Tranfusion Committee Audit Standards for The Use of Blood ...



Attachment 7 HPM 113-03JAMES A. HALEY VETERANS’ HOSPITAL HOSPITAL POLICYTAMPA, FLORIDA 33612 MEMORANDUM NO. 113-3 SEPTEMBER 2008TRANSFUSION COMMITTEE AUDIT STANDARDS FOR THE USE OF BLOOD, BLOOD PRODUCTS, AND BLOOD DERIVATIVES1. PURPOSE: In order to provide a systematic mechanism for the Transfusion Committee to review the use of blood, blood components, and plasma derivatives as required by the Joint Commission (TJC), it is necessary to develop clinical guidelines for the use of such products. If, upon initial retrospective review, a case meets the following guidelines, the Transfusion Committee will conduct no additional review. Cases that do not meet these guidelines will be reviewed by the Chairperson of the Transfusion Committee and, if deemed necessary, will be evaluated by the entire Transfusion Committee at their monthly meeting. There are occasional clinical exceptions to these guidelines, but the following criteria are considered by national experts to be reasonable. Implicit in these standards is the need for clinicians to record in the patient's electronic medical record the justification for all transfusions and the clinical circumstances necessitating any exceptions to these standards. 2. POLICY: Only a physician or dentist can order transfusion of blood, blood products, or blood derivatives. An electronic Florida Blood Services (FBS) Blood and Blood Component Request (BBCR) Consult or the appropriate Pharmacy request form must accompany all blood product or blood derivative requests. Please refer to HPM 113-12, INFORMED CONSENT FOR BLOOD AND BLOOD PRODUCT TRANSFUSION, for information regarding proper documentation of patient consent, prior to transfusion. The indication for the transfusion must be documented on the ELECTRONIC FBS BBCR CONSULT in the patient's electronic medical record and on the Blood Component Transfusion Consent form. Any health problems or clinical circumstances that influence the decision to transfuse or the type of product used must also be documented. Cases that do not meet the following criteria must have clear, written documentation in the patient's electronic medical record indicating the clinical circumstances that necessitate an exception to these standards. A physician’s order stating the number of units and type of components to transfuse must be placed in the patient’s medical record, prior to the initiation of any transfusion.3. DELEGATION OF AUTHORITY AND RESPONSIBILITY: a. The Transfusion Committee and Chair are responsible for: (1) Retrospectively monitoring compliance with these standards by hospital providers (2) Reviewing cases that do not meet these standards (3) Requesting additional information from the ordering provider’s Service Chief, if necessary (4) Rendering a final decision on the appropriateness of any transfusion reviewed (5) Notifying the appropriate Service Chief of any decisions regarding cases reviewed (6) Reviewing all cases of suspected transfusion reaction (7) Monitoring all aspects of transfusion, including proper documentation of informed consent for transfusion, transfusion administration, and performance of the Blood Bank. (8) Monitoring and/or reviewing autologous blood donations, therapeutic phlebotomy requests, and apheresis requests at their discretion. b. The appropriate Service Chiefs are responsible for: (1) Assuring that their providers abide by these standards (2) Responding to Transfusion Committee requests for additional information on cases related to their providers (3) Maintaining records and documentation for JCAHO inspection purposes of any investigations, follow-up actions and corrective actions on cases reviewed by the Transfusion Committee 4. PROCEDURES: a. RED BLOOD CELLS (1) TYPES OF PRODUCTS AND INDICATIONS: (a) RED BLOOD CELLS (RBCs): Red blood cell transfusion is useful to increase oxygen carrying capacity in patients with significant bleeding or symptomatic anemia. RBCs do not provide a significant osmotic effect; therefore intravascular volume status must be maintained using crystalloid or colloid solutions. Due to universal leukocyte reduction, all RBCs transfused at this facility are pre-storage leukocyte reduced. Patients who receive red blood cells must meet one of the following criteria: Clinical evidence of decreased oxygen-carrying capacity and hypovolemia secondary to bleeding.Clinical evidence of acute loss of > or = 15% of the blood volume or estimated blood loss > or = 750 mL.Hemoglobin < or = 8 g/dL and symptoms related to anemia.Hemoglobin < or = 10 g/dL and angina, acute myocardial infarction with the previous 90 days, or previous open heart surgery (e.g. CABG).Hemoglobin < or = 10 g/dL and MVO2 (PVO2) < 30 mm Hg and a normal A-VO2 difference.Hemoglobin < or = 10 g/dL and age > or = 65 and in an ICU and history of significant cardiopulmonary disease. (b) RED BLOOD CELLS, LEUKOCYTE-REDUCED BY PRE-STORAGE FILTRATION: Due to universal leukocyte reduction, all RBCs transfused at this facility are pre-storage leukocyte reduced. Leukocyte-reduced RBCs are useful for reducing the risk febrile non-hemolytic transfusion reactions, Human Leukocyte Antigen (HLA) alloimmunization, and for markedly reducing the risk of CMV transmission in patients whose CMV IgG and IgM status are unknown. (c) RED BLOOD CELLS, UNCROSSMATCHED: Patients must meet one of the above criteria for RBCs. In addition, the transfusion must be deemed a medical emergency with insufficient time to allow completion of a crossmatch. Group O blood will be issued. American Association of Blood Banks (AABB) standards make no Rh requirements for emergency release situations. However, if the recipient is a female of childbearing age, every effort will be made to give D-negative (Rh negative) red blood cells until her Rh status can be determined. The name of the requesting physician and the name of the individual to whom the units are issued are required by FDA regulations. The Transfusion Committee will review usage of this product for appropriateness at their discretion. (d) RED BLOOD CELLS, IRRADIATED: Patients must meet one of the above criteria for RBCs. Irradiated RBCs are indicated for the prevention of transfusion-associated graft-versus-host disease (GVHD) in immunocompromised patients and in recipients of directed donations from relatives. All directed donations from blood relatives of the patient will be irradiated by the collection facility per standard operating procedure. Other patients who should receive irradiated blood are individuals who are status post bone marrow or solid organ transplantation; selected patients undergoing chemotherapy for acute myelogenous leukemia (AML), acute lymphoblastic leukemia (ALL), Hodgkin’s disease, and malignant lymphoma; and patients with congenital immunodeficiency disorders. This product is more costly than regular RBCs and delays are common due to the time required to irradiate the product. It is imperative that the patient’s physician requests this product by properly completing the electronic FBS BBCR consult and documenting the correct clinical indication for the request. All requests for this product will be reviewed by the Transfusion Committee. (e) RED BLOOD CELLS, CMV NEGATIVE: Patients must meet one of the above criteria for RBCs. CMV Negative RBCs are indicated for the prevention of transfusion-associated CMV (Cytomegalovirus) infection in immunocompromised patients who are known to be negative for CMV antibodies and who are not currently infected with CMV. Patients who receive CMV negative RBCs must be immunosuppressed due to chemotherapy, hematologic malignancy, bone marrow or solid organ transplantation, congenital immunodeficiency disorders, or acquired immunodeficiency disorders. Such patients must have recent (within the previous six months) documentation by laboratory testing in their electronic medical record that they are negative for both CMV IgG and IgM. There must be no evidence of active CMV infection. This product is more costly than regular RBCs, less commonly available due to the low rate of CMV negative donors, and delays are common due to the time required for the additional testing necessary to locate suitable units. It is imperative that the patient’s physician requests this product by properly completing the electronic FBS BBCR consult and documenting the correct clinical indication for the request. All requests for this product will be reviewed by the Transfusion Committee. (2) CONTRAINDICATIONS AND PRECAUTIONS: Hemolytic transfusion reactions are always a risk with RBC transfusion. Transmission of viral infections, such as hepatitis viruses, human immunodeficiency virus (HIV), West Nile virus, and cytomegalovirus (CMV), and bacterial contamination are serious complications of transfusion. Allergic/Urticarial reactions, delayed hemolytic transfusion reactions, delayed serologic transfusion reactions, febrile nonhemolytic reactions, alloimmunization, graft-vs-host disease (GVHD), anaphylactoid reactions, transfusion-related acute lung injury (TRALI), and iron overload (due to long-term transfusions) are other complications that should be considered whenever blood is transfused. Transfusions are also suspected of causing immune dysregulation and result in an increased risk of postoperative infections and higher cancer recurrence rates in some cases. Patients who receive blood may develop fluid overload or hypothermia, especially if rapid infusion is attempted. Please refer to HPM 113-7, POLICY FOR REPORTING ADVERSE REACTIONS TO BLOOD OR BLOOD COMPONENTS, for detailed information regarding the proper evaluation of adverse reactions to transfusion. Recent studies show lower patient morbidity and mortality when a conservative transfusion strategy is used. RBCs should not be given to patients who have one of the following diagnoses but do not have symptoms of hypoxia: iron deficiency anemia, pernicious anemia, nutritional deficiency, intestinal malabsorption, and some hereditary hemoglobinopathies such as thalassemia minor, or autoimmune hemolytic anemia. Nutritional therapy, not transfusion is more appropriate for some of these patients.Autologous, predeposited blood is a safer form of RBC transfusion. Autodonation should be considered for any patient undergoing elective surgery who has a hemoglobin level > or = 11 g/dL. Please refer to HPM 113-4, POLICY FOR AUTOLOGOUS DONATION AND TRANSFUSION AND FOR THERAPEUTIC PHLEBOTOMY, for information on how to order/schedule autologous blood donations. (3) DOSE AND ADMINISTRATION: The appropriate number of units to transfuse must be determined by the patient's physician based on the patient's clinical status. RBCs must be transfused through a standard blood administration set. No solutions other than isotonic saline should be added to RBCs. Medications must not be added to RBCs. (4) DOCUMENTATION: A completed electronic FBS BBCR consult must be received by the FBS Blood Bank prior to transfusion. Patients who receive red blood cells must have a hemoglobin level recorded in their medical record within 24 hours prior to the transfusion for inpatients and 72 hours for outpatients. A post-transfusion hemoglobin level must be checked if additional units of red cells are to be given beyond the initial number requested, except in emergent cases. For patients undergoing an elective surgical procedure, the postoperative hemoglobin value should not be greater than the preoperative value. A blood sample for crossmatching must be obtained within three (3) days (e.g. 72 hours) of transfusion in patients who have been recently transfused or pregnant within the previous three (3) months and in patients with a history of clinically significant antibodies. A blood sample for crossmatching may be obtained within thirty (30) days of transfusion if the patient has not been transfused or pregnant within the last three (3) months and does not have a history of clinically significant antibodies. A physician’s order stating the number of units of red blood cells (RBCs) to transfuse must be placed in the patient’s medical record, prior to initiation of the transfusion. b. PLATELETS (1) TYPES OF PRODUCTS AND INDICATIONS: a. PLATELETS, PHERESIS: This product is generally supplied by the FBS Blood Bank in lieu of Platelets, Pooled. Use of this product may decrease the risk of alloimmunization of patients who are candidates for bone marrow transplantation, since this product has already been leukoreduced by the collection facility. Pheresis platelets may have a lower risk of bacterial contamination, since this product is screened by the collection facility for this potential problem. Also, this product may be more rapidly available for transfusion in STAT or emergency situations, since the time delay required to pool units is not required. Please note that this product costs significantly more than Platelets, Pooled. Transfusion of platelets is useful in bleeding patients with significant thrombocytopenia or congenital, drug-induced, or acquired platelet dysfunction. Prophylactic transfusions are useful in certain clinical situations. Patients who receive platelets must meet one of the following criteria:Bleeding and platelet count < or = 50 G/L.Bleeding and documentation of platelet dysfunction by an abnormal platelet function assay (PFA) or medication specific platelet aggregation testing.Bleeding within 24 hours of cardiac bypass surgery (on bypass pump).Bleeding and patient on Ticlopidine or Clopidogrel (Plavix) or other agent in this class.Prophylactic transfusion and platelet count < or = 10 G/L.Prophylactic transfusion and platelet count < or = 50 G/L and prior to an operative or invasive procedure within 12 hours of the transfusion.Prophylactic transfusion and platelet count < or = 100 G/L and prior to a neurological operative procedure within 12 hours of the transfusion.Prophylactic transfusion and documentation of platelet dysfunction by an abnormal platelet function assay (PFA) or medication specific platelet aggregation testing and prior to an operative or invasive procedure within 12 hours of the transfusion.Prophylactic transfusion and patient on Ticlopidine or Clopidogrel (Plavix) or other agent in this class and prior to an operative or invasive procedure within 12 hours of the transfusion.How supplied: Platelets, Pheresis are obtained from one (1) donor and one (1) unit is equivalent to six (6) units of Platelets, Pooled, which constitutes a platelet transfusion dose. Each Platelet pheresis unit has a volume of about 200 mL and contains about 4.0 X 10^11 platelets. (b) PLATELETS, POOLED: This product is supplied by the FBS Blood Bank in lieu of Platelets, Pheresis, in times of shortage of pheresis platelets. This product is not pre-storage leukocyte reduced; therefore, use of a leukocyte depletion filter can provide equivalent effectiveness in reducing risk of alloimmunization and CMV transmission. Pooled platelets may have a higher risk of bacterial contamination, since this product is not screened by the collection facility for this potential problem. Since pooling of six individual units is required, this product is not as rapidly available for transfusion in STAT or emergency situations. The same indications as for Platelets, Pheresis apply. How supplied: Each platelet concentrate is prepared from one whole blood donation. A pool of six (6) units constitutes a platelet transfusion dose (Platelets, Pooled) and is, thus, derived from six (6) different donors. Each unit is about 50 mL and contains about 7.0 X 10^10 platelets. Therefore, a pool of six (6) units is about 300 mL and contains about 4-5 X 10^11 platelets. (c) CROSSMATCH COMPATIBLE PLATELETS: The units supplied are compatible when crossmatched with the patient's serum. This product may be useful for patients that have become platelet refractory secondary to platelet specific or HLA alloimmunization. Documentation of serologic incompatibility per testing by FBS is required for use of this product.How supplied: This product is typically supplied as a Platelet, Pheresis unit and can usually be available within 24 hours of request. (d) HLA MATCHED PLATELETS: These products are Platelet Pheresis units and obtained from donors who are HLA matched as closely as possible with the patient. They are intended for use in platelet refractory patients with documented HLA alloimmunization and in patients who crossmatch incompatible with all platelets tested. The degree of HLA matching is often variable. The patient's HLA-A and HLA-B type must be available. Due to the difficulty in obtaining this product and the availability and effectiveness of Crossmatch Compatible Platelets, this product is rarely necessary. An FBS pathologist or designee must approve requests for HLA matched platelets. HLA typing is performed by All Children’s Hospital and will only be done Monday through Thursday. Testing is not performed Friday, Saturday, Sunday or on holidays.How supplied: This product is supplied as Platelets, Pheresis and may take from 1 to 3 days to obtain. All HLA matched platelets will be irradiated by the collecting facility. (2) CONTRAINDICATIONS AND PRECAUTIONS: Platelet transfusions are usually not effective in patients with rapid platelet destruction or platelet sequestration. These conditions include thrombotic thrombocytopenic purpura (TTP), immune thrombocytopenic purpura (ITP), and untreated disseminated intravascular coagulopathy (DIC). In such patients, platelet transfusions should be employed only in the presence of active bleeding. Patients with thrombocytopenia due to septicemia or hypersplenism may also fail to benefit from platelet transfusions. Transmission of viral infections, such as hepatitis viruses, human immunodeficiency virus (HIV), West Nile virus, and cytomegalovirus (CMV), and bacterial contamination are serious complications of platelet transfusion. Allergic/Urticarial reactions, febrile nonhemolytic reactions, platelet and red blood cell alloimmunization, graft-vs-host disease (GVHD), anaphylactoid reactions, and transfusion-related acute lung injury (TRALI) are other complications that should be considered whenever platelets are transfused. Please refer to HPM 113-7, POLICY FOR REPORTING ADVERSE REACTIONS TO BLOOD OR BLOOD COMPONENTS, for detailed information regarding the proper evaluation of adverse reactions to transfusion. Platelet transfusions have been suspected of causing immune dysregulation and an increased risk of postoperative infections and cancer recurrence has been reported.Repeated transfusions and/or previous pregnancies may lead to alloimmunization to HLA or other platelet antigens and result in the development of a "refractory" state manifested by unresponsiveness to platelet transfusions.Prophylactic platelet transfusions are not required prior to a bone marrow biopsy or other procedures where direct pressure can be applied to control bleeding, regardless of the patient's platelet count. (3) DOSE AND ADMINISTRATION: The usual dose is six (6) units Platelets, Pooled or one (1) unit of Platelets, Pheresis. For this dosage, the expected increase in the platelet count of a 70 kg adult would be about 30-40 G/L. Failure to achieve hemostasis or the expected increment in platelet count may signify a refractory state. (4) EVALUATION OF PLATELET TRANSFUSIONS: An 18-24 hour post transfusion platelet count is acceptable for monitoring patients with satisfactory increments in their platelet counts (30-40 G/L increment per dose transfused). Patients with less than a satisfactory post-transfusion increment must have a one (1) hour post-transfusion platelet count checked to determine whether immune destruction of platelets might be occurring. Antibodies directed against platelets often cause a very low one (1) hour post-transfusion platelet increment. This assessment can be performed as soon as 10 minutes post-transfusion. Since fever, sepsis, and bleeding can also result in a low post-transfusion platelet increment, these factors should be taken into account. If none of these factors apply, the finding of a one (1) hour post-transfusion platelet increment of < or = 10 G/L on two occasions strongly supports platelet alloimmunization. Once platelet alloimmunization has been documented, the physician should contact the FBS Blood Bank and request a platelet crossmatch. If the crossmatch shows any evidence of serologic incompatibility, crossmatch compatible platelet units will be supplied to the patient per the physician’s order. (5) DOCUMENTATION: A completed electronic FBS BBCR consult must be received by the FBS Blood Bank prior to transfusion. The patient's medical record must contain a platelet count performed within 24 hours prior to the transfusion and within 24 hours following the platelet transfusion. These platelet counts are necessary to evaluate the effectiveness of platelet therapy. For patients receiving platelets to treat bleeding due to platelet dysfunction, documentation of platelet dysfunction by an abnormal platelet function assay (PFA), or medication specific platelet aggregation testing must be present in the patient's electronic medical record. A physician’s order stating the number of units of platelets to transfuse must be placed in the patient’s medical record, prior to initiation of the transfusion. c. FRESH FROZEN PLASMA (FFP): (1) INDICATIONS: FFP is indicated for use in bleeding patients with multiple coagulation factor deficiencies such as those secondary to liver disease, Coumadin therapy, DIC, and rarely the dilutional coagulopathy resulting from massive blood or volume replacement. FFP may be indicated for prophylactic use prior to invasive or surgical procedures. FFP is also indicated for patients with congenital factor deficiencies for which there is no coagulation factor concentrate available, such as deficiencies of Factors II, V, VII, X, or XI. FFP may occasionally be indicated for rapid reversal of Coumadin (Warfarin) effect when Vitamin K therapy is not effective or not timely enough. Demonstration of sufficiently abnormal clotting factor activity by a significant elevation of the International Normalized Ratio (INR) is mandatory. Patients who receive FFP must meet one of the following criteria.Clinically significant bleeding and INR > or = 1.5.Prophylactic and prior to an invasive or surgical procedure and INR > or = 1.5.Clinically significant bleeding or prophylactically and a specific factor assay indicating a significant coagulation defect.Prophylactic and prior to most minor procedures (paracentesis, bone marrow biopsy) and INR > or = 2.0. (2) CONTRAINDICATIONS AND PRECAUTIONS: FFP should not be used to provide blood volume expansion or to enhance wound healing as this product would expose patients unnecessarily to the risk of hepatitis, HIV, West Nile Virus, and other transfusion transmitted diseases. Hetastarch, crystalloids, or albumin solutions are safer products to use for blood volume expansion. Other specific side effects of FFP infusion include allergic/urticarial reactions, anaphylactoid reactions, and transfusion-related acute lung injury (TRALI). Please refer to HPM 113-7, POLICY FOR REPORTING ADVERSE REACTIONS TO BLOOD OR BLOOD COMPONENTS, for detailed information regarding the proper evaluation of adverse reactions to transfusion. FFP should not be used as a source of protein for nutritionally deficient patients, prophylactically in patients with liver disease not scheduled for an operative or invasive procedure or in patients during the consumptive or clotting phase of disseminated intravascular coagulopathy (DIC). FFP can worsen or even cause initiation of bleeding in patients with liver disease or DIC since the plasminogen supplied by this product may increase lysis of any clots that form. Prophylactic use of FFP prior to minor invasive procedures such as paracentesis, thoracentesis, bone marrow biopsy, bronchoscopy with biopsy, or liver biopsy has not been shown to be of benefit unless the patient's INR exceeds the above noted values. Transfusion of FFP in patients undergoing open-heart surgery has been shown to be of no proven benefit, unless the patient is bleeding and has a significantly abnormal INR after the reversal of heparin effect by Protamine. FFP is not indicated in patients with lupus anticoagulant or Factor XII deficiency, since these patients are not at risk for bleeding regardless of the degree of elevation of their aPTT. FFP is only rarely indicated for isolated elevations of the aPTT, since the majority of these cases are either not associated with bleeding or are more effectively treated with another blood product. Consultation with a hematologist and/or hematopathologist should be obtained whenever possible. (3) DOSE AND ADMINISTRATION: The dosage of FFP must be determined by the patient's physician and depends on the clinical situation and underlying disease processes. The usual minimum recommended dose is two (2) units. Post-transfusion assessment of the patient's clinical and laboratory coagulation status is important for monitoring the effect of FFP therapy. FFP should be transfused as soon as possible after thawing. Compatibility testing is not required, but ABO compatible FFP should be used. (4) DOCUMENTATION: A completed electronic FBS BBCR consult must be received by the FBS Blood Bank prior to transfusion. The patient's electronic medical record must also contain a determination of a PT/INR or a specific coagulation factor assay performed within eight (8) hours prior to the transfusion for nonsurgical patients and within 24 hours prior to the transfusion for pre-op surgical patients. A post-transfusion PT/INR or specific coagulation factor assay must be checked if additional units of FFP are to be given beyond the initial number requested. These coagulation assays are important when evaluating the effectiveness of FFP therapy. A physician’s order stating the number of units of FFP to transfuse must be placed in the patient’s medical record, prior to initiation of the transfusion. d. CRYOPRECIPITATE: (1) INDICATIONS: Cryoprecipitate is only useful for selected situations. Patients who receive cryoprecipitate must meet one of the following criteria.Bleeding and fibrinogen level < or = 100 mg/dL.Bleeding or prior to an invasive procedure and documented von Willebrand's disease, congenital hypofibrinogenemia, congenital dysfibrinogenemia, or Factor XIII deficiency.During or within 24 hours of cardiac bypass surgery (on bypass pump) to aid surgical hemostasis and no more than 10 units.Bleeding or prior to an invasive procedure and documented Hemophilia A when Factor VIII concentrate is not available.Bleeding and uremia unresponsive to administration of DDAVP (desmopressin). (2) CONTRAINDICATIONS AND PRECAUTIONS: Cryoprecipitate should not be used to treat patients with deficiencies of factors other than Factor VIII, fibrinogen, von Willebrand's factor, or Factor XIII. When large amounts of cryoprecipitate are used, the patient's fibrinogen level may become markedly elevated and should be monitored, as hyperfibrinogenemia can be associated with an increased risk of thromboembolism.ABO-compatible cryoprecipitate should be used whenever possible as small amounts of anti-A and anti-B isoagglutinins are present. The risk of infectious disease transmission is present. Other complications include transmission of infectious diseases, allergic reactions, bacterial contamination, and hemolysis. Please refer to HPM 113-7, POLICY FOR REPORTING ADVERSE REACTIONS TO BLOOD OR BLOOD COMPONENTS, for detailed information regarding the proper evaluation of adverse reactions to transfusion. Use of desmopressin (DDAVP) should be considered to treat patients with mild Hemophilia A, some patients with von Willebrand's disease, and patients with bleeding associated with uremia. Use of Factor VIII concentrate (if available) is recommended for treatment of patients with Hemophilia A.Cryoprecipitate has not been proven to be effective in treatment of patients with bleeding or elevations of the aPTT and/or thrombin time due to Lepirudin. This medication is a direct thrombin inhibitor and no known therapy is available, other than to allow the medication effect to wear off. Also, since cryoprecipitate does not contain thrombin (Factor II), use of this product is obviously not indicated or appropriate for treatment of any medication that inhibits thrombin. (3) DOSE AND ADMINISTRATION: The proper dosage of cryoprecipitate must be determined by the patient's physician and depends on the clinical situation and underlying disease processes. Used at a dosage of 1 unit per 10 kg, fibrinogen levels will increase by approximately 50 mg/dL over pretransfusion levels. Post-transfusion assessment of the patient's coagulation status is often important for monitoring the effect of cryoprecipitate therapy. For Factor VIII replacement, transfusions are generally repeated every 8-12 hours after therapeutic levels are achieved. Consultation with a hematologist must be obtained in these cases.Cryoprecipitate is supplied as a pool of cryoprecipitate units; each prepared from one (1) whole blood donation. A pool of ten (10) units typically constitutes a cryoprecipitate transfusion dose and is, thus, derived from ten (10) different donors. No compatibility testing is required; however, units should be of the same ABO type as the patient. Cryoprecipitate should be transfused as soon as possible after thawing, since it can be stored for no more than six (6) hours. (4) DOCUMENTATION: A completed electronic FBS BBCR consult must be received by the FBS Blood Bank prior to transfusion. If the transfusion is for treatment of hypofibrinogenemia, the patient's electronic medical record must contain a determination of a fibrinogen level, PT/INR, and aPTT performed within 24 hours prior to the transfusion. A post-transfusion fibrinogen level, PT/INR, and aPTT must be checked if additional units of cryoprecipitate are to be given beyond the initial number requested. These coagulation assays are important when evaluating the effectiveness of cryoprecipitate therapy.If the transfusion is for treatment of Factor VIII deficiency, von Willebrand's disease or platelet dysfunction due to uremia, documentation of the disease process or abnormality with appropriate lab tests must be present in the patient's electronic medical record. A physician’s order stating the number of units of cryoprecipitate to transfuse must be placed in the patient’s medical record, prior to initiation of the transfusion. e. ALBUMIN: (1) INDICATIONS: In general, patients receiving albumin should be both hypovolemic and hypoproteinemic. Indications for the appropriate use of albumin are described as follows.ALBUMIN CRITERIA CONDITIONS*ParacentesisWhen > 2 liters of fluid removed, as below:< or = 2 liters - No albumin2.1 - 3.9 liters - give 2 units (25 grams of albumin)4.0 - 5.9 liters - give 3 units (37.5 grams of albumin) 6.0 - 7.9 liters - give 4 units (50 grams of albumin) 8.0 - 10 liters - give 5 units (62.5 grams of albumin)Hemorrhagic ShockWhen blood products are not available, sodium restriction is required and non-protein colloids (e.g. Hetastarch) are contraindicated.SBP < 80mm Hg or CVP < 6mm Hg or PCWP < 10mm Hg or SBP < 25% of pre-op MAP.At least 1 L of crystalloid solution administered before second dose of albumin.Blood or blood products not available at or before albumin administration time.Administered within first 2 hours after blood loss.Hetastarch is contraindicated.Nonhemorrhagic ShockWhen > 2L of crystalloids are administered without effect, and non-protein colloids (e.g. Hetastarch) are contraindicated.SBP < 80mm Hg or CVP < 6mm Hg or PCWP < 10mm Hg or SBP < 25% of pre-op MAP.Hemoglobin and hematocrit levels stable (< 10% decrease over preceding 24 hours).At least 1 L of crystalloid solution administered before second dose of albumin.Hetastarch is contraindicated.HemodialysisSecond-line to crystalloids in patients experiencing symptoms of hypotension.Serum albumin < or = 2.5 g/dL or clinical symptoms of Hypotension and SBP < 80mm Hg or CVP < 6mm Hg or PCWP < 10mm Hg.Albumin used during or immediately following hemodialysis session.No greater than 25g of albumin used per hemodialysis session.PlasmapheresisLarge-volume (> 20 mL/kg per session) plasma exchange.Performed by FBS5% albumin usedSpontaneous Bacterial a. Peritoneal fluid Neutrophils > or = 250 M/L or positive fluidPeritonitis and Cirrhosis gram stain or positive fluid culture.to prevent Hepatorenal b. Serum bilirubin > or = 4.0 mg/dL or bilirubin < 4.0 mg/dL andSyndrome serum creatinine > or = 1.0 mg/dLc. 1.5 g/kg on Day 1 and 1.0 g/kg on Day 3.Prevention of Cerebrala. Status post neurosurgical procedureartery vasospasmb. 5% albumin used* All conditions must be met.CVP = central venous pressure; PCWP = pulmonary capillary wedge pressure; SBP = systolic blood pressure; MAP = mean arterial pressure. (2) CONTRAINDICATIONS AND PRECAUTIONS: Use of 25% albumin solution is contraindicated in dehydrated patients unless it is supplemented by the infusion of crystalloid solutions to provide volume expansion. Reported side effects include flushing, urticaria, chills, fever, and headache. Transmission of Creutzfeldt-Jakob disease is a concern. (3) DOSE AND ADMINISTRATION: The proper dosage must be determined by the patient's physician, depending on the clinical situation and utilizing the guidelines noted above. Consultation with a pharmacist is recommended whenever possible. Albumin does not need to be given through a filter. (4) DOCUMENTATION: The "Transfusion of Plasma Derivatives Dispensed by the Pharmacy Service" form must be properly completed prior to transfusion. The medical records of all patients who receive albumin must contain a written order signed by a physician, the indication(s) for the transfusion, documentation of all pertinent lab studies or test results, and an explanation of any exceptions to these guidelines. f. SERUM IMMUNE GLOBULIN: (1) INDICATIONS: Serum immune globulin (SIG) preparations can be used to provide passive antibody prophylaxis to susceptible individuals exposed to certain diseases. It can be used as replacement therapy to help prevent chronic bacterial infections in patients with chronic lymphocytic leukemia (CLL) or other lymphoproliferative diseases and congenital hypogammaglobulinemia or agammaglobulinemia resulting from such diseases as common variable immunodeficiency or other congenital immunodeficiency syndromes. Intravenous preparations can be used to treat selected patients with acute and chronic immune thrombocytopenic purpura (ITP) with bleeding or who are about to undergo an imminent invasive procedure and who are refractory to steroid therapy. Other approved uses include treatment of chronic inflammatory demyelinating polyneuropathy (CIDP), Guillain-Barre syndrome, autoimmune hemolytic anemia unresponsive to steroids, pure red blood cell aplasia secondary to infection by Parvovirus B19, myasthenia gravis, dermatomyocytis/polymyocytis unresponsive to steroids, and vasculitis due to SLE or other connective tissue diseases that are unresponsive to steroids. Use as a prophylaxis in bone marrow transplant recipients must follow the transplant institution's protocol. (2) CONTRAINDICATIONS AND PRECAUTIONS: Adverse reactions to serum immune globulin preparations include back pain, chest pain, chills, fever, flushing, headache, malaise, myalgias, nausea, vomiting, nephrotoxicity, and aseptic meningitis. There is a possibility of immediate hypersensitivity and anaphylactic reactions. Individuals with a history of IgA deficiency or severe anaphylactic reactions to plasma products should not, in general, receive SIG. Transmission of Creutzfeldt-Jakob disease, hepatitis C, and HIV is a concern. (3) DOSE AND ADMINISTRATION: The dose of immune globulin is dependent on the reason for administration, patient characteristics, and whether an IM or IV preparation is utilized. Some of the recommended dose schedules are as follows:Prophylaxis for hepatitis A: 0.02 - 0.04 mL/kg IMCongenital immunodeficiencyIM - 0.7 mg/kg monthlyIV - 100 mg (2mL) /kg monthlyc. Hyperimmune globulins for specific diseasesd. Hepatitis B - 0.06 mL/kg IM: repeat at 1 month (4) DOCUMENTATION: Consultation with and approval by an appropriate specialist physician is recommended prior to initiating therapy. The medical records of all patients who receive serum immune globulin must contain a written order signed by a physician, the indication(s) for the transfusion, and an explanation of any exceptions to these guidelines. g. Rh IMMUNE GLOBULIN (RhIG): (1) INDICATIONS: Rh immune globulin may be indicated for Rh negative patients who may receive Rh positive red blood cell containing blood components. Treatment with RhIG may prevent Rh sensitization. Since platelet concentrates may contain sufficient red cells to immunize an Rh negative patient if the cells are Rh positive, consideration should be given to administration of RhIG after transfusing these components. Of note, particular emphasis is placed on treatment of Rh-negative premenopausal women who receive Rh-positive red cell containing blood components. FFP and cryoprecipitate may be transfused without regard to Rh type. Intravenous formulations of RhIG may be used in Rh positive, non-splenectomized patients with immune thrombocytopenic purpura in lieu of serum immune globulin. (2) CONTRAINDICATIONS AND PRECAUTIONS: Adverse reactions to RhIG preparations include back pain, chest pain, chills, fever, flushing, headache, malaise, myalgias, nausea, vomiting, nephrotoxicity, and aseptic meningitis. There is a possibility of immediate hypersensitivity and anaphylactic reactions. Individuals with a history of IgA deficiency or severe anaphylactic reactions to plasma products should not, in general, receive RhIG. Transmission of Creutzfeldt-Jakob disease, hepatitis C, and HIV is a concern. (3) DOSE AND ADMINISTRATION: RhIG is available as an IM or IV preparation and may be inappropriate for certain patients. One standard dose vial for IM administration is sufficient to protect against 15 mL of packed red blood cells or 30 mL of whole blood. This dose is sufficient prophylaxis for 6 units of Platelets, Pooled. For ITP patients, inject 250 IU/kg, IV bolus. If repeat therapy is required, use 100 IU/kg, IV bolus. Patients must be observed for signs of anaphylaxis. (4) DOCUMENTATION: An FBS pathologist and the patient's physician should decide jointly on usage of RhIG formulations. h. FACTOR VIII AND FACTOR IX CONCENTRATES: (1) INDICATIONS: Factor VIII concentrate is indicated for treatment of patients with Hemophilia A who are bleeding and prophylaxis in such patients before and/or after surgery or invasive procedures. Factor IX concentrate is indicated for patients with Hemophilia B in similar circumstances. (2) CONTRAINDICATIONS AND PRECAUTIONS: Adverse reactions include headache, fatigue, chills, backache, lightheadedness, fever, flushing, and nausea. There is a possibility of immediate hypersensitivity and anaphylactic reactions. Patients with Hemophilia A and B have about a 10% incidence of developing inhibitors to these factors. Such patients may require higher doses of the concentrate to obtain therapeutic levels or use of other products to bypass this block when the inhibitor titer is very high. (3) DOSE AND ADMINISTRATION: Consultation with a hematologist is mandatory when these products are used in order to determine the appropriate dosage and schedule for each patient. These concentrates are supplied through the Pharmacy Service. (4) DOCUMENTATION: The medical records of all patients who receive these concentrates must contain documentation of the diagnosis and evidence of consultation with a hematologist. i. RECOMBINANT FACTOR VIIa: (1) INDICATIONS: Factor VIIa is a recombinant preparation of activated human coagulation factor VII (rFVIIa). The US Food and Drug Administration (FDA) has approved rFVIIa for the treatment of bleeding episodes in patients with hemophilia A (Factor VIII deficiency) or B (Factor IX deficiency) and inhibitors to Factor VIII or Factor IX and in patient with congenital Factor VII deficiency. It is also approved for the prevention of bleeding prior to surgical interventions or invasive procedures in these patient populations. Due to increased interest in off-label usage of rFVIIa, the VHA Pharmacy Benefits Management Strategic Healthcare Group and the Medical Advisory Panel has derived general recommendations for usage of this product. The Transfusion Committee at our facility has reviewed these recommendations and, with the input of medical experts at our facility, has determined the approved indications for usage at this facility and the required documentation necessary prior to and after such usage. FDA Approved usage criteria:Bleeding or prior to surgery or an invasive procedure in patients with Hemophilia A (Factor VIII deficiency) AND with documentation of an inhibitor to Factor VIII.Bleeding or prior to surgery or an invasive procedure in patients with Hemophilia B (Factor IX deficiency) AND with documentation of an inhibitor to Factor IX.Bleeding or prior to surgery or an invasive procedure in patients with congenital deficiency of Factor VII.Hospital Approved off-label usage criteria, based on quality of evidence: Intracerebral hemorrhage (ALL subsequent criteria must be met)Symptom onset < 4 hoursGlasgow Coma Scale > 5No plan for surgical evacuation within 24 hoursNo history of thrombotic or vaso-occlusive diseaseHospital Approved off-label usage criteria, BENEFIT IS UNCLEAR. Lack of evidence of effectiveness suggests use should only be considered ONLY when standard/conventional treatments have been exhausted or proven ineffective.Reversal of prolonged INR prior to invasive procedures in patients with liver disease (ALL subsequent criteria must be met).INR > 2.5Not responsive to Vitamin K replacementNot responsive to FFP administrationReversal of Coumadin effect (ALL subsequent criteria must be met).Active bleeding and/or urgent major surgical intervention plannedINR >2.5Not responsive to FFP administrationNot responsive to Vitamin K replacementIntractable bleeding associated with surgery, including cardiac surgery. Standard/conventional treatments for bleeding cessation must be exhausted or proven ineffective prior to consideration/utilization of this therapy. (ALL subsequent criteria must be met).INR > 1.5Unresponsive to FFPFibrinogen > 100 mg/dL or Fibrinogen < 100 mg/dL and unresponsive to cryoprecipitate transfusionPlatelet transfusions either not indicated or ineffective if hospital criteria metOff-label Usage is NOT APPROVED in the following situations:Bleeding due to esophageal or gastric varices in patients with cirrhosisPreoperative (prophylactic) use in patients undergoing surgery who do not meet any of the above noted criteria (1, 2, 3a, or 3b) (2) CONTRAINDICATIONS AND PRECAUTIONS: The risk for thromboembolic events in patients with hemophilia and inhibitors is unknown, but considered to be low. However, patients with disseminated intravascular coagulopathy (DIC), advanced atherosclerotic disease, crush injury, septicemia, or concomitant treatment with activated or nonactivated prothrombin complex concentrates (aPCCs/PCCs) may have an increased risk for developing a thrombotic event (cerebral infarct, cerebral ischemia, myocardial ischemia, myocardial infarct, venous thromboembolism, and arterial thromboembolism) due to circulating tissue factor (TF) or a predisposing coagulopathy. Usage is contraindicated in patients with known hypersensitivity to mouse, bovine or hamster proteins. There is a possibility of immediate hypersensitivity and anaphylactic reactions. Patients must be monitored closely during administration. (3) DOSE AND ADMINISTRATION: Consultation with a hematologist is mandatory when this product is used outside of the operating room in order to determine the appropriate dosage and schedule for each patient. This product is supplied through the Pharmacy Service. The exact dosage is unknown for particular circumstances. One group has recommended a dosage of 20-40 mcg/kg for nonemergent anticoagulation reversal and doses of 41-90 mcg/kg for other situations. (4) DOCUMENTATION: The medical records of all patients who receive rFVIIa MUST contain documentation that informed consent of the patient and/or surrogate was obtained prior to product administration. The standard consent for transfusion of blood, blood components, and blood derivatives is not considered adequate. The informed consent must state that the usage is not FDA approved, that the indications, risks (including risk of thromboembolic events, stroke and MI), and benefits have been discussed with the patient or surrogate and that all standard/conventional therapies have been exhausted or proven ineffective. If usage is not within the operating room, there must be documentation of consultation with a hematologist prior to administration. Any complications/adverse effects related to administration of rFVIIa must be immediately reported to the Pharmacy Service per Hospital and FDA policy. j. ANTI-INHIBITOR COAGULANT COMPLEX (FEIBA, AUTOPLEX) AND FACTOR VIIa: (1) INDICATIONS: Anti-inhibitor coagulant complexes and Factor VIIa are used for prevention and control of bleeding in patients with Hemophilia A or Hemophilia B who have developed inhibitory antibodies to Factor VIII or IX concentrates. (2) CONTRAINDICATIONS AND PRECAUTIONS: Adverse reactions include headache, fatigue, chills, backache, lightheadedness, fever, flushing, and nausea. There is a possibility of immediate hypersensitivity and anaphylactic reactions. A high possibility of acute disseminated intravascular coagulopathy (DIC) exists with use of some of these products. Patients must be monitored extremely closely during their administration. (3) DOSE AND ADMINISTRATION: Consultation with a hematologist is mandatory when these products are used in order to determine the appropriate dosage and schedule for each patient. These products are supplied through the Pharmacy Service. (4) DOCUMENTATION: The medical records of all patients who receive these products must contain documentation of the diagnosis, proof that a factor inhibitor is present and has been titered, and evidence of consultation with a hematologist. k. ANTITHROMBIN III CONCENTRATE: (1) INDICATIONS: Antithrombin III (ATIII) concentrate is presently approved for very limited uses. Patients who receive ATIII must meet one of the following criteria.Acute thrombosis and congenital deficiency and ATIII < 64%.Prophylaxis for high risk (Surgery, trauma, inflammatory disease) and congenital deficiency and ATIII < 64%.DIC due to traumatic shock and bleeding from two or more sites (excluding nasogastric tube bleeding) and ATIII < 65% and physician must judge that patient's underlying disease is compatible with survival. (2) CONTRAINDICATIONS AND PRECAUTIONS: Adverse reactions include dizziness, chest tightness, nausea, foul taste in mouth, chills, cramps, shortness of breath, hives, fever, bleeding, hematomas, and hypotension. There is a possibility of immediate hypersensitivity and anaphylactic reactions. Patients must be monitored closely during administration. (3) DOSE AND ADMINISTRATION: Consultation with a hematologist is mandatory when these products are used in order to determine the appropriate dosage and schedule for each patient. These products are supplied through the Pharmacy Service. (4) DOCUMENTATION: The medical records of all patients who receive ATIII must contain documentation of the diagnosis, determination of an ATIII level < 64% done within the previous 24 hours, and evidence of consultation with a hematologist. l. TISSEEL VH KIT - FIBRIN SEALANT: (1) INDICATIONS: Fibrin Sealant is approved for use during surgery to help achieve hemostasis as a topical agent (fibrin glue). It comes prepared in a syringe system with fibrinogen and thrombin that are mixed during application. (2) CONTRAINDICATIONS AND PRECAUTIONS: Adverse reactions include hives, fever, bleeding, and hypotension. There is a possibility of immediate hypersensitivity and anaphylactic reactions. Patients must be monitored closely during administration. (3) DOSE AND ADMINISTRATION: One to two applications. Supplied as a 2 mL kit. This product is supplied through the Pharmacy Service. (4) DOCUMENTATION: The medical records of all patients who receive Tisseel VH Kit must contain documentation of the use of this product. m. TRANSFUSION COMMITTEE MUST MONITOR:The Transfusion Committee will use these audit standards to retrospectively monitor (screen) the appropriateness of 10% of RBC, 100% of platelet, 100% of FFP, 100% of cryoprecipitate, 100% of CMV negative RBCs and platelets, 100% of irradiated RBCs and platelets, 100% of any other special request blood components, and 100% of blood derivative transfusions on a monthly basis. Please refer to HPM 113-2, BLOOD TRANSFUSION COMMITTEE, for information on Committee membership and duties. Monthly, FBS will supply the Chairperson of the Transfusion Committee with data on all blood and blood components issued. This data will include the number and type of products, full patient name and SS#, physician name, and date of transfusion. The Chairperson of the Transfusion Committee or designee will review all cases of transfusion that do not comply with these standards, secondary to insufficient information, improper/incomplete documentation, or potential inappropriate usage. Information examined for the initial review will include FBS Blood Bank records, laboratory test results, and the patient’s electronic medical record. If further review is felt to be necessary by the Chairperson of the Transfusion Committee, the case will be referred to the Transfusion Committee for review at its monthly meeting. These cases will be subjected to an intensive assessment. The patient's medical record will be examined and the patient’s attending physician’s Service Chief will receive a memo from the Transfusion Committee requesting justification for the transfusion and/or use of the specific blood product or derivative. A copy of this memo will be sent to Quality Management, the Associate Chief of Staff, and the Chief of Staff. The Transfusion Committee strongly encourages a response to this memo. The Service Chief may respond to this memo themselves, select a designee to respond, or request a response from the patient’s attending physician and forward these responses to the Transfusion Committee. By responding, the attending physician is allowed an opportunity to present any additional information that influenced their decision to transfuse the patient or clarify the reason that a specific product was used.After the intensive assessment is completed and all appropriate records have been examined, the case will undergo a final review by the Transfusion Committee. Based on the information available, the Transfusion Committee will render a decision regarding the appropriateness of the transfusion. If the case was deemed inappropriate or inadequately justified, the patient’s attending physician’s Service Chief will receive a memo from the Transfusion Committee stating this decision. A copy of this memo will also be sent to the Associate Chief of Staff, the Chief of Staff, and Quality Management. It is the responsibility of the Service Chief to maintain records and documentation for JCAHO inspection purposes of any investigations, follow-up actions and corrective actions. The Transfusion Committee minutes will document the findings and decisions on all cases reviewed by the committee.The Transfusion Committee will maintain a list of all providers who have been cited by the committee. After every meeting, a list of providers cited within the last fiscal year will be supplied to the appropriate Service Chiefs. The names of physicians who are repeatedly cited for inappropriate or inadequately justified transfusions will be referred to the Chief of their Service and a copy of this notice will also be sent to the Chief of Staff or designee for any additional corrective actions deemed necessary.The Transfusion Committee will also review all cases with suspected transfusion reactions characterized by hemolysis, severe allergic or anaphylactic manifestations, circulatory overload, or infection. They will review all Incident Reports related to adverse blood reactions, suggest any additional corrective actions, and guarantee that all corrective actions are completed to their satisfaction.The Transfusion Committee will also monitor all aspects of transfusion, including proper documentation of informed consent for transfusion, transfusion administration, and performance of the Blood Bank. The Transfusion Committee will monitor and/or review autologous blood donations, therapeutic phlebotomy requests, and apheresis requests at their discretion.Please take special notice of the indications and required documentation for each specific blood component. Compliance with these requirements is mandatory and aids the Blood Bank's ability to provide the best and most appropriate services to the patient.5. REFERENCES:1. Stehling L, Luban NLC, Anderson KC, et al. "Guidelines for Blood Utilization Review". Transfusion. 1994; 34/5: 438-448.2. Circular of Information for the Use of Human Blood and Blood Components. American Red Cross, Council of Community Blood Centers, and AABB. Current Edition.3. Fresh-Frozen Plasma, Cryoprecipitate, and Platelets Administration Practice Guidelines Development Task Force of the College of American Pathologists. "Practice Parameter for the Use of Fresh-Frozen Plasma, Cryoprecipitate, and Platelets." JAMA. 1994; 271/10: 777-781.4. McVay PA and Toy PTCY. "Lack of Increased Bleeding after Paracentesis and Thoracentesis in Patients with Mild Coagulation Abnormalities". Transfusion. 1991; 31/2: 164-171.5. McVay PA and Toy PTCY. "Lack of Increased Bleeding after Liver Biopsy in Patients with Mild Hemostatic Abnormalities". AJCP. 1990; 94/6: 747-753.6. Martinowitz U, et al. "Is Transfusion of Fresh Plasma after Cardiac Operations Indicated?" J Thoracic Cardiovasc Surg. 1990; 100: 92-98.7. Blumberg N and Heal JM. "Effects of Transfusion on Immune Function". Arch Pathol Lab Med. 1994; 118/4: 371-379.8. Stehling L and Simon TL. "The Red Blood Cell Transfusion Trigger: Physiology and Clinical Studies". Arch Pathol Lab Med. 1994; 118/4: 429-434.9. Ratko TA, Burnett DA, Foulke GE, et al. "Recommendations for Off-Label Use of Intravenously Administered Immunoglobulin Preparations". JAMA. 1995; 273/23: 1865-1870.10. Romac DR, Poole P, Owings JT, et al. "Developing Guidelines for Biotechnology Drug Use: Experience with Antithrombin III". Formulary. 1995; 30; 520-531.11. UHC Clinical Practice Advancement Center. "Technology Assessment: Intravenous Immunoglobulin Preparations" UHC Services Corporation. 1995.12. UHC Technology Advancement Center. "Albumin and Nonprotein Colloid Solutions Multicenter Technology Use Surveillance". UHC Services Corporation. 1993.13. Kozak EA and Brath LK. "Do 'Screening' Coagulation Tests Predict Bleeding in Patients Undergoing Fiberoptic Bronchoscopy with Biopsy?" Chest. 1994; 106/3: 703-705.14. Hebert PC, Wells G, Marshall J, et al. "Transfusion Requirements in Critical Care: A Pilot Study". JAMA. 1995; 273/18: 1439-1444.15. Spence RK. "Surgical Red Blood Cell Transfusion Practice Policies". Am J Surg. 1995; 170/6A: 3S-15S.16. Goodnough LT and Despotis GJ. "Establishing Practice Guidelines for Surgical Blood Management". Am J Surg. 1995; 170/6A: 16S-20S.17. Carson JL. "Morbidity Risk Assessment in the Surgically Anemic Patient". Am J Surg. 1995; 170/6A: 32S-36S.18. Standards for Blood Banks and Transfusion Services, Current Edition. AABB, Bethesda, MD. 19. Gelb AB, Roth RI, Levin J, et al. “Changes in Blood Coagulation During and Following Cardiopulmonary Bypass: Lack of Correlation with Clinical Bleeding.” Am J Clin Pathol. 1996; 106: 87-99.20. Bracey AW, Radovancevic R, Riggs SA, et al. “Lowering the Hemoglobin Threshold for Transfusion in Coronary Artery Bypass Procedures: Effect on Patient Outcome.” Transfusion. 1999; 39: 1070-1077.21. Simon TL, Alverson DC, AuBuchon J, et al. “Practice Parameter for the Use of Red Blood Cell Transfusions: Developed by the Red Blood Cell Administration Practice Guideline Development Task Force of the College of American Pathologists.” Arch Pathol Lab Med. 1998; 122: 130-138.22. Hebert PC, Wells G, Blajchman MA, et al. “A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care.” N Engl J Med. 1999; 340/6: 409-417.23. Bush RL, Pevec WC, Holcroft JW. “A Prospective, Randomized Trial Limiting Perioperative Red Blood Cell Transfusions in Vascular Patients.” Am J Surg. 1997; 174: 143-148.24. Carson JL, Duff A, Berlin JA, et al. “Perioperative Blood Transfusion and Postoperative Mortality.” JAMA. 1998; 279/3: 199-205.25. Sort P, Navasa M, Arroyo V, et al. “Effect of Intravenous Albumin on Renal Impairment and Mortality in Patients with Cirrhosis and Spontaneous Bacterial Peritonitis.” N Engl J Med. 1999; 341: 403-409.26. Kasper SM, Giesecke T, et al. “Failure of Autologous Fresh Frozen Plasma to Reduce Blood Loss and Transfusion Requirements in Coronary Artery Bypass Surgery.” Anesthesiology. 2001; 95: 81-86.6. FOLLOW-UP RESPONSIBILITY: The Chairman of the hospital Transfusion Committee (113) has responsibility for the contents of this hospital policy memorandum.7. RESCISSION: Hospital Policy Memorandum (HPM) 113-3 dated June 2005Stephen M. LucasDirectorDISTRIBUTION: Electronic Distribution to All Employees ................
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