Red Blood Cells

Leukoreduction: All RBCs at Fairview are leukoreduced. For benefits of leukoreduction see page 24.

Contents: Volume is approximately 300-350 mL with 200-225 mL of RBC in 100 mL of preservative fluid. Each contains approximately 10-20 mL of citrated plasma. Hematocrit is approximately 55%.

Adult Dose: In non-urgent settings, transfuse one unit at a time.

Expected Result: One unit will increase hemoglobin approximately 1 g/dL and the hematocrit by 3% in a 70 kg adult.

Infant/Child Dose: 2.5-5 mL/kg will increase hemoglobin approximately 1 g/dL; 10-15 mL/kg will increase hemoglobin approximately 2 to 3 g/dL.

Handling: Transfusion must be initiated within 30 minutes of release from the Blood Bank (e.g., as indicated by time stamp) and completed within 4 hours of release. In specific situations, the Blood Bank may provide RBCs in a cooler. These units may be stored for up to 24 hours in a cooler under a bag of wet ice, provided the ice is changed every 4 hours. These situations may include: Operating Room, ECMO or EXCOR, exchange transfusion, or massive transfusion protocol.

RBC Components for NICU

RBCs are provided to the Neonatal Intensive Care Unit (NICU) as AS-3 packed RBCs. All AS-3 units provided to the NICU are leukoreduced, irradiated and are less than 7 days old. AS-3 RBCs are produced from whole blood collected in CPD (citrate, phosphate, dextrose) by centrifugation to remove most of the plasma and pack the RBCs. Adsol (dextrose, adenine, saline and no mannitol) is then added. Aliquots of RBCs from AS-3 are administered by syringe in the NICU.

Indications for RBC Transfusion

RBCs are provided to the Neonatal Intensive Care Unit (NICU) as AS-3 packed RBCs. All AS-3 units provided to the NICU are leukoreduced, irradiated and less than 7 days old. AS-3 RBCs are produced from whole blood collected in CPD (citrate, phosphate, dextrose) by centrifugaton to remove most of the plasma and pack the RBC's. Adsol (dextrose, adenine and saline—without manitol) is then added. Aliquots of RBCs from AS-3 are administered by syringe in the NICU.

The major indication for a RBC transfusion is symptomatic anemia. RBC transfusion restores the oxygen carrying capacity of blood and thus alleviates the symptoms of tissue hypoxia. A patient’s hemoglobin level should NOT be the sole deciding factor in starting red cell transfusions. The decision to transfuse should be supported by the need to relieve clinical signs and symptoms and to prevent morbidity and mortality. The indications are the following:

1. Hemoglobin 7 g/dL or less

2. Hemoglobin 8-10 g/dL and acute (within the last 24 hours) coronary syndrome.*

3. Hemoglobin 8-10 g/dL and severe thrombocytopenia in Hematology/Oncology patients at risk of bleeding.*

4. Hemoglobin 8-10 g/dL and chronic transfusion dependent anemia.*

5. Hemoglobin 13 g/dL or less in neonates and children: •Term neonates less than 24 hours old

  • Premature neonates
  • Patients with cardiopulmonary disease; however, infants with symptomatic cyanotic heart disease may require a hemoglobin level greater than 13 g/dL.
  • Infants prior to emergency surgery; however, asymptomatic, full term infants less than four months of age undergoing surgery, may tolerate a hemoglobin level less than 13 g/dL.

6. Acute bleeding greater than or equal to 15% blood volume:When deciding whether to transfuse RBCs to a patient who is actively bleeding, the clinical assessment of the rate or volume of blood loss (and, in particular, the development of signs and symptoms of hypovolemia) is more important than the hemoglobin level or hematocrit, since they may not reflect the degree of blood loss.

7. Massive blood loss:See Massive Transfusion Protocol section page 33.

8. Hemoglobinopathies:In selected clinical situations red cells less than 14 days old and partially matched for key RBC antigens will be provided. For patients with sickle cell disease, hemoglobin S negative RBCs will be used.

9. Red blood cell or neonatal whole blood exchange transfusion

10. Priming of extracorporeal circuit (e.g., bypass, ECMO, apheresis)

11. Intrauterine transfusion for fetal anemia

* Carson JL, Guyatt G, Heddle NM, et al. Clinical Practice Guidelines from the AABB: Red Blood Cell Transfusion Thresholds and Storage: JAMA. 2016;316(19):2025-2035. doi:10.001/jama.2016.9185

The indications for transfusion of preoperatively donated autologous RBCs are equivalent to those for allogeneic blood.

STOP - Do NOT transfuse red cells for volume expansion or to enhance wound healing. A patient with a pharmaco-logically treatable anemia (i.e., iron, B12, folate or other specific deficiency) should not be transfused, regardless of hemoglobin level, unless there are other risk factors for tissue hypoxia or symptoms severe enough to require immediate treatment.

Washed Red Blood Cells

Washing RBCs removes almost all the plasma and is associated with a 10-20% loss of red blood cells.

Contents: Volume is approximately 180 mL and hematocrit approximately 70-80%. Washed RBCs are suspended in saline with only traces of plasma remaining.

CAUTION - Washing exposes the product to an increased risk of bacterial contamination. This component has a 24-hour expiration date and requires coordination with the Blood Bank.

Indications for Washed Red Cells:
  1. IgA deficiency and antibodies to IgA
  2. Haptoglobin deficiency and antibodies to haptoglobin
  3. Repeated severe transfusion reactions to plasma proteins unresponsive to medications

Irradiated Cellular Blood Components

Blood components are irradiated to prevent transfusion-associated graft-versus-host disease (TA-GVHD) in patients with profound immunodeficiency or immune suppression. Transfused viable lymphocytes of donor origin can proliferate and cause damage to the tissues of immunodeficient recipients. Irradiation of the blood component prevents the proliferation of transfused lymphocytes in the patient.

Irradiation has no significant effect on the oxygen carrying capacity of red blood cells but it increases the rate of potassium leakage during storage. Irradiation has no significant effect on platelet and granulocyte function. Leukoreduction is not sufficient to prevent transfusion-associated graft versus host disease. Irradiation of blood components does not prevent the development of transfusion-induced alloimmunization (i.e., antibodies to HLA, red cell, platelet, or neutrophil antigens).

All platelets and granulocytes at Fairview are irradiated. For a list of conditions where irradiated red blood cell use is indicated, see below. Irradiation is not needed for acellular components such as plasma, cryoprecipitate, albumin, immune globulin, or coagulation factor concentrates.

Use of Irradiated Cellular Blood Components

Irradiation is required for:
  1. Past, current, or scheduled hematopoietic stem cell transplant (marrow, cord, or peripheral blood stem cells). Irradiated blood components must be ordered when the workup for stem cell transplant is initiated.
  2. Hodgkin’s disease
  3. Treatment with purine analog drugs (e.g., fludarabine, cladribine, pentostatin) or alemtuzumab (CamPath®) in past 12 months
  4. Congenital immunodeficiency syndrome
  5. Intrauterine transfusion
  6. Pediatric oncology patients (hematologic and solid malignancies)
  7. Newborn up to 6 months of age
  8. Hematopoietic stem cell transplant donors prior to and during the collection
  9. Aplastic anemia treated with rabbit antithymoglobulin (ATG)
  10. Directed donations
  11. HLA-matched platelets
  12. Granulocyte transfusions
Irradiation is NOT needed for:
  1. Adults only: Acute or chronic leukemia
  2. Adults only: Non-Hodgkin’s lymphoma
  3. HIV infection/AIDS
  4. Severe leukopenia, lymphopenia, pancytopenia
  5. High dose steroids
  6. Immune suppression with medications such as azathioprine, cyclosporine, mycophenolate mofetil (Cellcept ®)
  7. Prevention of HLA alloimmunization
  8. Solid organ transplant
  9. Aplastic anemia treated with horse ATG

Leukocyte Reduced Blood Components

All UMMC components, except granulocytes, are leukoreduced. Leukoreduced cellular components are used because they reduce the:
  1. Rate of febrile non-hemolytic transfusion reactions,
  2. Risk of CMV transmission, and
  3. Leukocyte alloimmunization.
Leukoreduced components and CMV-seronegative components (tested for CMV antibodies and found negative) have a comparable risk of CMV transmission.

CMV-seronegative components are provided only for intrauterine transfusions and granulocyte transfusions when indicated.