Blood Product

Red Cells & Whole Blood

Dosage Dosage depends on Clinical Situations

 One Standard Unit:
 Derived from 450mL whole blood donation
 Should raise Hb level by up to 1.2g/dL in a 70kg adult
 One Small Unit:
 Derived from 350mL whole blood donation
 Should raise Hb level by about 0.85g/dL in a 70kg adult

For Children:
 4ml/kg should raise Hb level by 1g/dL
Indications  There is no single Hb value that must be taken as the transfusion trigger. However, a trend towards
cautious blood transfusion trigger has been observed but patients’ condition may affect clinical decision.
 In general, the following principles are considered:
 Hb Concentration <7g/dL:
 Based on assessment on the rate of ongoing red cell loss
 Hb Concentration 7-10g/dL:
 Transfusion strategy is less clear but general view is that transfusion is often not justified purely
based on Hb concentration
 For Patients who may tolerate anaemia poorly:
 A higher Hb concentration may be required
 E.g. patients over the age of 65 years, patients with cardiovascular or respiratory disease

Platelet

Dosage  For Adults up to 70kg  4 Random Donor Units

 Each derived from 350mL or 450mL whole blood donation
 Each unit should raise platelet count by 7-10 x 109/L
 1 unit of apheresis platelets is equivalent to one standard adult dose (for adults up to 70kg)

For Children:
 5 units/M2 for paediatric patients
Indications
<10 x 109/L  In stable patients (Usually NOT indicated in idiopathic thrombocytopenia, SLE,
Thrombotic thrombocytopenia and HUS)
<20 x 109/L  In patients with fever or sepsis
<50 x 109/L  In patients with diffuse microvascular/ mucosal bleeding, major bleeding or before
invasive procedures
 In stable premature neonates
<100 x 109/L  In patients with retinal or CNS bleeding/ surgery, or with active bleeding in post-
cardiopulmonary bypass
 In sick premature neonates
Any  Suspected platelet dysfunction with active bleeding or before invasive procedures
 Suspected platelet deficiency with severe active bleeding or following massive
transfusion

Plasma
Dosage  2-4 Units for Adults

For Children:
 12-15mL/kg for paediatric patients
Indications  Thrombotic Thrombocytopenic Purpura
 When Clotting Factors Deficiency is suspected or anticipated with active bleeding during operation or
following massive transfusion
 Immediate reversal of warfarin overdose (bleeding or impending surgery)
 PT/APTT >1.5x control values with active bleeding or before invasive procedure in the following situations:
 Single or multiple clotting factor deficiency (other than Haemophilia A/B)
 Disseminated Intravascular Coagulopathy
 Hepatic Failure

Cryoprecipitate

Dosage Depends on the target factor levels in particular diseases and clinical situations:
 Ranging from 6-30 units/ dose
 10 Units per dose for adults up to 70kg

Indications  Von Willebrand Disease (if desmopressin or factor concentrate is inappropriate)

 Documented Fibrinogen Deficiency (<100 mg/dL) or dysfunction)
 Documented Factor XIII Deficiency

Special Blood Products

Blood Products Dosage Indications

Fresh Whole Blood (≤5 days
from donation)
Leucocytes
(Must be irradiated)
(Require special arrangement
with the HKRCBTS)
Leukodepleted (filtered) Red
Cells
Irradiated Cellular Blood
Components
1-2 Units  Exchange transfusion
 Massive blood loss in neonates
10 Units/ Day for ≥4 days or until  Neutropenia (<0.5 x 109/L) with documented infection
fever subsides unresponsive to broad spectrum antibiotics including
antifungal agents for at least 48 hours
Same as other red cell  All thalassaemia patients on regular transfusion regimens
preparation  Haematological diseases
 Documented severe febrile non-haemolytic transfusion
reaction (≥2 episodes)
 Paediatric oncology patients
Same as non-irradiated  For prevention of transfusion-related graft versus host
counterparts disease in circumstances such as:
 Foetuses requiring intrauterine transfusion
 Patients with severe congenital cellular
immunodeficiency
 Stem cell transplantation patients
 Patients receiving transfusion from close relatives

Step 1: Non-Opioid Analgesics ± Adjuvant Drugs (e.g. NSAID) ± Local Anaesthesia

Step 2: Weak Opioid (e.g. Codeine, Tramadol) ± Options in Step 1

Step 3: Strong Opioid (e.g. Morphine) ± Options in Step 1

IV Fluids

Categories of IV Fluids
 Crystalloid
 Relatively low tendency to stay intravascular
 Examples: Normal Saline, ½ Normal Saline, D5 ½ DS + 20mEq/L KCl, Lactated Ringers
 Large volumes of normal saline can lead to a normal anion gap metabolic acidosis
 0.9% Saline (a.k.a. Normal Saline)
 Indication(s): Resuscitation (Replacement of fluid in hypovolemia from sepsis, haemorrhage or GI fluid loss)
 0.45% Saline (a.k.a. ½ Normal Saline)
 Not used to rapid resuscitation, but rather used for maintenance
 3% Saline
 Indication(s): Severe hyponatremia
 D5 ½ NS + 20Kcl
 Indication(s): Maintenance Fluid
 D5W
 Indication(s): Hypernatremia, Hypoglycemia
 Lactated Ringer’s / Hartmann’s Solution
 Indication: Resuscitation
 LR is relatively contraindicated in：
(1) Hyperkalaemia (due to presence of K+)
(2) Concurrent blood transfusion (due to binding of Ca2+ with citrate in blood products)

Fluid Na Cl K Ca Glucose Buffer Osmolarity Tonicity

(mEq/L) (mEq/L) (mEq/L) (mEq/L) (g/L) (mOsm/L)
Normal Plasma ~140 ~100 ~4 ~2.4 ~0.85 HCO3- ~24mEq/L ~ 290 N/A
Normal Saline 154 154 0 0 0 0 308 Isotonic
½ Normal Saline 77 77 0 0 0 0 154 Hypotonic

3% Saline 513 513 0 0 0 0 1026 Hypertonic

D5 ½ NS +20 KCl 77 97 20 0 50 0 446 Hypertonic
 Hypotonic
D5W 0 0 0 0 50 0 252 Hypotonic
Hartmann’s 130 109 4 3 0 Lactate28mEq/L 273 Isotonic
Solution

 Colloid
 Relatively high tendency to stay intravascular
 Colloids can be divided into natural (e.g. Albumin, FFP) and synthetic (e.g. Dextrans, Hydroxyethyl Starch, Gelatins)
 Volume expansion due to a colloid is determined by its molecular weight and concentration
 Colloid fluids can be either saline-based solutions or balanced solutions
 Colloids are typically only used for resuscitation in severe hypovolemia. Exceptions include use of albumin in cirrhotic
patients when:
 Part of the treatment protocol for spontaneous bacterial peritonitis
 Patient has renal failure of undetermined etiology, but in which decreased renal perfusion from hypovolemia is a
possibility
 Examples: Albumin, Fresh Frozen Plasma (Typically used to correct coagulopathy), Dextran, Hydroxyethyl Starch
 Major side effects of synthetic colloids include:
(1) Allergic reactions (including anaphylaxis)
(2)

Fluid Average Molecular Oncotic Pressure Initial Volume Expansion Duration of Volume Expansion
Weight (kD) (mmHg)
4-5% Albumin 69 20-30 70-100% 12-24 hours
20-25% Albumin 69 70-100 300-500% 12-24 hours
10% Dextran 40 40 20-60 100-200% 1-2 hrs
6% Hydroxyethyl 450 25-30 100-200% 8-36 hours
Starch (Hespan)

 Electrolyte-Free Water
 We never infuse pure water due to haemolysis.
  Because electrolyte-free water fully distributes to all three fluid compartment, it is a terrible choice to expand intravascular
volume. Instead, it is only used in situations like persistent hypoglycaemia or prominently elevated serum osmolarity
 Examples: D5W, D10W
 Blood
 Examples: Packed RBCs (used to treat severe anaemia)

Volume Resuscitation
 Lactated Ringer (Surgeon’s Fluid)
 Every Litre contains 4mEq K
 Normal Saline (Physician’s Fluid)
 Risk of Acidosis
 No K to worry about

Maintenance Fluid
 ¼ Normal Saline
 ¼ Normal Saline with D5
 ½ Normal Saline
 ½ Normal Saline with D5
 Total Daily Fluid Requirement: 1500 + [(kg – 20) x 20]

Free Water
 Free Water PO