Transfusion problems

Hassan now weighs 16.8 kg and is transfused with 250cc packed cells. Since he gets transfused in a private hospital we have to arrange for the donor as they usually do not have fresh blood. This time the blood bag had 285cc blood and Hassan needed 250cc. Each time 50cc is filled in a syringe and is transfused mechanically @ of 66cc/hour. When the syringe was to be filled the fourth time the nurse could draw only 40cc as the blood bag was empty and the blood was not coming out of the filter. There was around 15 - 20 cc blood in the tubing and he was given everything. So instead of getting 250cc he could get only 210cc.
When we contacted the lab they informed us that only 10cc could get lost in the filter. We asked the lab superviser to come and check the unit and when we questioned him he said the filter probably had 40-50cc blood trapped. Then what happened to the rest of the blood.This was the sixth time he had received 250cc and the earlier transfusions had gone fine. Usually the bag has over 350cc and this was the first time the bag weighed 285cc. According to him only 260- 295 RBC`s can be obtained from a single donor(450cc) and to avoid such problems we should bring in two donors. When I told him the blood bag weighed 392cc during Hassan`s last transfusion, he said it was because of the anticoagulant added to it. Now what does he mean by that ?does Hassan receive only 200cc of packed RBC`s and 50cc anticoagulant. I have been trying to verify what he has said but haven`t had any luck so far. I would really appreciate every little info you all could give about RBC`s as I want to go for the next transfusion armed with answers.

maha

maha. well i guess making all those things calculated is NOT EASY. because of the fact that evrytime you will never get same amount of RBC's it depend from person to person. If u get that bag of 300cc then u r very lucky ... we normally get 250ml and that is really OK... ideal to raise hb in this formula ...   ml of RBC  / (3x bodyweight in kgs)  . I remember in pakistan especially during summer an whole blood bag of 420ml would yield only around 100cc sumthin and we had to laugh at the bag. No body can do anything in it. but if u get atleast one bag of 250 ml then you shud b satisfied ... and having said that ..there's always leftover blood thats wasted in the blood tube and filter ... no matter in wut quantity the blood is trapped in it what i experienced thru all my life is still 250ml bag wud raise my hb by 2 according to the above formula ... and if anticoagulant is added in 250RBC and makes it 310ml IT DOES NOT MEAN of 310ml of RBC it still mean250 ml. you should not worry about those 20-30 cc trapped. its all that we face and not a big deal i think. cuz if u'll arrange another donor for mere 40-50 cc u'll b wasting the rest of the blood which i think nobody would like as that blood cud hav saved another life ... Just cheers

Hi Waleed
Here the blood volume is calculated at 15ml/kg. When you require 250cc and you get 210cc will it not affect his hb. This time around we have decided to take him in three weeks time instead of four weeks as he got only 12.5ml/kg.You had mentioned that you have never used a WBC filter to date but there are many who use one. So if one unit is 250cc and a filter is used, only 160-170cc is transfused, the rest is trapped in the filter. Is it? I just want to know this so as I can know if the lab has made any mistakes in calculating the weight of the bag.

maha

We took Hassan  for a tx today, it was actually 3 weeks instead of his usual 4 weeks as his tx last time was less than his requirement and also he was also sick this past 2 weeks with gaps inbetween (Gastro entritis). I felt all that vomitting fever and diarhea would have affected his hb but surprisingly his hb was 11.2. The doc refused transfusion as according to them it was clinically unacceptable. I was very disturbed as all the tests are conducted after fixing the IV and now it was useless. We requested if they could transfuse 200ml instead of 250ml and we could come back after 4 weeks since the cannulation was done and it is not easy for Hassan. Now we will have to go back again next week and this time a CBC would be done before admission....more pricking. Is it dangerous to transfuse if the hb is over 11? I am mentally prepared for one pricking session in a month and now next week is going to be a repeatation. Feeling so heavy

maha

Maha,

I have many times been transfused with hb 11. It is not dangerous but it is useless. The thing with transfusions is to receive only the necessary ones, not to burden yourself with one more transfusion than what is necessary. It is not clinically unacceptable though, you are not in any danger when in 11(for higher counts it is different),  but it would be better to avoid any unnecessary transfusion.
Remember that a transfusion does not only mean good things--higher hb and so on. It also means higher iron load, infections, reactions - so it is advisable to avoid any unnecessary transfusions like I said.

Lena.

Exactly what Lena said. Don't add iron when blood isn't needed. The harm greatly outweighs the benefit.

Thankyou Lena and Andy
I suppose whatever happens, happens for the best. Now I am relieved as it was the right thing the doc did. Thankyou once again.

maha

On thursday we took Hassan for his tx. His hb was tested first and it was 10 (last week it was 11.2). The doc had a brief discussion with dunno whom and decided to transfuse 200cc instead of his usual 250cc. This past year his pre tx hb has been hovering around 10 (9.5- 10.8) and the doc never had any problem in transfusing him with 15ml/kg, can`t understand why this sudden onset of brain wave. Once he was admitted the CBC showed hb to be 9.2. I asked the head nurse to inform the doc so as to increase the blood volume to be transfused. He suggested 220cc. Now why is he doing this? Why couldn`t he give his full requirement of 250cc? Other times I wouldn`t have mind his little experiments but now since he has started going to school I am unnecessarily more worried.

maha

Do not freak out, Maha. There is no need to worry.Do not face his school as something so strenuous, so as to change the blood taken because of this. Keep the same transfusion intervals and if you notice the hb drops considerably, then discuss it with the doctor. No need to worry, indeed. No need to let Hassan feel unsafe with this new change in his life.

Lena.

Hi Lena
That`s exactly why I am freaking out I don`t want to change anything but the doc is doing it unnecessarily. I didn`t argue nor question him this time, if Hassan can maintain his hb with less blood then its better for him and I would probably start praising his doc but what if its drops down to 8 because of this?

As for worrying about school its probably a habit and nothing thal related. I probably caused my hubby premature greying of hair when my daughter had started school

thankyou Lena I know its best to wait and see how his hb behaves after 4 weeks and then sit down and discuss further if required.

maha

Maha,

There are formulas that doctors use to determine the volume needed for transfusion. I am certain your doctor is abiding by the formula and does not want to exceed the volume indicated by the formula. In the young and elderly, this is most important as to avoid unnecessary transfusion complications, specifically volume overload. The formula is based on hematocrit before transfusion, desired hematocrit after the transfusion and the weight of the patient. It is in the best interest of the patient to abide by this formula. The result is to minimize both the iron intake and the stress that transfusion volume can have on the heart.

The formula, from http://www.scinfo.org/transfus.htm

Formulas of use in Blood Transfusion (Useful Approximations):

Total Blood Volume = 70 cc X Weight in kg.or 75 cc X Weight in Kg (With chronic anemia).

Red Cell Volume of Patient = Total Blood Volume X Hematocrit

Giving 3 cc/kg of packed red cells will raise the hemoglobin by 1 gm/dl

Giving 10 cc/kg of packed red cells will raise the hematocrit by 10 points (vol%) or hemoglobin by about 3 gm/dl

Quick Formula to Approximate Volume of Red Cells for Transfusion

Transfusion volume = [Total Blood Volume X (Hcrit goal - Hcrit pre Tx)]/ Hcrit of Donor Unit

Example: For 50 kg person with pre-transfusion Hcrit 23%, goal Hcrit 30%, average PRBC unit Hcrit 70%,

[(75 cc/kg) (50 kg) (0.30 – 0.23)]/0.70 = 375 cc (or 7.5 cc/kg)

Hematocrit of donor unit average values in transfused units

Whole blood donor unit average Hematocrit = 35%

Packed red cell unit average Hematocrit = 70%

PRBC unit with AdSol averages Hematocrit = 60%

Those being treated for acute anemia, aplastic crisis, heart failure, splenic sequestration, and bleeding should be given packed cells to raise the hematocrit to 28 - 33 vol.%. Patients should receive further transfusions based on symptoms.

Caution is the word when transfusing those with the lowest blood capacity. Infants, young children and the elderly all fall into this category. Many steps are taken to make transfusion as safe as possible, and restricting the blood volume taken is one of these steps.

Hi Andy
For the past 2 years his doc has been following 15ml/kg formula. Hassan weighs 16.8kg and this time he was given 220cc which is around 13ml/kg. Probably the doc has decided to take some interest in his case, by the way he is only a paediatrician and not a thal specialist.

Maha