Table 4: STANDARDS FOR TRANSFUSION PRACTICE
(Adopted by the Medical Board of the University Hospital of Arkansas)
Contact CP Resident (688-2820) for assistance.

Component Indication/Exception Evaluation
 Criteria
Whole Blood
(Not routinely available at
    UAMS or ARC)		 A-1 Actively bleeding, evidence
      of 25% total blood volume (TBV) loss		 A-1 Hgb/Hct recommended within 24 hrs of transfusion
 
Red Blood Cells
(RBC's)		 B-1 Hypovolemia & decreased 02 carrying
     capacity due to surgery, GU bleed,
     trauma, GI bleed, etc.		 B-1 Hgb/Hct recommended
within 24 hrs of transfusion
B-2 Estimated acute blood loss >15% TBV, OR Hgb <8, OR Hct <24% B-2 Hgb/Hct recommended
within 24 hrs of transfusion
B-3 Clinical symptoms of anemia and:
      a. Specified chronic anemia
      b. Leukemia
      c. Lymphoma
      d. Hodgkin's disease
      e. Aplastic anemia
      f. Thalassemia
      g. Renal failure treated by hemodialysis		 B-3 Hgb/Hct recommended
within 24 hrs of transfusion
B-4 If a patient receives RBC's for Hgb >8 but does not have symptoms of hypovolemia, and has a diagnosis of:
      a. Iron deficiency anemia
      b. Pernicious anemia
      c. Malabsorption
      d. Nutritional deficiency
      e. Hereditary hemolytic anemia
         (Comment: A pre-op Hgb of <10 may be
         acceptable.  Each case should be
         evaluated by the anesthesiologist. Nutri-
         tional therapy may be more appropriate.)		 B-4 Exception for review by Transfusion Committee
B-5 Patient with chronic disease or chronic anemia and
       Hgb >8, chart review not necessary if diagnosis is
       associated coronary artery disease, pulmonary
       disease, or cerebrovascular disease		 B-5 Hgb/Hct recommended
within 24 hrs of transfusion
 
Platelets C-1 Platelet count <20,000 per ul C-1 Platelet count immediately before transfusion & within 18 hrs after platelet transfusion. Must get 1-2 hrs post-infusion platelet count if more than 8 units are ordered in 24 hrs.
C-2 Platelet count <50,000 per ul; pt having operative procedure within 6 hours C-2 Acceptable practice. Counts of 60,000-80,000 are adequate for minor procedures. >100,000 are necessary for major operations. One unit of platelets raises the count 5-10,000
C-3 Patients receiving <4 units/day or >12
      units/day, not appropriate adult dose;
      exception to be reviewed		 C-3 Exception for review by Transfusion Committee
C-4 Patients who receive platelets with a
       diagnosis of:
       a. Idiopathic thrombocytopenic
           purpura (ITP)
       b. Thrombotic thrombocytopenic
           purpura (TTP)
       c. Hemolytic uremic syndrome (HUS)		 C-4 Exception for review by Transfusion Committee
C-5 Patients with ongoing bleeding during or
      after surgery; ie, massive trauma,
      with counts <75,000		 C-5 Acceptable practice.
 
Fresh Frozen Plasma
(FFP)		 D-1 Nonspecific coagulation defects as
      indicated by:
       
      a PTT >55 sec (i.e.1.5x the upper level of
      normal, 27-38 sec) or PT >17 sec (greater
      than 1.5x the midpoint of the normal
      range, 9-13 sec).

      Patients not meeting these criteria,
      exception to be reviewed by Transfusion
      Committee. Recommendation:
      3-4 units of FFP will correct PT/PTT to
      normal when PT up to 18 sec and a PTT
      up to 60 sec		 D-1 Patients must have a PT/PTT or a specific coag factor assay within 4 hrs of transfusion of the FFP to determine the efficacy of FFP therapy.
D-2 Clinically significant factor defect or
      fibrinogen deficiency with significant
      bleeding.
D-3 Volume replacement is UNACCEPTABLE use of FFP. D-3 Use of FFP for volume
without demonstrable coag defects is an EXCEPTION to be reviewed.
D-4 DIC - indicated usage.

Comment: The Clinical Pathologist (beeper 688-2820) is available 24 hours/day, 7 days/week to assist in management of patient with DIC		 D-4 Acceptable.
 
Cryoprecipitate
(CRYO)		 COMMENT: Normal fibrinogen 200-400 mg/dl.
10 units CRYO will increase FBG by 70-100 mg/dl.
E-1 Documented severe hemophilia A E-1 Factor VIII  level prior to & 12 hr postinfusion
E-2 Documented deficiency of fibrinogen
     (Comment: adult dose = 10 bags cryo)		 E-2 Fibrinogen level prior to
& postinfusion
E-3 Documented deficiency of  Factor XIII E-3 Factor XIII level prior to & postinfusion
E-4 Documented vonWillebrand's disease with
      bleeding time > 15 min.		 E-4 Bleeding time pre- & post-infusion. Add'l factor levels (VIII, vWF antigen)
E-5 "Fibrin glue", when used for cessation of
      "oozing" on operative field. 		E-5 Acceptable practice when used in mix with autologous cryo or 1 unit donor cryo
 
Factor VIII
(Antihemophilic Factor, Human)		 F-1 Severe hemophilia A F-1 Factor VIII level prior to & 12  hrs postinfusion
F-2 Acquired Factor VIII inhibitor in patients
      without history of hemophilia A		 F-2 Acceptable. High titer
inhibitors may require use of porcine FVIII
F-3 Moderate or mild hemophilia A F-3 Exception for  review by Transfusion Review Committee
F-4 vonWillebrand's disease F-4 Exception for  review by Transfusion Review Committee
 
Factor VIII, Recombinant
(Antihemophilic Factor, Recombinant)		 G-1 Severe hemophilia A G-1 Factor VIII level prior to & 12 hours post-infusion
G-2 Moderate or mild hemophilia A G-2 Acceptable for trauma
and opertive mgmt. FVIII
levels prior to & 12 hrs post-infusion.
G-3 vonWillebrand's disease G-3 Exception for  review by Transfusion Review Committee
 
 
Factor IX
(Coagulation Factor IX, Human)		 J-1 Documented Factor IX deficiency with
     bleeding, or for perioperative management.
     (NOTE: Highly purified Factor IX, essentially
     free of Factors II, VII, & X. Preferred
     first-line product.)		 J-1 Monitor with Factor IX
assay
 
Prothrombin Complex Concentrate
(PCC, Konyne)		 K-1 Documented Factor IX deficiency with
       bleeding, or for perioperative management.
       (NOTE: Contains a mixture of Factors IX, II,
       VII, & X, with some activated factors.
       Risk of thrombosis is present.)		 K-1 Monitor with Factor IX
assay
K-2 Factor VIII inhibitor, high titer, unresponsive
      to high dose FVIII, with bleeding, in pts with
      hemophilia A or acquired FVIII inhibitor		 K-2 Monitor Factor IX level, clinical status
   
 
 
Albumin
(5% & 25% Human Serum
Albumin)		 N-1 All of the following constitute approved
       indications for use of albumin:
       a. Hypovolemia, with or without shock (given
          with crystalloids in 1:3 or 1:4 ratio unless
          patient adequately hydrated)

       b. Plasma replacement during large-volume
           plasma exchange (PLEX)

       c. Hypoalbuminemia, (pt albumin <3 g/dl):
           *burns (after first 24 hrs)
           *ARDS (given with diuretic)
           *cirrhosis (repeated or large-volume
            parcentesis for ascites)
            *nephrosis (in combination with steroids
            &/or diuretics when acute)

        d. Hemolytic disease of the newborn (25%
            only, to bind bilirubin)

        e. Cardiopulmonary bypass

        f. Cerebral ischemia (when patient has
           normal Hct)		 N-1b. Use in PLEX for TTP/HUS is Exception to be reviewed
N-2 The following uses of albumin constitute
      EXCEPTIONS to be reviewed:
      a. Treatment of nutritional deficiency