QUICK REFERENCE

2012 Clinical
Practice Guide on
Red Blood Cell
Transfusion
Presented by the American Society
of Hematology, adapted from Red
Blood Cell Transfusion: A Clinical
Practice Guideline from the AABB
Ann Intern Med. 2012;157:49-58.
Robert Weinstein, MD
University of Massachusetts
Medical School
1

Introduction: Red Blood Cells as a Therapeutic Product
Proper uses of red blood cell (RBC) transfusion
Treatment of symptomatic anemia
Process

Irradiation
Indications

Prevention of TA-GVHD in
certain circumstances:
Technical
Considerations

Radiation dose:
2500 cGy to center
Prophylaxis in life-threatening anemia
Restoration of oxygen-carrying capacity in case of hemorrhage of product
Donor categories
RBC are also indicated for exchange transfusion Gamma or X-
Product donated by family
w Sickle cell disease
irradiation
member
w Severe parasitic infection (malaria, babesiosis)
Shelf life of irradi-
Product from HLA-selected
w Severe methemoglobinemia
ated product: up
donor
w Severe hyperbilirubinemia of newborn
to 28 days unless
Products from directed donors
original expiration
RBC transfusion is not routinely indicated for pharmacologically treatable whose relationship to recipients
date is sooner
anemia such as: family has not been established
NB: Supernatant K+
Iron deficiency anemia Pediatric practice may be higher than
Vitamin B12 or folate deficiency anemia Intrauterine transfusion (IUT) usual
Dosage and administration Exchange or simple transfusion
One unit of RBC will raise the hemoglobin of an average-size adult in neonates if prior IUT Allogeneic HPC
by ~1g/dL (or raise HCT ~3%) Congenital immune deficiency transplant recipient:
ABO group of RBC products must be compatible with ABO group states Start with initiation
of recipient Acute leukemia: HLA-matched or of conditioning
RBC product must be serologically compatible with the recipient family-donated products regimen
(see Pretransfusion Testing). Exceptions can be made in Continue throughout
Allogeneic hemopoietic progenitor period of GVHD
emergencies (see Emergency Release of Blood Products).
cell (HPC) transplant recipient prophylaxis
Rate of transfusion
w Transfuse slowly for first 15 minutes Allogeneic HPC donor 7 days Usually for at
w Complete transfusion within 4 hours (per FDA) prior to, or during, HPC harvest least 6 months

2
Until lymphocytes
Autologous HPC recipient are > 1 x 109/L
Major Red Cell Products for Transfusion
Hodgkin disease Indefinitely if treat-
Most RBC products are derived by collection of 450-500 (10%) ed for chronic
mL of whole blood from volunteer donors and removal of the plas- History of treatment with purine GVHD
ma by centrifugation (see Table 1). After removal of the plasma, the resulting analogues and related drugs
product is red blood cells (referred to informally as packed red blood cells). Fludarabine Autologous HPC
2CDA (Cladribine) recipient
The most commonly available US RBC product has a 42-day blood bank Deoxycoformycin (Pentostatin)
shelf life and HCT 55-65% 7 days prior
Clofarabine (Clolar) to, and during,
Table 1. Special Processing of RBC for Transfusion Bendamustine (Treanda) harvest
Nelarabine (Arranon) Initiation of con-
Process Indications Technical
Considerations History of treatment with alemtu- ditioning through
zumab (anti-CD52) 3 months post
Leukocyte Decrease risk of recurrent febrile, Most commonly transplant
Reduction nonhemolytic transfusion reactions achieved by filtration Aplastic anemia on rabbit anti- 6 months if TBI
Decrease risk of cytomegalovirus Usually soon thymocyte globulin was used

(CMV) transmission (marrow
transplant)
Decrease risk of HLA-alloimmuni-
zation
Does not prevent transfusion-
associated graft-versus-host
disease (TA-GVHD)
Washing Decrease risk of anaphylaxis in
(removes IgA-deficient patient with anti-IgA
residual antibodies
plasma) Decrease reactions in patients with
history of recurrent, severe allergic
or anaphylactoid reactions to blood
product transfusion
3
after collection
(prestorage)
May be per-
formed at bedside
<5x106 leukocytes Pretransfusion Testing
per product (per
Prevents incompatible red cell transfusion
FDA)
Compatibility of donor red cells and recipient plasma
Wash fluid is 0.9% Avoid immune hemolytic transfusion reactions in the recipient
NaCl dextrose
Pretransfusion blood sample from the intended recipient
Shelf life of washed
Usually EDTA tube (plasma and red cells)
RBC
Proper labeling of the sample
24 hours at 1-6C
w 2 independent patient identifiers
4 hours at 20-
w Identity of the phlebotomist
24C
w Date and time of sample collection
May lose 20% of
w SAMPLE REJECTED WITHOUT THESE
red cells in washing
Age of the sample
process
w Up to 3 days if hospital inpatient or, in past 3 months, recipient
- Has been pregnant
- Has been transfused
- Has uncertain history of either
w Longer (often 1-2 weeks, according to hospital policy) for
outpatient pre-op testing if negative history within 3 months
Table 2. Pretransfusion Testing
Blood bank will retrospectively crossmatch all emergently issued units when
Test Purpose Reagents Time it receives the patients testing sample
ABO Group Recipients blood Test recipients red ~25 Blood bank will begin issuing type-specific and crossmatched products
& Rh Type group Rho(D) pos cells with anti-A, min when testing is complete

5
or neg anti-B, anti-D; test
recipients plasma
with A1* and B cells
Antibody Detect unexpected, Test recipients plas- ~50
Screen clinically significant ma with phenotyped min Transfusion of Incompatible RBC
(non-ABO) anti- reagent RBC
Clinical scenario: severe warm (or cold) autoimmune hemolytic anemia
RBC antibodies in
Patients plasma autoantibody reacts with all of the blood banks
recipients plasma
reagent red cells
Antibody Identify specificity of Test recipients Varies: Blood bank unable to determine presence or absence of underlying
Identification anti-RBC antibody plasma with many Hours alloantibodies
if antibody screen reagent RBC to days All RBC units are crossmatch-incompatible
is pos
Balance of risks
Immediate Ensure ABO Test recipients ~10 Severe anemia requiring transfusion support
Spin compatibility plasma with sample min Possibility of hemolytic transfusion reaction due to undiagnosed
Crossmatch between recipients of red cells from underlying alloantibodies
(ANTIBODY plasma and RBC product chosen for
Principles of approach to this situation
SCREEN IS product chosen for transfusion
Communication between bedside clinician and transfusion service
NEGATIVE) transfusion
physician is essential
Full Ensure full Test recipients Up to w Obtain careful history of prior transfusion or pregnancy
Serological serological plasma with sample an hour - If history negative, probably safe to transfuse ABO-compatible
Crossmatch compatibility of red cells from RBC
(WHEN between recipients product chosen for - If history positive or uncertain, assess risk:benefit of delaying
ANTIBODY plasma and RBC transfusion. Includes transfusion to complete testing
SCREEN IS product chosen for extra incubations w Assess how long it may take for blood bank or reference lab to
POSITIVE) transfusion (e.g. at 37C and with complete pretransfusion testing
Coombs reagent). w Agree on best approach to choosing among incompatible RBC
Electronic Match ABO/Rh Validated blood bank ~10- units (transfusion physician will advise)
Crossmatch compatible RBC computer system. 15 min Attempt to mitigate need for immediate transfusion: bed rest, oxygen
from inventory with Ultimately, do not deprive a patient with autoimmune hemolytic anemia of a
(not patient whose ABO/ needed, lifesaving transfusion
universally Rh status has been Autoantibody will shorten survival of transfused RBC and patients
available) confirmed and who endogenous RBC to a similar extent
has no history of, and Most undetected alloantibodies will cause delayed hemolytic
negative testing for, transfusion reactions
RBC alloantibodies w May be misdiagnosed as worsening of autoimmune hemolysis
w Not usually life-threatening
*A1 is the most common subgroup of Group A
Bedside team must be hypervigilant for acute intravascular hemolytic

4
reaction during transfusion (see Section 6 below)

Table 3. RBC Transfusion Recommendations* for Hospitalized,

Emergency Release of Blood Products Hemodynamically Stable Patients in Specific Clinical Situations

Clinical setting precludes waiting for completion of pretransfusion and Clinical Potential Transfusion Evidence Recommen-
compatibility testing Situation Threshold Quality dation
Severe, ongoing, life-threatening hemorrhage ICU Patients Hgb** 7 gm/dL High Strong
Presentation with life-threatening anemia (adult or ped)
What you should do Post- Hgb 8 gm/dL High Strong
Notify blood bank of need for emergency release of RBC Operative or for symptoms
Complete hospitals emergency release form
w Documents your declaration of a transfusion emergency
Cardiovascu- Hgb 8 gm/dL Moderate Weak
w U.S. federal regulations require 2 specific items on the form
lar Disease or for symptoms:
- Statement of the nature of the emergency (e.g. massive GI Acute AABB cannot recom- Very Low Uncertain
hemorrhage) Coronary mend for or against a
- Signature of MD or equivalent; (PA, NP, RN, etc. cannot sign) Syndrome liberal or restrictive RBC
Send patient blood sample to blood bank ASAP (before emergency transfusion strategy
transfusion begins, if possible)
All Patients Guided by symptoms as Low Weak
What you will get from the blood bank (depending on how much testing has well as by Hgb level
already been performed) *Adapted from Red Blood Cell Transfusion: A Clinical Practice Guideline from the
Uncrossmatched RBC (ABO group-specific if determined on a AABB. Ann Intern Med. 2012;157:49-58.
current blood specimen) **Hgb=Hemoglobin level
Group O RBC if blood bank has not documented patients ABO Applicability to hospitalized patients outside of the ICU setting has not been deter-
group on a fresh blood sample mined.
w Rh neg depending on availability and hospital policy, if patients Rh Cannot be generalized to the pre-operative setting, where expected surgical blood
status is unknown loss must be taken into account in transfusion decision making.
Chest pain, orthostatic BP or tachycardia unresponsive to fluids, or congestive heart
failure.
There remains some uncertainty regarding the risk of perioperative myocardial infarc-
tion with a restrictive transfusion strategy.
6 Adverse Effects of Transfusion
The most clinically important adverse effects of transfusion in
medical patients are infectious or immunological phenomena. The
most significant infectious risks are addressed during the donor screen-
ing process, and most blood centers employ bacteriological surveillance
About this Clinical Quick Reference Guide
This guide is adapted from Carson JL, Grossman BJ, Kleinman S et al. Red Blood
Cell Transfusion: A Clinical Practice Guideline from the AABB. Ann Intern Med
2012;157:49-58.
It also presents selected information from:
measures on certain blood products. Roback JD, Grossman, BJ, Harris T, Hillyer CD eds. Technical Manual, 17th Edition.
Bethesda, MD: AABB Press 2011
Table 4. Some Infectious Risks of Blood Transfusion (all products)
Circular of Information for the Use of Human Blood and Blood Components. AABB,
Transfusion-Transmitted Residual Risk Per Transfused ABC, ARC, ASBP. Revised December, 2009.
Infection Component This guide is intended to provide the practitioner with clear principles and strategies for
HIV 1 in 1,467,000 quality patient care and does not establish a fixed set of rules that preempt physician
judgment.
Hepatitis C 1 in 1,149,000
ASH website: www.hematology.org/practiceguidelines
Hepatitis B 1 in 282,000 For further information, contact the ASH Department of Government Relations, Practice,
West Nile Virus Uncommon and Scientific Affairs at 202-776-0544.

Cytomegalovirus 50-85% of donors are carriers. Copyright 2012 by the American Society of Hematology. All rights reserved.
Leukocyte reduction is protective.
Bacterial Infection 1 in 2-3,000 (mostly platelets)
Parasitic Diseases Relatively uncommon
Babesiosis, Chagas, Malaria
American Society of Hematology
2021 L Street NW, Suite 900
Other Important Adverse Effects of Blood Transfusion (STOP transfu-
Washington, DC 20036
sion and return remaining product to blood bank with transfusion
reaction report. Exception: see allergic (urticarial) reaction). www.hematology.org
Acute hemolytic transfusion reaction (AHTR): Preformed antibodies to
incompatible product (1:76,000). ABO incompatibility (1:40,000). Sometimes fatal
(1:1.8x106). Presents with chills, fever, hypotension, hemoglobinuria, renal failure,
back pain, DIC. Keep IV open with normal saline. Keep urine output >1 mL/kg/hour.
Pressors PRN. Treat DIC.
Delayed HTR: Anamnestic immune response to incompatible red cell antigen. May
present with fever, jaundice, falling hemoglobin, newly positive antibody screen in
blood bank. Occurs 1-2 weeks after transfusion. Identify offending antibody in blood
bank. Transfuse PRN with compatible RBC.
Febrile non-HTR: 0.1-1.0%. Due to preformed anti-WBC antibodies in recipient.
Risk minimized with leukocyte-reduced products. 1C (2F) rise in temperature
within 2 hours of start of transfusion with no other explanation for fever.
Acetaminophen premedication if reactions are recurrent.
Allergic (urticarial) reactions: 1-3%. Antibody to donor plasma proteins. Presents
with urticaria, pruritus, flushing, mild wheezing. Pause transfusion, administer
antihistamines; may resume transfusion if reaction resolves, but still report reaction
to blood bank.
Anaphylactoid/anaphylactic: 1:20,000-50,000. Caused by antibody to donor
plasma proteins (IgA, haptoglobin, C4). Hypotension, urticaria, bronchospasm,
angioedema, anxiety. Rule out hemolysis. Administer epinephrine 1:1000 0.2-0.5 ml
SC, antihistamines, corticosteroids.
Transfusion-related acute lung injury (TRALI): ~1:10,000. Preformed HLA or
neutrophil antibodies in donor product. Hypoxemia, hypotension, bilateral pulmonary
edema, transient leucopenia, and fever within 6 hours of transfusion. 10-20% fatal.
Supportive care. Defer implicated donors.
Transfusion-associated graft-versus-host disease: Rare but almost always fatal.
Immunosuppressed recipient receives transfusion from HLA-similar donor (usually
a family member). Pancytopenia, maculopapular rash, diarrhea, hepatitis presenting
1-4 weeks after transfusion. Prevented by irradiating blood products. See Section 2
above.