Transfusions

NHMRC guidelines

• PRBC
  • <70 – Almost always. Lower thresholds if asymptomatic or if specific therapy available
  • 70-100 – Likely appropriate during surgery or signs/symptoms of impaired O2 transport
  • >80 – May be appropriate for symptoms control in patient on chronic transfusion regime or during marrow suppressive therapy
  • >100 – Not likely to be appropriate

NHMRC guidelines

• Platelets
  • Bone marrow failure
    • Plt <10
    • Plt <20 with risk factors: Fever, antibiotics, evidence of systemic haemostatic failure
  • Surgery/invasive procedure:
    • To maintain Plt >50 (or >100 for cardiothoracic, ocular or neurosurgery)
  • Platelet function disorders:
    • May be appropriate if platelet count not reliable indicator (consult haematology)
  • Bleeding:
    • May be appropriate if thrombocytopaenia thought to be a major contribute to haemorrhage
  • Massive transfusion
    • Use should be confined to thrombocytopaenia and/or functional impairment with significant bleeding from this cause
    • May be appropriate if Plt <50 (or <100 with diffuse microvascular bleeding)

NHMRC guidelines

• FFP
  • Single factor deficiencies: Use specific factors if available
  • Warfarin effect: IN the presence of life-threatening bleeding
  • Acute DIC: Indiated if bleeding and abnormal coagulation
  • TTP: Accepted treatment
  • Coagulation inhibitor deficiencies: May be appropriate for high risk procedures
  • Massive transfusion
  • Cardiopulmonary bypass if bleeding with abnormal coagulation
  • Liver disease if bleeding with abnormal coagulation
• Cryoprecipitate
  • Fibrinogen deficiency: May be appropriate if clinical bleeding, invasive procedure, trauma or DIC

Effects of storage on red blood cells

• Immediate effect likely due to volume replacement
• May not be fully functional for 2-6 hours due to decreased 2,3-DPG in storage, loss of red cell viability, reduced deformability, relative acidosis and potassium leakage
• Reduced 2,3-DPG causes leftward shift in Hb-O2 dissociation curve, thus causing red cells to have increased affinity for O2 and reduced tissue release
• Transfused red cells regenerate 2,3-DPG but takes 6-24 hours
• Clinically signicant hypocalcaemia does not occur unless rate of transfusion is >1U per 5 minutes or hepatic dysfunction

Compatibility of PRBC

• O negative blood
  • Rhesus negative in women of childbearing age or young female children
  • Rhesus positive or negative in men
  • 3% risk of adverse reaction
• ABO compatible blood
  • 3% risk of adverse reaction
• X-matched blood with no atypical antibodies identified
  • 0.01% risk of adverse reaction

PRBC checks

• Full cross-match takes 60 minutes
• Type-specific with abbreviated cross-match takes 30 minutes
  • ABO and Rh compatibility
  • Recipient serum screened for unexpected antibodies
  • X-match at room temperature only (vs. 37 degrees)
• Type-specific takes 2 minutes
• Type O blood
  • Can give either Rh + or negative but Rh + risks sensitisation so not suitable for women of child-bearing age

PRBC

• Overall very few patients will not benefit from transfusion if Hb<60 and very few will benefit if Hb >100. If in between, case-by-case decision making applied
• Usual clinical practice to transfuse a minimum of 2U to increase Hct by 6% and Hb by 20g/L
  • Single unit transfusion of minimal benefit given effort required
• In children, 15mL/kg of PRBC = 1 Unit = Hct 3% rise/Hb 10g/L
• Usually given over 2-3 hours (can be faster but must be in by 4 hours)

PRBC

• Variants
  • Leukocyte-reduced
    • 70-85% of leukocytes removed
    • Avoids non-haemolytic febrile reactions due to antibodies to WBC if exposed to previous transfusions or pregnancies
    • Prevents sensitisation in patients who may be eligible for bone marrow transplant
    • Minimises risk of virus transmission such as HIV and CMV
  • Irradiated PRBC
    • Eliminates capacity of T-lymphocytes to proliferate, thus preventing graft-versus-host disease
    • Should be considered in transplant patients, neonates and the immunocompromised
  • Washed PRBC
    • Indicated for those with hypersensitivity to plasma e.g. IgA deficiency or repeated allergic reactions to red cells

Irradiated products

• Used to prevent GVHD (occurs when donor T lymphocytes attack recipient  in the setting of immuosuppression
• Red cells, granulocytes and platelets
• Not required for FFP, cryo, albumin or IVIG

Irradiated products

• Indications
  • Haematopoietic stem cell transplant (before and 12 months after)
    • Solid organ transplants do not need irradiated blood productsas not as intensely immunosuppressed and rates of transfusion-associated GVHD are much lower
  • Congenital severe immune deficiency
  • Aplastic anaemia treated with anti-thymocyte globulin
  • Granulocyte transfusions
  • Purine analogue therapy
  • HLA-matched single donor platelets
  • Leukaemia
  • Lymphoma

CMV-negative products

• Red cells and platelets
• Patients have to be confirmed CMV negative
• Indications
  • Pregnancy
  • Likely to have stem cell transplant
  • Immunodeficiency
  • HIV
  • Heart/lung/kidney organ transplant

Platelets

• Can be prophylactic or therapeutic
• One apheresis-collected single donor platelet concentrate contains 3-6×10^11 platelets
  • Will increased platelet count by 50
  • Should survive 3-5 days (lower in thrombocytopaenic patients as 7-10 000/microlitre are used daily to plug endothelial gaps
  • If failure to respond, suggests:
    • Increased consumption of platelets due to ongoing underlying process
    • Active thrombosis due to ongoing haemorrhage
    • Destruction due to platelet antibodies
    • Sequestration due to hypersplenism
  • Should check response at 1-24 hours
  • If collected from whole blood, need 6 donors to achieve one dose (which increases risk of disease transmission)

Platelets

• Cause of thrombocytopaenia dictates transfusion thresholds
  • ITP: Platelets that do exist are younger, larger and more functional so even very low platelet levels have minimal bleeding complications
  • Platelet hypoplasia: Platelet function is impaired so even higher levels of platelets still carry risk of haemorrhage
  • Those with comorbid infection, fever, medications and CNS involvement may be more likely to bleed and threshold may be lower
• Type-specific
  • Platelets are bathed in plasma so should be type specific
  • Non-typed platelets are sometimes used but should be avoided in children or patients receiving multiple transfusions. May have shorter half-life.

Platelets

• Non-functional platelets and active bleeding
  • Antiplatelet medications, vWF deficiency, uraemia of hyperglobulinaemia
  • Consult with haematology as no clear guideline exists
• If repeated transfusions, risk of alloimmunisation and poor response to platelet transfusion
  • Need HLA-matched or cross-matched platelets
• Leukocyte-reduced platelets and washed platelets also available
• Contraindications to platelet transfusion
  • TTP, HITS may have worsened thrombosis 
  • Consult with Haematology

Platelets

• General indications
  • Plt <10 asymptomatic (unless ITP, DIC, TTP or HITS)
  • Plt <15 with coagulation disorder or minor bleeding
  • Plt <20 with major bleeding
  • Plt <50 with invasive procedure (thoracentesis, paracentesis or general surgery) or massive transfusion
  • Plt <100 with neurologic, opthalmological or cardiac surgery
• In ITP/DIC/TTP/HUS/snake envenomation
  • Only use as last resort if life-threatening haemorrhage

Fresh frozen plasma

• 200-250mL of blood with RBC and platelets removed
• Contains 1U of all coagulation factors and 2mg fibrinogen/mL
• Appropriate for rapid replacement in multiple coagulation deficiencies
  • Liver failure
  • Warfarin overdose
  • DIC
  • Massive transfusion in bleeding patients
  • Antithrombin III deficiency
  • TTP (if indicated)
• Also useful for specific coagulation deficiencies
• FFP has INR of 0.9-1.2 so transfusion will not improve INR beyond 1.2 to 1.3 normally
• Not indicated for prophylaxis in non-bleeding patients
• Pre-procedural prophylaxis for paracentesis, thoracentesis
  • Only if INR, APTT or PT >2x ULN 
• May also be indicated for antithrombin deficiency and hereditary angioedema

FFP

• Takes 20-40 minutes to thaw
• For isolated factor deficiencies, specific factor replacement is safer and better
• 1U of FFP will increase most coagulation factors by 3-5% in 70kg adult
• Giving 2U is essentially inconsequential
• Need 15mL/kg (or 4U in 70kg adult) for relevant correction of coagulopathy
• Should be ABO-compatible to avoid donor Anti-A or Anti-B haemolysis
• Give as rapidly as possible if actively bleeding or 10mL/min (30 minutes total)
• Rhesus compatibility is not required
• 4U = 10% coagulation activity and is minimum required replacement for each blood volume (5L) replaced

Cryoprecipitate

• Cold insoluble protein fraction of FFP
• 1U volume is 20-50mL and contains 225mg fibrinogen and 80IU of Factor VIII and vWF
• Also contains some Factor XIII and fibronectin
• ABO compatible preferred
• Primarily used for replacement of fibrinogen or vWF (previously was for Factor VIII replacement in haemophilia but not anymore)
• Bleeding patients with fibrinogen <1.0g/L due to severe liver disease, DIC or dilutional coagulopathy may benefit from cryoprecipitate, although minimal evidence of improved outcomes
  • Some evidence for targeting fibrinogen 1.5-2.0 in severe haemorrhage
• Dose is 1U/5-10kg bodyweight which should raise fibrinogen by 0.75g/L (usually 10U at a time)
• Give at 10mL/min

Fibrinogen concentrate

• May be indicated if fibrinogen levels not >1.0 g/L despite FFP
• Haematology involvement is key
• Only licensed for bleeding in congenital fibrinogen deficiency
• 900-1400mg per vial
• No cross-match required
• Half-life is 2.7 days
• Dose 4-8g (4g increases levels by 1g/L) = 70mg/kg
• Deliver at <5mL/min
• Increasing data has shown Fibrinogen level of 1.5g/L may be safer for major bleeding and must be maintained for 7 days
• Only use if ongoing bleeding
• Current guidelines at PAH would suggest fibrinogen concentrate or Cryo 20IU if FIBTEM A5 <8mm vs. Cryo precipitate 10IU if FIBTEM A5 8-10mm

Prothrombin complex concentrate

• Prothrombinex
• Sterile, freeze-dried powder prothrombin complex concentrate
• Advantages over FFP
  • Small volume
  • ABO compatibility not required
  • INR reversal within 15 minutes
  • No time delay in thawing
  • Rapid administration
• 500 units contains Factors II, IX, X (low levels of VII, V), heparin (200IU) and antithrombin (25IU)
• Indications
  • Prophylaxis or treatment of deficiency in Factor II, IX, X
  • Reversal of anticoagulation in significant bleeding
    • 70% effective in NOAC-related haemorrhage
    • More effective in warfarin reversal
• Lasts 12-24 hours
• Deliver at 3mL/min

PCC

• Dose
  • 25-50U/kg = 0.5-1 vial / 10kg body weight
  • 25U/kg provides 50% of normal factor replacement (except V, VII)
  • 50IU/kg provides 100% normal factor replacement
• INR
  • >6 – 50U/kg
  • 4-5.9 – 35U/kg
  • 2-3.9 – 25U/kg

IVIG

• Pooled IgG that has been virally attenuated
• Indications include ITP, paediatric HIV, primary humoral immunodeficiency, GBS, Kawasaki disease and some autoimmune disorders

Albumin

• Virally inactivated purified plasma protein
• May transiently increase oncotic pressure in plasma in those with reduced plasma oncotic pressure, but albumin still rapidly redistributes to extravascular spaces
• No advantage in volume resuscitation

Antithrombin

• Indicated in antithrombin deficiency-related thrombosis and thrombosis prophylaxis during procedures
• Only used if difficulty with heparinisation or recurrent thrombosis despite therapeutic anticoagulation

Massive transfusion

• Definition: Replacement of one blood volume OR 10U of PRBC in 24 hours
• Others define as 50% blood volume in 4 hours
  • Blood volume 70mL/kg
• In children defined as 40% of blood volume in 4 hours
  • Blood volume 80mL/kg
• Some experts advocate 1:1:1 ratio of PRBC:FFP:Platelets (6 pooled or 1 apheresis)
• The presence of an MTP protocol alone improves mortality

Complications of transfusion

• 20% of all transfusions lead to a complication
• Immediately stop transfusion and contact blood bank/haematology immediately
• Take a new specimen for re-typing and cross-matching for further transfusions
• Divided into:
  • Immunological acute
  • Non-immunological acute
  • Immunological delayed (>24 hours)
  • Non-immunological delayed (>24 hours)

Transfusion adverse reactions

• Immunological acute (<24 hours)
  • Haemolytic acute 1/76 000
  • Haemolytic fatal 1/1.8 million
  • Febrile non-haemolytic transfusion reaction 0.1-1%
  • Mild allergic 1-3%
  • Anaphylaxis 1/20000 – 50 000
  • TRALI 1/1200 – 1/190 000

Transfusion adverse reactions

• Non-immunological acute (<24 hours)
  • Massive transfusion complications
  • Non-immune mediated haemolysis (physical or chemical) – Rare
  • Transfusion transmitted bacterial infection – 1/ 250 000 platelets
  • Transfusion transmitted bacterial infection – 1/2.5 million red cells
  • Transfusion-associated circulatory overload (TACO) – 1/100 transfused platelets

Transfusion adverse reactions

• Immunological delayed (>24 hours)
  • Delayed haemolytic transfusion reaction – 1/2500 – 1/11 000
  • Post-transfusion purpura – Rare
  • Transfusion-associated GVHD – Rare
  • Alloimmunisation – RBC antigens 1/100
  • Alloimmunisation – HLA antigens 1/10
  • Transfusion-related immune modulation (TRIM) – Unknown

Transfusion adverse reactions

• Non-immunological delayed (>24 hours)
  • Iron overload requiring chelation – May occur with 10-20 PRBC
  • Iron overload with organ dysfunction – May occur with 50-100 PRBC
  • Transfusion transmissible infection

Acute intravascular haemolysis

• Fevers, chills, lower back pain, dyspnoea, tachycardia, shock, haemoglobinuria
• Need high degree of suspicion in already critically ill patients
• Haemolysis of donor red blood cells by recipient antibodies
• Mostly ABO/Rh or non-ABO alloimmunised incompatibility and technical/identification errors
• 1 in 12 000 – 38 000 with 1/1 million mortality
• Morbidity and mortality correlated to how much donor blood received prior to cessation. This is why in non-emergent transfusion, should give at slow rate for first 30 minutes to identify transfusion reaction
• Can result in DIC and anaphylactic-type reaction
• Stop transfusion, IV fluids to maintain diuresis, cardiorespiratory support as required

Acute intravascular haemolysis

• Ix
  • Retype and repeat X-match
  • Direct and indirect Coombs
  • FBC, creatinine, PT, APTT
  • Haptoglobin, unconjugated bilirubin, LDH, plasma free Hb
  • Urine for haemoglobin
• Rx
  • Stop transfusion and Ix as above
  • Maintain BP and urine output
  • Induce diuresis with fluids and diuretics
  • Consult blood bank and Haematology

Febrile non-haemolytic transfusion reaction

• Fever and chills during or within 6 hours of transfusion defined as >=38 or rise in temperature by 1 degree above baseline
• 1 per 300 units 
• Diagnosis of exclusion
• 20% of non-leukocyte reduced transfusions vs. 2% if leukocyte-reduced
• More common in multiparous women or those with multiple prior transfusions
• Due to combination of recipient antibodies to donor leukocytes and release of cytokines produced during blood product storage
  • Most commonly platelets
• Stop transfusion, manage as for acute haemolysis as impossible to differentiate non-haemolytic from haemolytic in early stages
• Can treat fever and chills with paracetamol
• Usually mild but can be dangerous if cardiopulmonary instability
• Consider infectious workup
• Still need haemolytic workup as for acute haemolytic reaction
• Can re-start transfusion at a slower rate if other causes of fever have been excluded

Febrile non-haemolytic reaction

• Mild reaction
  • Temp rise <1.5 degrees
  • No rash or severe systemic features
  • Recommence transfusion at slower rate
• Moderate reaction
  • Hives
  • Temp increase >1.5 degrees
  • Phenergan 50mg PO + paracetamol 1g PO
  • Recommence after 20 minutes at slower rate
  • Cease transfusion if symptoms return and send new EDTA sample + blood pack back to lab
• Severe reaction
  • Stop and send back with new EDTA sample

Allergic reaction

• Mild fever, urticaria, pruritis through to anaphylaxis
• Seen in 1-2% of transfusions
• Anaphylaxis in 1/20 000 to 50 000 units
• Due to immune response to plasma proteins in donor blood product
• Most common with FFP
• Stop transfusion, phenergan if mild, adrenaline if severe +- glucocorticoid
• Notify blood bank
• If severe (>2/3 body or other signs of anaphylaxis), do haemolytic workup and IgA levels
  • IgA deficient patients may have more severe reactions to donor IgA
• Washing plasma from transfusion product may help prevent this

Severe allergic reaction

• Usual causes
  • IgA deficient patients who have anti-IgA antibodies
  • Patient antibodies to plasma proteins (IgG, albumin, haptoglobin, transferrin, C3/C4 or cytokines)
  • Transfusing an allergen e.g. penicillin in donor blood
  • IgE antibodies in transfusion from donor to allergen present in recipient
• Ix
  • DAT, FBC, repeat ABO
  • Check pretransfusion recipient IgA and anti-IgA antibodies if levels are low
• Stop transfusion
• Treat as for anaphylaxis

Transfusion-related acute lung injury

• TRALI within 24 hours
• Acute onset fever, chills, dyspnea, tachypnoea, tachycardia, hypotension, hypoxaemia and non-cardiogenic pulmonary oedema infiltrates within 6 hours of transfusion
• MOST COMMON CAUSE OF TRANSFUSION-ASSOCIATED FATALITY
• 1 in 5000 to 100 000 units (1 in 5 million mortality)
• Passive transfer of HLA or human neutrophil antigen antibodies in donor plasma are directed against the recipient’s leukocyte antigen with subsequent granulocyte recruitment and degranulation within lung tissue causing damage to lung vasculature
• Usually due to FFP or platelet transfusions vs. PRBC
• Bilateral pulmonary infiltrates due to non-cardiogenic pulmonary oedema during or within 6 hours of transfusion
• Self-limiting but does require supportive care
• Aggressive diuresis for mistaken cardiogenic pulmonary oedema can cause rapid deterioration

TRALI

• Need to differentiate from anaphylaxis, acute haemolytic, transfusion-associated sepsis, TACO, APO
• Send donor and recipient serum for HLA and HNA antibodies + HLA typing of recipient
• Support cardiorespiratory system
• Avoid diuretics

Complications of massive transfusion

• Hypothermia
• Dilutional coagulopathy
• Hypocalcaemia, hypomagnesaemia, citrate toxicity
• Metabolic acidosis
• Hyperkalaemia
• Air embolism

Non-immune mediated haemolysis

• Usually benign
• Fever, tachycardia +- haemoglobinuria and haemoglobinaemia
• Rare
• Causes
  • Transfusion under pressure
  • Overheating of cells
  • Infusion of red cells with hypotonic solutions or drugs
  • Bacterial contamination of red cell unit
  • Old red cells
  • Patients underlying haemolytic disease
• Rx
  • Rule out immune-mediated (DAT) and repeat ABO
  • Stop transfusion
  • Maintain haemodynamics + induce diuresis

Transfusion-transmitted bacterial infection

• Sepsis during or soon after transfusion
• 1/250 000 platelets and 1/2.5 million red cells
• Esp. Yersinia enterocolitica
• Key to diagnosis is culturing same organism from patient and PRBC
• Stop transfusion
• BC (from opposite arm), broad-spectrum antibiotics (PipTaz + Vanc), support cardiorespiratory
• Notify blood service

TACO

• Transfusion-related circulatory overload
  • Due to heart failure
• 2^nd leading cause of transfusion-related fatality
• Any 4 of the following within 6 hours:
  • Acute respiratory distress
  • Tachycardia
  • Hypertension
  • Acute or worsening pulmonary oedema on CXR
  • Evidence of positive fluid balance
• Raised BNP provides useful evidence
• Hypertension is a constant feature of TACO but is rare/transient in TRALI
• Give diuretics with transfusions in high risk patients and give slowly

Delayed haemolytic transfusion reactions

• 2-14 days post-red cells. Presents as less severe acute haemolytic reaction
• Fever, inadequate rise in Hb, jaundice, high LDH, reticulocytosis, spherocytosis, positive DAT and positive antibody screen
• 1/2500
• Typically previously developed antibodies too weak to be identified in pre-transfusion testing but subsequent transfusion leads to an amnestic antibody response and haemolysis
  • Kidd > Duffy > Kell > MNS
• Need same Ix as intravascular haemolysis

Post-transfusion purpura

• Rare delayed dramatic self-limiting thrombocytopaenia (Plt <10 in 80% of cases) 7-10 days after blood transfusion
• Thrombocytopaenia lasts 2 weeks
• 5x more common in females due to pregnancy
• Due to antibodies to platelet-specific antigens
• Ix – Antiplatelet antibody levels
• IVIG 1g/kg as single dose and repeat as necessary
• Steroids and plasma exchange if refractory

Transfusion-associated GVHD

• Transfusion of viable donor T-lymphocytes, which proliferate and damage skin, GI tract, liver, spleen and bone marrow of recipient
• Rare and almost always fatal
• Clinical signs arise 10-14 days after transfusion with fever, erythematous skin rash, pancytopaenia, diarrhoea and abnormal lFT
• Leads to profound marrow aplasia with mortality >90% (overwhelming infection)
• High risk patients are bone marrow transplant recipients, transfusions from biologically-related donor, a fetus, exchange transfusion, Hodkin lymphoma
• Need skin or intestinal biopsy to confirm diagnosis
• Gamma irradiation of cellular components is the only method of prevention

Red cell alloimmunisation

• Alloimmunisation = Antibodies formed against foreign antigens from ones own species
  • Against red cells, HLA or HPA (human platelet antigen)
• Transfused non-leukocyte deplete red cells and platelets contain leukocytes to which antibodies can be generated
• Results in acute or delayed haemolytic reaction and haemolytic disease of the newborn
• 1% of red cell transfusions result in alloimmunisation
• Those with selected high-risk transfusion-dependent diseases e.g. sickle cell anaemia, beta-thalassaemia major need leukocyte-deplete blood products + phenotypically-matched blood products (HLA, Rhesus and Kell useful, others not clear)

Platelet alloimmunisation

• Both HLA and HPA alloimmunization can cause platelet refractoriness with less than expected rise in Plt
• Seen in 20-70% of those receiving multiple Plt transfusions
• Can result in post-transfusion purpura

Transfusion related immune modulation (TRIM)

• Transient immunosuppression following allogeneic blood transfusion
• Unknown mechanism
• May improve transplant acceptance or increase risk of bacterial infection/cancer recurrence

Infectious complications of transfusion

• Window period is most concerning for risk
• Antigen testing minimises this but does not abolish risk entirely
• CMV antibodies in general population in 50-80%
• Units are not tested for this unless recipient is seronegative + pregnant, potential or future transplant candidate, immunocompromised or premature infant
  • Leukocyte-reduced blood components also reduces risk of CMV transmission as most virus resides in WBC and may be equivalent
• Yersinia enterocolitica can grow in refrigerated blood and lead to bacterial sepsis in recipient if donor was bacteraemic at time of donation
• Risk of bacterial sepsis is 1/500 000 units and 1/6 million for platelets

Blood screening

• In Australia, blood is screened for:
  • HIV 1 and 2
  • Hepatitis B and C
  • HTLV 1 and 2
  • Syphilis

Risk of infection

• CMV 1 in 127 000
• HIV: <1 in 1 million
• HTLV: <1 in 1 million
• Syphilis: <1 in million
• HepB: <1 in 1 million
• HepC: <1 in 1 million
• Parvovirus B19: 1 per 10 000 units
• Variant CJD: Possible and cannot be excluded
• Malaria: <1 in 1 million
• Bacterial sepsis:
  • 1 per 6 million platelet apheresis units
  • 1 per 40000 to 500 000 PRBC units (1 in 4-8 million mortality)

Electrolyte disturbance

• Hypocalcaemia, hypokalaemia and hyperkalaemia are all seen
• Citrate chelates calcium but is normally cleared effectively by the liver
  • Hepatic metabolism impaired by hypotension, hypothermia and liver disease
• Seen if infusion >100mL/min
• iCa <0.7 impairs coagulopathy, iCa <1 increases mortality
• In massive transfusion or hepatic impairment, may get clinical effects of hypocalcaemia
  • Early symptoms include metallic taste or perioral paraesthesia
• Bicarbonate can cause alkalaemia and subsequent hypokalaemia
• Potassium content of blood products rises with time in storage carrying risk of hyperkalaemia, especially in children and those with renal impairment
• Hypernatraemia can result from sodium content of whole blood and FFP in sodium citrate form

Potential future solid organ or bone marrow transplant recipients

• Consider immunosuppression at the time of transfusion to prevent alloimmunisation i.e. tacrolimus

Last Updated on March 8, 2023 by Andrew Crofton