What’s in Your Transfusion? A Bedside Guide to Blood Products and Their Preparation
Myron Yaster MD and Priti G. Dalal MD FRCA
Before discussing today’s PAAD1, I’d like to invite you to take a virtual walk with me down a grocery aisle in your local supermarket. We are first going to go down the aisle with fresh chicken. You’ll see row after row of chicken parts and a smaller section for whole chickens. Have you ever wondered why? Well obviously, for the home chef, there is the convenience factor of using the parts. What may not be so obvious is that the mark up for the parts is substantial and grocery stores want you to buy the parts and not the whole chicken to increase their profits. Next let’s walk over to the milk section of the refrigerator case. The oldest milk is up front, and the freshest milk is stocked in the back. Obviously, as a consumer, you reach to the back to get the freshest milk with the longest expiration date. Again, this makes perfect sense, the owner of the supermarket is trying to get rid of his oldest inventory and you want the milk that will last the longest in your home.
Why did we take this virtual walk? Because this is similar to how the blood bank operates. The blood bank will give you their oldest blood, just at the point of expiration, and may insist that you use blood components thereby making it as difficult as possible to get (fresh) whole blood!
Today’s PAAD1 is a must read review and I would encourage all of you to read it as a refresher course. It is concise and an easy read and has an enormous amount of useful information whether you routinely or infrequently transfuse blood products in the operating room (OR) or intensive care unit (ICU). Because of this, it is a perfect article for trainees and attending anesthesiologists at any stage of their journey.
Finally, I’ve asked Dr. Priti Dalal, the Director, Division of Pediatric Anesthesiology and Professor, Department of Anesthesiology and Perioperative Medicine at Penn State Health to assist. For those of you who don’t know her, she is an exceptional leader in SPA and the Chair of SPA’s Quality and Safety and Checklist committees. Myron Yaster MD
Original article
Hess AS. What's in Your Transfusion? A Bedside Guide to Blood Products and Their Preparation. Anesthesiology. 2024 Jan 1;140(1):144-156. doi: 10.1097/ALN.0000000000004655. PMID: 37639622.
It is beyond the scope of the PAAD, which by design is a 5-7 minute read to completely review all of the information contained in today’s article. So, we will provide highlights and reproduce some of the tables which are simply outstanding.
In this narrative review, Hess “discusses the five basic blood products (table 1) and five common modifications. Each product or modification is presented within a short clinical vignette; details are supplied in the figures and tables. He also included a brief section on important transfusion reactions and their management.”1
Some highlights/key points
“Low-titer group O whole blood contains all the components of donor blood in a mildly diluted form. Whole blood has many benefits in bleeding compared to crystalloid or component-based resuscitation, including the convenience of fewer bags, less volume per dose, and the ease of a resuscitation automatically balanced between erythrocytes, clotting factors, and platelets. The hemostatic advantages of whole blood also appear to be preserved even after several days of post collection quarantine and up to 3 weeks of storage2.”1
“Stored plasma contains all the acellular chemical and protein ingredients of blood, including albumin, coagulation factors, and immunoglobulins. Dilution with anticoagulant lowers the coagulation factor activity in stored plasma to around 80%, or roughly an INR of 1.1.3”1
“Units of platelets contain platelets (thrombocytes), plasma, storage solution, and trace amounts of red and white blood cells. Almost all platelets in the United States are now collected in concentrated units by apheresis from a single donor. Platelets stored “cold” at refrigerator temperatures are receiving renewed interest. Cold-stored platelets appear to have immediate hemostatic benefits and a reduced risk of infection compared to standard room-temperature platelets, although at the expense of shortened posttransfusion survival.”1 Platelets stored at room temperature increase the risk of bacterial infection.
“Cryoprecipitated antihemophilic factor, commonly known as “cryo,” is a plasma derivative containing concentrated fibrinogen, factor VIII, factor XIII, von Willebrand factor, and fibronectin.
“White blood cells release cytokines and other inflammatory mediators into the liquid portion of the unit during storage. These factors can cause a number of adverse events, of which fevers are the most common. After removing the white blood cells through filtration or centrifugation—“leukoreduction” of the blood—fever and other complications are less frequent.”1
“Even after leukoreduction, there are a large number of remaining white blood cells in any unit of whole blood, red cells, and platelets. In a severely immunocompromised patient, these white blood cells may become established and cause a severe multiorgan syndrome called transfusion-associated graft- versus -host disease, which is fatal in greater than 90% of cases. Fortunately, transfusion-associated graft- versus -host disease is both rare and preventable with irradiation.”1 Who should get irradiated blood? Primarily, patients with immunodeficiencies, newborns, and when used for intrauterine transfusions. Finally, irradiated blood may also increase the release of potassium and has been linked to hyperkalemic arrests.4
In summary, today’s PAAD provides a wealth of information regarding five blood components (low-titer group O whole blood, stored red blood cells, plasma, platelets, and cryoprecipitate), their preparation, storage, cost and use in certain scenarios; all nicely summarized at-a-glance in table 1 (below) in the article. While the whole blood would be ideal, it has a much shorter shelf life then red blood cells component. Of note, the shelf life of platelet component is the shortest and it is nearly as expensive as a whole blood unit. The cost increases with modification for pathogen reduction. On the other hand, both plasma and cryoprecipitate may be stored frozen for one year. Nevertheless, once thawed their shelf life is reduced to 6 hours. These are important points for consideration when ordering blood components and reducing wastage. In the latter part of the article, using clinical scenario examples, the author discusses five modifications (additive solutions, leukoreduction, irradiation, pathogen reduction and washing) applied to stored blood or blood products to reduce risks and complications with blood product transfusions; summarized in table 2 in the article. A review of this table will improve the understanding of the need for each modification for respective blood products and their indications.
Why is this important? From quality and safety standpoint, this knowledge will guide the anesthesiologists’ management of clinical scenarios with judicious usage of blood products, safe administration, identification, and treatment of transfusion reactions. The eight transfusion reactions, their cause, timing, clinical features, and management are aptly described in table 3 (above). Of these, the two transfusion reactions which the anesthesiologist may encounter, warranting immediate management include: acute hemolytic transfusion reaction (AHTR) and anaphylaxis. Another five transfusion reactions which the anesthesiologist may encounter include: febrile non-hemolytic transfusion reaction (NHTR), allergic reactions, sepsis, transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO). While the delayed hemolytic transfusion reaction (DHTR) occurs many days after blood transfusion, anesthesiologists’ knowledge of patient’s recent history of blood product transfusion is essential for unexplained decrease in hemoglobin or acute kidney injury. Diagnosis of the latter reactions may pose a challenge under anesthesia and these may occur even after hours of blood transfusion hence a high index of suspicion must be present when caring for anesthetized patients who have recently received blood component therapy. A valuable underlying message in this article is the importance of excellent communication between the anesthesiologists and the blood bank hematologist in special scenarios.
Finally, we will refer you to the article and to your Pedicrisis app to find management suggestions for anaphylaxis and transfusion reactions.
Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Hess AS. What's in Your Transfusion? A Bedside Guide to Blood Products and Their Preparation. Anesthesiology 2024;140(1):144-156. (In eng). DOI: 10.1097/aln.0000000000004655.
2. Jobes D, Wolfe Y, O'Neill D, et al. Toward a definition of "fresh" whole blood: an in vitro characterization of coagulation properties in refrigerated whole blood for transfusion. Transfusion 2011;51(1):43-51. (In eng). DOI: 10.1111/j.1537-2995.2010.02772.x.
3. Dumont LJ, Cancelas JA, Maes LA, et al. The bioequivalence of frozen plasma prepared from whole blood held overnight at room temperature compared to fresh-frozen plasma prepared within eight hours of collection. Transfusion 2015;55(3):476-84. (In eng). DOI: 10.1111/trf.12864.
4. Burke M, Sinha P, Luban NLC, Posnack NG. Transfusion-Associated Hyperkalemic Cardiac Arrest in Neonatal, Infant, and Pediatric Patients. Front Pediatr 2021;9:765306. (In eng). DOI: 10.3389/fped.2021.765306.