of New Mexico, Albuquerque, NM 87131 (email: jraval@salud.unm.edu). Reprints are not available from the authors.

Author disclosure: Dr. Raval is involved in research in the field of therapeutic apheresis, in particular optimizing the use of therapeutic plasma exchange, red cell exchange, and extracorporeal photopheresis. He has received funding to serve as a medical advisor and speaker for Terumo BCT, Alexion, and Sanofi Genzyme on these topics. This manuscript addresses practical blood banking and transfusion medicine and is unrelated to the areas of therapeutic apheresis for which Dr. Raval has received funding; the other authors have no relevant financial affiliations.

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show all references

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