Treatment. Therapy of thrombotic disorders depends on the underlying condition and usually involves standard or low-molecular-weight heparin and then longer term anticoagulation with warfarin. Major vessel thrombosis or life-threatening thrombosis may necessitate treatment with fibrinolytic agents (recombinant tissue plasminogen activator). In newborns, inherited deficiency syndromes may present as emergencies and necessitate replacement with plasma, antithrombin III concentrates, or protein C concentrates.
Transfusion of red blood cells (RBCs), platelets, plasma,cryoprecipitate, and granulocytes can be life-saving orlife-maintaining (Table 152-1). Whole blood is rarely indicated and is most useful to provide both oxygen-carryingcapacity and functional procoagulant and anticoagulant factors. Otherwise, packed RBCs are used to treat anemia to increase oxygen-carrying capacity. RBC transfusions shouldnot be used to treat asymptomatic nutritional deficienciesthat can be corrected by administering the appropriate deficient nutrient (iron or folic acid).
Blood component therapy requires proper anticoagulation of the component unit, screening for infectious agents and blood group compatibility testing before administration. Typical transfusion reactions are listed in Table 152-2. Transfusion may also result in circulatory overload, especially in the presence of cardiopulmonary deficiency. Filtering of blood products to remove white blood cells (WBCs) may prevent febrile reactions. Long-term complications of transfusions bleeding 50,000/μL 30,000-50,000/μL
Cryoprecipitate Fibrinogen, factor 8, Hypofibrinogenemia, factor 1 unit/5-10 kg ↑ Fibrinogen by 50–100 mg/dL vWF, factor 13 13 deficiency
Recombinant factor Units as labeled Hemophilic bleeding or F8: 20–50 units/kg F8: ↑ 2%/unit/kg concentrates prophylaxis F9: 40–120 units/kg F9: ↑ 0.7 unit/kg
Hgb, Hemoglobin; RBCs, red blood cells; vWF, von Willebrand factor.
Acute hemolytic transfusion Acute shock, back pain, flushing, early fever, 1. Stop transfusion; return blood to bank with reaction (incidence of 1:250,000 to intravascular hemolysis, hemoglobinemia, fresh sample of patient’s blood 1:1,000,000) hemoglobinuria (may be delayed 5–10 days and 2. Hydrate intravenously*; support blood less severe if anamnestic response is present) pressure, maintain high urine flow, alkalinize urine 3. Check for and correct electrolyte abnormalities (hyperkalemia)
Allergic transfusion reaction (incidence of 1:100)
Urticaria, pruritus, maculopapular rash, edema, respiratory distress, hypotension during or within 4 hours of transfusion; often because recipient has preformed antibodies against donor antigens, occasionally from passive infusion of antibodies from atopic donor Diphenhydramine ± hydrocortisone for acute management For future transfusions consider: 1.
Pretreatment with diphenhydramine ± hydrocortisone 2.
Volume reduction to reduce donor plasma 3.
Washing cellular products to remove all donor plasma (for severe reactions)
Adapted from Andreoli TE, Bennett JC, Carpenter CC, Plum F, et al: Cecil Essentials of Medicine, ed 4, Philadelphia, 1997, WB Saunders. HLA, Human leukocyte antigen; RBCs, red blood cells; WBC, white blood cell. *Normal saline is the compatible intravenous fluid.