HOSPITAL ADVISORY COMMITTEE
TRANSFUSION SUBCOMMITTEE
SUBJECT:
Surveillance to Monitor Transfusion Practices at The University of Iowa Hospitals and Clinics.
REASON FOR PERFORMING SURVEILLANCE:
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires Hospital Transfusion Committees both to review the appropriateness of all transfusions and to strive to correct transfusion practices that deviate from Hospital guidelines. The development of guidelines promotes the multi-disciplinary interactions needed to agree on fairly consistent practices, and the audit requires us to justify our transfusion practices. This process is not intended to dictate or to limit transfusion practices.
A major impetus for this requirement is the fact that transfusions may be accompanied by significant adverse effects. Although rare, some of these effects can be life-threatening. For example, the risk of either post-transfusion hepatitis or HIV per donor exposure is estimated to be about one per 1,000,000 to one per 2,000,000. Because of the rarity of posttransfusion hepatitis and HIV, these risks actually are not known. Other infections (human lymphotropic retroviruses, cytomegalovirus, West Nile virus, malaria, toxoplasmosis and E-B virus) are generally of lesser concern, but they can be fatal.
A second serious complication of transfusions is alloimmunization to blood cell antigens. Immunization to erythrocyte antigens occurs at a rate of 1 to1.5% per each donor exposure. Similarly, immunization to leukocyte and platelet antigens by transfusion of nearly any type of cellular blood product increases risks of febrile transfusion reactions and sometimes makes it nearly impossible to find compatible blood products for later transfusions (e.g., platelet transfusions for patients who have become refractory). Finally, transfusions can modulate the immune response. On one hand, this effect may enhance solid organ allograft engraftment. On the other hand, some investigators have reported that transfused patients have immune suppression that results in greater numbers of postoperative infections, decreased survival from cancer, and increased rates of multi-organ failure when compared to comparable patients who have not been transfused. Attempts have been made to minimize these controversial effects by autologous transfusions and leukocyte-reduction of allogeneic blood components, but these efforts are questionably effective.
In addition to these potential adverse effects, it is becoming apparent that fewer donors are acceptable because of new screening procedures, and that supplies of blood are diminishing and are at risk of not meeting patient needs. Thus, blood components must be transfused judiciously. Another reason for reviewing practices is the impression, at a national level, that transfusions are not always given with clear indications that they truly benefit patients. Thus, in the interest of patient care, we must continue to carefully monitor transfusion practices.
POLICY:To comply with JCAHO standards, medical records will be reviewed on a continuing basis using guidelines for transfusion practice developed by the Transfusion Subcommittee and contained within this document. These guidelines were designed to facilitate a uniform and accurate review. It is impossible to anticipate every clinical situation and, understandably, medical reasons may exist to justify transfusions that do not fit within the guidelines. In such instances, as described in the following section, an additional explanation or justification for the transfusion will be sought from the attending physician who is responsible for the care of the patient—rather than making the judgment based entirely on the review by Medical Records Staff.
PROCEDURE:
The following guidelines have been written and periodically updated by the Transfusion Subcommittee for Medical Records (MR) staff to use during medical record review. When one or more of the guidelines that generally indicate need for transfusion can be found in the medical record, the transfusion will clearly fit within Hospital guidelines of accepted practice and the review will be complete at this point. Transfusions given in the complete absence of these guidelines may be perfectly appropriate for the clinical circumstances present, but will require further review (i.e., the clinical circumstances present must be explained to justify the transfusion). If review of the audit documents does not offer a satisfactory justification, the attending physician responsible for the patient's care and/or supervision of house staff involved will be contacted and will be required to submit a brief letter of justification to the Subcommittee. After receipt of the letter, members of the Subcommittee will review the transfusion episode in light of the audit review information plus the letter of justification and act accordingly. Presumably, many apparently unjustified transfusions will be easily explained by additional history. As is necessary in review procedures, however, the Subcommittee will refer repetitive or unusually serious incidents to departmental heads or to appropriate Subcommittees of the Hospital Advisory Committee that are concerned with medical practices, credentials, etc.
GENERAL PLANS TO CONDUCT TRANSFUSION PRACTICE SURVEILLANCE:
1. A predetermined number of patient medical records will be selected for review on the basis of blood products dispensed from the DeGowin Blood Center. This will include a sampling of blood components issued within the previous seven days. The list of patients will be provided to Medical Records staff Monday thru Friday. Prompt review is mandatory. If a record cannot be reviewed within 72 hours, Medical Records staff will request a new case to substitute for the original one.
2. Following Medical Records staff review of patient medical records, if the transfusion appears to not be justified, the transfusion review materials plus a letter requesting additional information must be sent to the attending physician involved to ensure that she/he has opportunity for input. For transfusions given in the operating room and/or the surgical intensive care unit, letters will be sent to both the attending surgeon and the attending anesthesiologist or intensivist.
3. If the attending physician fails to respond within 10 days to the letter of inquiry, a reminder will be sent. If there is no response within 10 days, the transfusion will be considered to be not justified. In addition, a copy of this request for a response will be sent to the physician’s department head.
4. Information from the audit review worksheet and from the attending physician's letter of justification will be reviewed by a member of the Transfusion Subcommittee, who will present the information and offer a recommendation at a meeting of the Transfusion Subcommittee. Members of the Subcommittee will judge the appropriateness of each questioned transfusion individually and will vote, with a simple majority prevailing. To provide feedback, the physician involved will then be sent a letter from the Transfusion Subcommittee reporting results of the review. In many instances, it is likely that the additional history supplied by the physician's letter will justify the transfusion. When justification is not apparent, however, the physician will be informed about Hospital transfusion policies in writing and by personal contact with a selected Subcommittee member.
5. All physicians are offered the opportunity to appeal to the Subcommittee in writing if he/she proposes to revise the transfusion practice guidelines. It is clear that guidelines must change as acceptable transfusion practices change. Also, guidelines can not be all inclusive and still be manageable for review purposes. Thus, the Subcommittee recognizes its responsibility to consider all suggestions for change that are presented in written form with appropriate documentation. Appropriate documentation might include literature citations, personal data that have been analyzed to convincingly support the proposed revision, or evidence (such as letters of support) that the proposed change is a standard of practice recognized by at least three other university medical centers.
SPECIFIC MEANS FOR CONDUCT OF THE SURVEILLANCE:
It is to be emphasized that the transfusion practice guidelines presented on the following pages are not to serve as medical indications for transfusion. Clearly, not all patients who might be eligible for a transfusion according to the guidelines, actually would benefit from one. Also, transfusions may be necessary for patients who fail to fit the guidelines. Thus, these guidelines simply list clinical circumstances in which transfusions might be given without need for additional justification. They are not to forbid transfusions given for additional conditions.
GUIDELINES FOR RED BLOOD CELL (RBC) TRANSFUSIONS
RBC transfusions should not be given simply in response to a given blood hemoglobin or hematocrit laboratory value; a clinical indication must also be present.
No Further Justification for RBC Transfusion is Required if One or More of the Following can be found in the medical record:
1. Critically ill patients (e.g., trauma, perioperative period, sepsis):
a. < 7 g/dL (< 21% HCT) without significant heart, lung, vascular, renal or neural disease.
b. <9 g/dL (< 27% HCT) with significant underlying heart, lung, vascular, renal or neural disease.
c. For patients with sepsis, transfusion is justified to maintain a Hct of > 30%.
2. Acutely bleeding patients as might be indicated by: Rapid (within four hours) blood loss of > 15% of total blood volume regardless of the measured blood hemoglobin or hematocrit value. This would correspond to a recorded volume lost, or need to replace with intravenous fluids, of 10 ml per kg patient body weight (e.g. 700 ml blood loss with 4 hrs in a 70 kg patient).
Other evidence for serious acute bleeding might include mention in the medical record of circumstances often associated with acute, rapid, serious, massive bleeding (e.g., "massive or serious gastrointestinal bleeding" or "acute hemoptysis") in a patient with hemoglobin < 10 g/dl (hematocrit < 30%).
3. Patients with marrow failure and blood hemoglobin concentration < 10 g/dl (HCT < 30%) PLUS a diagnosis of progenitor cell transplant or cancer such as leukemia, lymphoma, carcinoma, sarcoma, or precancerous state or evidence of severe bone marrow hypoplasia as by the diagnosis of aplastic or hypoplastic anemia.
4. Patients with chronic anemia (myelofibrosis, refractory anemia, chronic inflammation) with blood hemoglobin concentration < 8 g/dl (HCT < 24%) PLUS evidence of either diminished circulating blood volume (hypovolemia), poor oxygen delivery to tissues (hypoxia or cyanosis), congestive heart failure, or angina (chest pains believed to be of ischemic cardiac origin). If the clinical criteria for transfusion are not mentioned in the physician's note, they may be suggested by the following criteria present in the medical record:
a. systolic blood pressure < 90 mm Hg or a fall of systolic blood pressure of > 40 mm Hg within 4 hrs prior to transfusion
b. diastolic blood pressure < 40 mm Hg or a fall of diastolic blood pressure > 40 mm Hg within 4 hrs prior to transfusion
c. Heart rate > 100/min. within 4 hrs prior to transfusion
d. Pulse oximetry of < 90% saturation or arterial blood PO2 < 70 mm Hg
e. radiology report noting cardiomegaly or pulmonary edema
f. peripheral edema and/or, rales in chest and/or, gallop heart sounds
GUIDELINES FOR WHOLE BLOOD TRANSFUSIONS *
* Review of whole blood transfusions discontinued September, 1992, because whole blood is not available for transfusion.
GUIDELINES FOR FRESH FROZEN PLASMA TRANSFUSIONS
Fresh frozen plasma and plasma frozen within 24 hours of collection will be used interchangeably and, for convenience, both will be referred to as fresh frozen plasma. Fresh frozen plasma should not be transfused simply as a plasma volume expander; instead, infuse a sterile crystalloid or colloid solution. Plasma transfusions are indicated only to replace plasma proteins that are likely to be deficient in the recipient's plasma, and when the deficiency is considered to be clinically significant. When available, commercial concentrates of individual plasma proteins are preferred to treat single protein deficiencies because they are generally safer.
No Further Justification for FRESH-FROZEN PLASMA Transfusions is Required if One or More of the Following can be found in the medical record:
1. To treat congenital coagulation factor deficiencies except von Willebrand’s disease for which DDAVP, commercial concentrates or cryoprecipitate should be used; Factor VIII disorders for which commercial Factor VIII concentrates should be used; Factor IX disorders for which Factor IX concentrates should be used; Factor VII deficiency for which Factor VIIa concentrates should be used; and hypofibrinogenemia for which cryoprecipitate is indicated. Antithrombin III and activated protein C concentrates have been approved and should be considered as an alternative to plasma. Factor XII deficiency does not require plasma replacement.
The medical record (physician progress note within 24 hrs of the transfusion in question, the physician admitting note written at the beginning of the current hospitalization, or the physician progress note written at the beginning of a series of plasma transfusions) should state that the patient has deficiency of Factor II, V, X, XI, XIII, antithrombin III, protein C, protein S or plasminogen. Alternatively, when such a note is not evident, a laboratory report should show that < 50% of the protein in question is present in the patient's plasma.
2. To treat acquired coagulation problems including, but not limited to, liver disease, vitamin K deficiency, or warfarin (coumadin, coumarin) effect as mentioned in the physician progress notes written within 24 hrs of the transfusion in question, in the physician admitting note at the beginning of the current hospitalization, or in physician progress notes written at the beginning of a series of plasma infusions.
Patients with these conditions should exhibit prolonged partial thromboplastin time and/or prothrombin time using current normals PLUS either the presence of overt hemorrhage or mention of plans to perform an invasive procedure within 12 hrs. The interval of > 12 hrs would permit an attempt to correct the clotting abnormalities with vitamin K therapy, so that plasma may not be needed.
3. To provide clotting factors during treatment of massive blood transfusion in which > one blood volume of total fluids has been infused intravenously in < 24 hours. If the volume of blood lost has been recorded, measured or estimated in the medical record, the volume lost can be related to the assumed normal blood volume of 70 ml/kg (e.g., a 70 kg patient has an estimated blood volume of 4900 ml and would be considered to require massive blood transfusions if the recorded volume of blood lost exceeded 4900 ml or if the patient had received > 4900 ml of intravenous fluids within 24 hrs). Alternatively, the physician's note may state that "massive" blood loss is occurring and plasma may be given without need for documentation of blood loss and/or replacement.
Whenever plasma is given for massive blood loss, clotting studies (minimum of PT, PTT, fibrinogen and platelet count) should be done within 6 hours, before or after, transfusion. If not performed, the physician must be sent a letter, before the audit is discussed at a Transfusion Subcommittee meeting, requesting information to justify plasma transfusion in the absence of documented abnormal clotting studies. To justify plasma infusions for smaller volumes of blood lost (i.e., < 70 ml/kg), the patient must exhibit active hemorrhage (as mentioned in the clinical progress or operative notes) and prolongation of either the partial thromboplastin time or the prothrombin time noted within 6 hours, before or after the transfusion.
4. Treatment of thrombotic thrombocytopenic purpura and related disorders by infusion or plasma exchange and as treatment for other disorders in which plasma exchange is specifically indicated as stated on the Blood Center consultation sheet.
GUIDELINES FOR PLATELET TRANSFUSIONS
Platelet transfusions should not be given simply in response to a given blood platelet count. The underlying mechanism causing thrombocytopenia and the clinical risks of thrombocytopenia must be considered.
No Further Justification for PLATELET Transfusions is Required if One or More of the Following can be found in the medical record:
1. Blood platelet count < 50,000/ul and either significant active bleeding as recorded in physician notes or suggested by fall in hemoglobin of 2 g/dl (Hematocrit 6%) within 24 hours prior to transfusion or a trauma patient or one in the perioperative period (up to 3 days postop or patient in ICU) or a patient scheduled to undergo an invasive procedure such as biopsy, thoracentesis, lumbar puncture, bronchoscopy, etc.
Transfusion of platelets to bleeding or injured patients with blood platelet counts > 50,000/ul can be justified only by continued bleeding thought due to thrombocytopenia (i.e., other clotting studies normal); demonstration of qualitative platelet defect (see item 3).
2. Blood platelet count < 10,000/ul and no evidence of significant bleeding PLUS bone marrow failure by a diagnosis of progenitor cell transplant, or cancer such as leukemia, lymphoma, carcinoma, sarcoma, or precancerous state or evidence of severe bone marrow hypoplasia as by the diagnosis of aplastic/hypoplastic anemia or myelodysplastic syndrome. Transfusion at a blood platelet count of 10,000 to 20,000/ul in this "prophylactic" setting is justified only by factors that increase the risk of bleeding (e.g. active infection, liver disease with abnormal clotting study results, renal failure).
3. Mention of active bleeding in physician, anesthesia or operative notes in patients likely to have qualitative (functional) platelet defects — regardless of blood platelet counts. Patients with qualitative platelet disorders should not receive platelet transfusions unless they exhibit bleeding or are to undergo an invasive procedure. Such patients may be identified by either the diagnosis of a "qualitative or functional" platelet disorder (e.g., storage pool disease) mentioned in physician progress note or by a diagnostic platelet function test reported to be abnormal. Abnormal results of platelet function tests are poorly predictive of bleeding risk and should not, by themselves, serve to justify a platelet transfusion.
4. Acute, massive bleeding in any patient regardless of clotting studies, except as follows:
a. The first transfusion of platelet concentrates may be of an urgent nature and may be given without further justification during treatment of massive blood transfusion in which > 1 blood volume has been lost in < 24 hrs. The quantity of blood lost can be estimated by one of several methods.
First, if the volume of blood lost has been recorded, measured or estimated in the medical record, the volume lost can be related to the assumed normal blood volume of 70 ml/kg (e.g., a 70 kg patient has an estimated blood volume of 4900 ml and would be considered to require massive blood transfusion if the recorded volume of blood lost in 24 hrs exceeded 4900 ml).
Second, when the volume of blood lost has not been recorded, it can be estimated by noting the quantity of fluids infused intravenously to maintain acceptable vital signs (e.g., the illustrative patient above would be considered to experience massive transfusions if > 4900 ml of intravenous fluids had been administered in < 24 hrs).
Third, the physician's note may state that "massive" blood loss is occurring and platelet transfusions need not await documentation of total blood lost or replaced.
Additional platelet transfusions might be necessary if bleeding continues, but the blood platelet count must be documented to be < 50,000/ul. To justify additional platelet transfusions (i.e., the second and all subsequent ones during the 24 hours that follow the first platelet transfusion given for massive blood loss), clotting studies (minimum of PT, PTT, fibrinogen and platelet count) must be done within 6 hours, before or after the transfusion, and the blood platelet count should be documented to be < 50,000/ul.
b. To justify platelet transfusions for smaller volumes of blood lost (< 70 ml/kg in < 24 hrs), the patient must exhibit both active hemorrhage (as described above) plus have a blood platelet count documented to be < 50,000/ul.
GUIDELINES FOR GRANULOCYTE TRANSFUSIONS *
Granulocyte transfusions should not be given simply in response to a given blood neutrophil count; a clinical indication must also be present.
No Further Justification for GRANULOCYTE Transfusions is Required if One or More of the Following can be found in the medical record:
1. Absolute blood neutrophil count < 500/ul plus strong evidence for bacterial or fungal infection (mentioned in physician notes or positive culture of blood, CSF, body fluid or biopsy tissue). During the course of granulocyte transfusions, an occasional increase of the blood neutrophil count is permitted. However, further justification is required for granulocyte transfusions given after the total blood leukocyte or the blood neutrophil count is > 3000/µL on three successive days. (See Special Notes).
2. Fever in a patient with strong evidence of a bacterial or fungal infection (as previously defined) plus a documented functional neutrophil defect regardless of blood neutrophil count. Diagnosis of functional (qualitative) neutrophil defect should be mentioned in physician notes of the current illness.
SPECIAL NOTES
Because of difficulties in accurate differential white blood cell counts in leukopenic patients and in distinguishing post-transfusion leukocyte increments from the onset of sustained endogenous neutrophil production, the following approach to monitoring patient white blood cell counts is suggested:
1. Perform the pretransfusion white blood cell count on the morning of the anticipated granulocyte transfusion—preferably several hours after completing the previous transfusion.
2. Assume that severe neutropenia is present whenever the total white blood cell count is < 1000/ul (i.e., a differential count is unnecessary).
3. A blood leukocyte count or absolute neutrophil count > 3000/µl on three successive days is defined as possible myeloid recovery, and granulocyte transfusions will be discontinued to see if adequate leukocyte counts are sustained.
* Review of granulocyte transfusions discontinued September, 1992, with each patient evaluation per DeGowin Blood Center protocols.
GUIDELINES FOR REVIEWING TRANSFUSIONS OF PATIENTS EXPERIENCING CARDIAC BYPASS
1. With the exception of the "operative period", as described in the paragraphs below, reviews of all types of blood products given at other times (e.g., pre and postoperatively) will be conducted using the standard guidelines for other patients.
2. The "operative period" will encompass all time spent in the operating room for a procedure during which the patient is placed on the cardiac pump (i.e., cardiac bypass) plus the first four hours after the surgery is complete. It will begin when the patient enters the operating room; includes the time on bypass and the period after bypass is terminated during neutralization of heparin, closure of incisions, etc.; and it will end 4 hours after the patient leaves the operating room to enter a recovery area. During the "operative period", blood transfusions will be reviewed as follows:
a. Fresh frozen plasma (FFP), cryoprecipitate and/or platelet concentrates can be given, without need for further justification, only if excessive bleeding is present as written in either the surgeon, or anesthesiologist records or evident by records of chest tube drainage (e.g., >50 mL/hr), etc. Recollection later during the review process that "excessive bleeding was occurring" is not a substitute for mention of bleeding in the record at the time of surgery and remembrances such as this will not be accepted to justify transfusion unless blood loss can be documented by chest tube drainage, etc. Review of FFP and platelet transfusions to treat bleeding, will be performed by the following guidelines:
1) Platelets are generally not transfused during bypass, but they can be given to treat excessive bleeding during bypass, regardless of the blood platelet count;
2) After bypass is terminated and for four hours later, a single platelet transfusion can be given to treat bleeding, regardless of the blood platelet count because of platelet dysfunction caused by the extracorporeal circuit or by antiplatelet drugs given to promote graft patency.
To justify additional platelet transfusions (i.e., the second and all subsequent ones during 24 hours following the first platelet transfusion), clotting studies (minimum of PT, PTT, fibrinogen and platelet count) must be done within 6 hours, before or after, transfusion. Additional platelet units can be given to treat bleeding, only if the blood platelet count is < 50,000/ul. However, if the patient experiences a second bypass or is placed on a mechanical assist device (artificial heart), a repeat platelet transfusion can be given for excessive bleeding, regardless of the blood platelet count.
3) FFP can not be given, without further justification, while the patient is actually on bypass and anticoagulated with heparin, except in infants < 1 year of age of children weighing µ 15 kg when FFP is used to prime the pump.
4) After heparin is neutralized by protamine, FFP can be given to treat bleeding, when either the prothrombin and/or partial thromboplastin times are prolonged beyond the normal range, or when the activated clotting time (performed in the operating room) remains prolonged after protamine administration—providing results of the activated clotting time are recorded in the medical record..
b. Cryoprecipitate should not be used as "topical fibrin glue" to treat bleeding—providing, commercial fibrin sealant preparations are available. Commercial preparations have been demonstrated to have superior efficacy and safety.
GUIDELINES FOR CRYOPRECIPITATE TRANSFUSIONS
Cryoprecipitate is generally given to replace fibrinogen or Factor XIII. Because purified preparations are now available, it should no longer be used to treat Factor VIII deficiency, von Willebrand’s disease or to form "topical" fibrin glue.
No Further Justification for CRYOPRECIPITATE Transfusions is Required if One or More of the Following can be found in the medical record:
1. To treat congenital or acquired hypofibrinogenemia as indicated either by the diagnosis of hypofibrinogenemia, afibrinogenemia or dysfibrinogenemia recorded in the medical record or by a plasma fibrinogen level < 100 mg/dl (measured within 24 hours before the transfusion) as might occur in disseminated intravascular coagulation or fibrinolysis.
2. To treat congenital or acquired Factor XIII deficiency as indicated by the diagnosis as stated in the medical record or by a laboratory report indicating abnormal Factor XIII activity (measured within 24 hours before the transfusion).
3. To treat active bleeding in a patient with the diagnosis of uremia, renal failure or with a blood urea nitrogen (BUN) > 50 mg/dl or serum creatinine > 4.0 mg/dl (measured within 24 hours before the transfusion). A trial of DDAVP therapy is preferred prior to cryoprecipitate.
4. Cryoprecipitate should not be used as "topical fibrin glue" to treat bleeding—providing, commercial fibrin sealant preparations are available. Commercial preparations have been demonstrated to have superior efficacy and safety.
GUIDELINES FOR REVIEWING TRANSFUSIONS OF INFANTS < SIX MONTHS OF AGE *
(*Added after general auditing began; probably about 1990)
These guidelines are not indications for the transfusion of infants < 6 months of age. Rather, no further justification for transfusion is required if evidence for one of the following can be found in the medical record. Infants > six months of age will be reviewed using standard guidelines for older patients.
RED BLOOD CELLS:
1. Hemoglobin < 15 g/dl (hematocrit <45%) AND severe respiratory disease in a term infant (> 37 weeks gestation at birth) requiring mechanical ventilation with > 70% inspired oxygen.
PLATELETS:
Small infants (gestational age < 34 weeks or birth weight < 2000 grams):
1. Blood platelets < 100 x 109/L with evidence of severe illness (as described in #1 and #2 of the red blood cell section).
2. Blood platelets < 50 x 109/L in a stable preterm infant (i.e., no evidence of severe illness).
Larger infants (gestational age > 34 weeks or birth weight·> 2000 grams):
1. Blood platelets < 50 x 109/L with active bleeding or the need for an invasive procedure.
2. Blood platelets < 20 x 109/L regardless of clinical status.
FRESH FROZEN PLASMA:
1. Documented or presumed plasma clotting factor deficiency, or prothrombin time > 12 sec, or partial thromboplastin time > 38 sec AND mention in the physician progress note of bleeding (e.g., bleeding, hemorrhage, hemoptysis, bloody nasal or gastric drainage, bloody stools, oozing from puncture sites, intracranial hemorrhage, etc.).
2. Replacement therapy for antithrombin III, protein C or protein S deficiency as stated in the physician progress note or by laboratory value < 50% of normal. Consider using purified or recombinant products if available.
CRYOPRECIPITATE:
Documented or presumed deficiency of fibrinogen, or Factor XIII as stated in the physician progress note or by laboratory value of < 50% of normal for those factors and < 100 mg/dL for fibrinogen.
GUIDELINES FOR REVIEWING TRANSFUSION OF PATIENTS UNDERGOING EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) *
(*Added to Guidelines 11/11/96)
These guidelines are not indications for the transfusing of ECMO patients. Rather, guidelines mean that no further justification for transfusion is required, if evidence for one of the following can be found in the medical record. Although the quantity of blood components transfused will vary depending on patient size, in general, the same guidelines will apply to ECMO patients of all sizes and ages.
RED BLOOD CELLS:
1. Red blood cells can be used to prime the ECMO circuit, regardless of the patient’s blood hemoglobin concentration or hematocrit value.
2. Red blood cells can be transfused emergently if the ECMO circuit is disrupted, regardless of the patient’s blood hemoglobin concentration or hematocrit value.
3. Red blood cells can be transfused when the blood hemoglobin is < 15 g/dl (hematocrit < 45%).
PLATELETS:
1. Platelets can be transfused whenever the blood platelet count falls below 100,000/uL.
2. Platelets can be transfused whenever the blood platelet count falls below 150,000/uL for postoperative patients or for patients with a confirmed intracranial hemorrhage.
FRESH FROZEN PLASMA:
1. Fresh frozen plasma can be used to prime the ECMO circuit, regardless of the results of blood clotting assays.
2. Fresh frozen plasma can be used to replace clotting factors whenever the patient is either actively bleeding or is stated in the medical record that a nonbleeding patient is at an increased risk of experiencing hemorrhage. Because ECMO patients are heparinized, performance of clotting assays is not mandatory for plasma to be transfused.
CRYOPRECIPITATE:
1. Cryoprecipitate may be used when the fibrinogen is below normal (<175 mg/dL), the remaining coagulation laboratory values are normal and there is no active bleeding.
2. Fresh frozen plasma is preferable to cryoprecipitate when the fibrinogen is low and the prothrombin time is >15 seconds, or other coagulation laboratory values are abnormal, or there is active bleeding.