A pathologist who works in a small community hospital reports that for several years his institution has benefited from an effective utilization/justification program for transfusions. He offers a copy of their existing blood product requisition form (MS Word), which includes local guidelines for when a transfusion might be clinically justified. They are in the process of updating their local guidelines and have created a proposed new blood product requisition form (MS Word) that was developed to reflect increasing requests for RBC transfusions to "elderly" (usually >65 years old) patients who have hemoglobin levels around 10 gm/dL and co-existing cardiac disease. The inquiring pathologist would appreciate input about their current and proposed local guidelines.

The following comments have been received.

ADDENDA Oct. 28, 2003

1. A colleague in New York reports that his hospital's local practice is to permit FFP transfusions for a patient with an abnormal PT and/or aPTT, if the patient is ACTIVELY BLEEDING and the cause for the abnormal coagulation test result(s) is not yet determined. However, if the patient is set for an elective procedure (medical or surgical) and their PT or aPTT is abnormal, FFP may NOT be indicated in the following situations:

• Contact factor deficiency (Factor XII, Fletcher, HMWK, etc.) [REF: Ref: CONSULTATIVE HEMOSTASIS AND THROMBOSIS BY KITCHENS, ALVING, KESSLER W.B. Saunders 2002 page 67]
• Anticoagulant treatment (such as heparin)
• Lupus anticoagulant
• Abnormal PT due to warfarin and the patient has only mild bleeding e.g. nosebleed (their protocol for severe bleeding due to warfarin toxicity calls for use of factor concentrate) REF: Vitamin K deficiency & NO active bleeding, Technical Manual by AABB 14th edition page 463-467

A few examples for the use of CRYO include:

• Fibrin Glue
• Bleeding in uremic patient with normal platelet count. REF: textbook by Kitchens (see above) page 142 and NEJM 1980; 303:1318-1322.

ADDENDA Oct. 30, 2003

2. A transfusion medicine physician in Texas reports that at his institution they would take a slightly different approach than that submitted by the New York colleague (#1, above). At the Texas hospital, if a patient has a prolonged aPTT, but a normal PT, this is NOT an indication for FFP transfusion, unless the patient is shown to have Factor XI deficiency. Instead, a patient with a prolonged aPPT due to hemophilia A (and vWD) and hemophilia B are treated with respective clotting factor concentrates. Other causes of long aPTT include FXII deficiency and lupus anticoagulant, which in the experience of the responding physician do not cause bleeding and hence should not usually get FFP. The commonest cause of long PTT in the responding physician's hospital setting is heparin administration, either via contamination from a heparinized central line or via heparin anticoagulation therapy. To reverse heparin effect, especially when a patient is bleeding, FFP is NOT indicated, since in the experience of the responding physician, anti-thrombin present in FFP may actually enhance heparin effect. Ideally protamine should be given for heparin-associated bleeding. In summary, at the responding physician's institution, FFP is not indicated for isolated prolonged aPTT, unless they know it is due to FXI deficiency.

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator