血品

Buzzwords → Dx

Fibrinogen / coagulation

• Fibrinogen <100–150 mg/dL with bleeding → cryoprecipitate (10 units / pooled bag) raises fibrinogen ~50–100 mg/dL.
• APL DIC → maintain fibrinogen >150, plt >30–50, with cryo + plt + FFP transfusion in induction.
• Warfarin reversal → 4F-PCC + vitamin K > FFP (faster, smaller volume).
• DOAC reversal → andexanet alfa (Xa) or idarucizumab (dabigatran); 4F-PCC off-label.

Modifications & Special Indications

• Leukoreduction (universal in many countries): reduces FNHTR, CMV transmission, HLA alloimmunization. Standard of care.
• Irradiation: prevents TA-GVHD. Required in: HCT recipients (lifelong), severe immunocompromise, intrauterine / neonatal, directed donations from blood relatives, Hodgkin lymphoma, purine analogues (fludarabine), ATG, alemtuzumab, CAR-T.
• CMV-safe (CMV-negative or leukoreduced): pregnant, neonates, severely immunocompromised, intrauterine, transplant recipients.
• Washed RBCs/platelets: IgA-deficient + anti-IgA antibodies; recurrent allergic reactions.
• Antigen-matched RBCs: SCD, thalassemia (chronic transfusion) — match Rh full + Kell at minimum, ideally also Kidd, Duffy.
• Crossmatch incompatible: AIHA — best-matched / "least incompatible" units.

Transfusion thresholds (key trials)

• General ICU / hospitalized: Hb 7 (TRICC, TRISS — non-inferior or better vs Hb 9–10).
• GI bleed: Hb 7 (Villanueva NEJM 2013).
• Cardiac surgery / acute coronary syndrome: Hb 8 (FOCUS).
• Orthopedic / hip surgery: Hb 8 (FOCUS).
• Stable ICU heme/onc: Hb 7 OK.
• Symptomatic anemia / cardiac decompensation: clinical judgment; transfuse symptomatic regardless of Hb.

Platelet thresholds

• Prophylactic: plt <10 in stable patient (PLADO trial — supported by ASH 2022 guidelines).
• <20 with fever/sepsis/coag abnormality.
• <50 for invasive procedure (LP, central line, chest tube).
• <80 for epidural anesthesia, eye/neuro surgery.
• <100 for high-risk neurosurgery.
• NEVER prophylactic in TTP, HIT — fuels thrombosis.
• Massive transfusion: 1:1:1 RBC:plasma:platelets.

Treatment Algorithm

flowchart TD
  A[Bleeding / cytopenic patient] --> B{Bleed source / lab abnormality}
  B -- symptomatic anemia --> C[Restrictive RBC transfusion<br>Hb 7 stable, Hb 8 cardiac/orthopedic]
  B -- thrombocytopenia + bleeding/procedure --> D[Platelet transfusion<br>plt <10 ppx, <50 procedure, <100 neuro]
  B -- coagulopathy + bleeding INR>1.5 --> E[FFP or 4F-PCC<br>4F-PCC preferred for warfarin reversal]
  B -- low fibrinogen <100-150 --> F[Cryoprecipitate]
  B -- IgA-deficient + anaphylactic hx --> G[Washed RBCs / platelets]
  B -- immunocompromised / HCT / Hodgkin --> H[Irradiated products]
  B -- pregnant / neonate / transplant --> I[CMV-safe leukoreduced]
  B -- ABO-mismatch hemolysis --> J[Switch to type-specific products]
  C --> K{Adequate response?}
  D --> K
  E --> K
  F --> K
  K -- yes --> L[Continue management; monitor]
  K -- ongoing bleeding --> M[Reassess source; surgical, endoscopic, IR]

Pearls / Pitfalls

• Restrictive RBC transfusion (Hb 7) is the answer for most stable inpatients — not "Hb 10".
• Don't transfuse asymptomatic anemia — clinical context matters.
• Don't give prophylactic platelets in TTP, HIT, ITP (unless life-threatening bleeding).
• Cryoprecipitate is the right answer for low-fibrinogen DIC / OB hemorrhage / APL — not FFP (too dilute for fibrinogen).
• Massive transfusion protocol = 1:1:1 ratio + tranexamic acid (within 3 h trauma) + warming + Ca replacement.
• Granulocyte transfusion is rarely used and rarely effective; reserved for severe neutropenia + refractory invasive infection.
• IVIG indications in heme: ITP, AIHA, parvovirus B19 PRCA in immunocompromised, HUS post-pneumococcal, secondary hypogammaglobulinemia.
• Albumin is NOT a routine resuscitative fluid — saline equivalent in most ICU contexts (SAFE study).
• TXA: trauma (within 3 h, CRASH-2), OB hemorrhage (WOMAN trial), surgery (orthopedic, cardiac); avoid in TTP.

Cross-references

• Transfusion Reactions
• Blood Groups + crossmatch
• Anticoagulation reversal
• APL DIC management
• DIC
• Lab Values

相關題目

• Q-166 — Platelet transfusion threshold
• Q-167 — Restrictive RBC transfusion threshold
• Q-168 — Cryoprecipitate vs FFP for low fibrinogen

Sources