Oncology handbook

BLOOD PRODUCT SUPPORT

I. Hypoproduction Anemia

A) Indications for pRBC transfusions:

The decision to transfuse should be based on clinical assessment and not on Hgb or Hct alone. Patient with chemotherapy-induced hypoproduction anemia or anemia secondary to bone marrow infiltration generally tolerate lower Hgb than do patients with acute blood loss or hemolysis, as the cardiovascular system has had more time to compensate in the former situation. The usual rate of decline in Hgb is 1 g/dl per week if the anemia is purely from hypo-production (a faster decline suggests blood loss, splenic sequestration, infection, or hemolysis).

B) Criteria for pRBC transfusion:
1) Symptomatic anemia: significant tachycardia, gallop, light-headedness, malaise, irritability, congestive heart failure: very unusual with Hgb  7 g/dl in child and  8 in adolescent.
2) Hgb < 7 g/dl: tissue oxygen delivery is usually suboptimal. Patients with elevated retic counts or nucleated red blood cells seen on smear may not need to be transfused.
3) Hgb < 9 g/dl at start of intensive course of in-patient chemotherapy. For the convenience of not having to transfuse the patient as an out-patient one or two weeks later, consider transfusing such patients before discharge, as the expected decrease in Hgb of 1 g/dl per week will result in a Hgb of < 7 g/dl at the time of nadir two weeks later.
4) Hgb should generally be kept > 10 g/dl during radiation therapy to maximize RT efficacy.
C) Volume and rate of pRBC transfusion:
Standard transfusion volume = 10 – 15 ml/kg (this amount will increase the Hgb by 2.5 to 3.5 g/dl if the Hct of pRBC is 70%). Transfuse over 3-4 hours.
If hemoglobin has had a quick drop (such as hemolysis) or the patient is in congestive heart failure, transfuse slower. Transfuse PRBCs in 5ml/kg aliquots each given over 3-4 hours with at least an hour or two break in between.
II. Hypoproduction Thrombocytopenia
A) Guidelines for platelet transfusions in hypoproduction thrombocytopenia:
1) Frank bleeding
2) Mucosal oozing or extensive bruising and petechiae (this is unusual if platelet count >10,000/mcl unless associated DIC or clotting factor deficiencies are present)
3) Prior to LP if plts < 10,000/mcl (rare complication of epidural hemorrhage)
4) Prior to invasive procedures: intubation, arterial line placement, CVP line placement, endoscopy, dialysis catheter placement, etc., if plts < 40-50,000/mcl

(< 75,000/mcl before central venous line placement by peds surgery)

5) Febrile patients with plts <20,000/mcl
6) Plts < 10 -15,000/mcl and expected continued decline over next several days
7) Plts < 30-40,000/mcl in DIC (associated with sepsis or AML induction)
8) Plts < 50,000/mcl with large brain tumors or brain surgery in previous three months.
9) Plts < 50,000/mcl for 48h after major surgery (including dental extractions)
Most intracranial hemorrhages are associated with platelet counts < 5,000/mcl and rarely occur spontaneously without prior mucosal or cutaneous bleeding. The maximum platelet decline if due solely to hypoproduction is a decrease of 50% per day. A faster decline suggests consumption or sequestration.
B) Volume and rate of platelet transfusions
Infant: 10 cc/kg

Child 10 – 30 kg: ½ apheresis platelet pack

Child > 30 kg: 1 apheresis platelet pack (occasionally 2 packs for large adolescent)
C) Transfusion reactions
Fever and shaking chills can occur in reaction to platelet transfusions, and less often to pRBC transfusions. The proteins in the plasma of platelet packs are the most likely cause, and not an infected unit, although the latter occasionally occurs. Pretreatment with Benadryl (l mg/kg) and Tylenol or Ibuprofen often prevents these reactions. Occasionally hydrocortisone, 50-100 mg IV, is also needed. Treatment with Benadryl or Demerol (1 mg/kg) usually stops the reaction. Transfusion can usually be resumed, provided the reaction stops following treatment. If anaphylaxis requiring epinephrine occurs, that product should not be resumed; that donor should be marked as unacceptable for that patient. The possibility of an infected unit should be considered.

III. BLOOD PRODUCTS SPECIFICATIONS:

A) Irradiated products: irradiated pRBC and plts are required for all oncology patients (2500 cGy). Irradiation inhibits leukocyte proliferation, thus preventing graft-versus-host disease (GVHD) in immuno-compromised hosts.
B) Single donor apheresed platelets: Each donation is equivalent to 6 to 12 random donor units in a volume of about 200 cc. Apheresed platelets reduce exposure to HLA antigens because fewer WBC are present in the transfused product.
C) Leukodepletion: pRBC and apheresed plts are leukodepleted in the blood bank for all oncology patients. This procedure reduces exposure to HLA antigens, and refractoriness to platelet transfusions, and helps prevent transfusion reactions caused by leukocyte antigens (fever, chills, hives). They also decrease transmission of CMV.