Page 1977 - Hematology_ Basic Principles and Practice ( PDFDrive )

Chapter 115 Transfusion of Plasma and Plasma Derivatives 1751

Severe Maternal Hemorrhage TABLE Administration of Albumin
115.3
Major obstetric hemorrhage is a leading cause of maternal morbidity
and mortality, and is preventable and/or treatable. Significant obstetric Indicated
hemorrhage is defined as active bleeding >1000 mL within the 24 After large-volume paracentesis
hours following birth that continues despite the use of initial measures Nephrotic syndrome resistant to potent diuretics
including first-line uterotonic agents and uterine massage. Early assess- Ovarian hyperstimulation syndrome
ment and aggressive treatment of postpartum hemorrhage (PPH) are Volume/fluid replacement in plasmapheresis
important for reducing morbidity and mortality rates. A critical first step Possibly Indicated
in managing PPH is rapid recognition that clinically significant bleeding
has occurred, with effective communication of the situation to the Adult respiratory distress syndrome
appropriate team members, both clinical and laboratory staff. Subse- Cardiopulmonary bypass pump priming
quent measures include immediate resuscitation with definitive action Fluid resuscitation in shock/sepsis/burns
to arrest the bleeding (obstetric, surgical, and/or hematologic) and Neonatal kernicterus/hyperbilirubinemia
ongoing assessment and monitoring of the response to treatment. In To reduce enteral feeding intolerance
these cases, blood ordering protocols specific to obstetric patients may Not Indicated
be helpful. A massive transfusion protocol, similar to that seen in acute Correction of measured hypoalbuminemia or hypoproteinemia
trauma patients ensures sustained availability of blood products while
the bleeding remains uncontrolled. Unique to maternal hemorrhage, Nutritional deficiency, total parenteral nutrition
hypofibrinogenemia is an important predictor for the later development Preeclampsia
of severe bleeding. Consequently, point-of-care technologies, such as Red blood cell suspension
thromboelastography and rotational thromboelastometry, in addition to Simple volume expansion (surgery, burns)
fibrinogen levels can identify decreased fibrin clot quality during PPH, Wound healing
which correlate with low fibrinogen levels and can assist in transfusion Investigational
management. Early administration of 1 to 2 g tranexamic acid is also
recommended, followed by an additional dose in cases of ongoing Cadaveric renal transplantation
bleeding. Early fibrinogen replacement using an appropriate dose of Cerebral ischemia
cryoprecipitate may also be beneficial in these cases. Stroke
Common Usages
Cardiopulmonary bypass, pump priming
have revised target levels to at least 150 to 200 mg/dL, or a TEG Extensive burns
Maximum clot firmness (MCF) reading of 6 to 8 mm. It is estimated Hypotension
that a dose of 8 to 10 units of cryoprecipitate will increase the Intraoperative fluid requirement exceeding 5–6 L in adults
fibrinogen in a 70 kg adult by 50 to 70 mg/dL, but how this dose Labile pulmonary, cardiovascular status
affects a TEG is unclear. Dosing frequency should be determined Liver disease, hypoalbuminemia, diuresis
based on clinical and laboratory responses, as factor XIII and fibrino- Nephrotic syndrome, proteinuria, and hypoalbuminemia
gen are very stable proteins. Specifically, the half-life of fibrinogen is Plasma exchange
4 days, and factor XIII has a half-life of 9 days. Premature infant undergoing major surgery
Protein-losing enteropathy, hypoalbuminemia
Resuscitation
Compatibility Serum albumin <20 g/dL

Cryoprecipitate can contain minimal anti-A and/or anti-B antibodies
and, as such, ABO and D compatibility is not necessary for most
adult and pediatric patients. Indications
A decrease in measured plasma albumin is found in many situations,
Adverse Events including chronic liver disease, chronic renal failure, sepsis, malig-
nancy, burns, critical illness, severe head trauma, and hemorrhage,
Cryoprecipitate has similar adverse event risk as other blood products, and is often, in itself, not a clinically significant concern. Mild edema
including transfusion-transmitted diseases, hemolytic reactions and arising from hypoalbuminemia does not require albumin therapy.
allergic reactions. Since it contains less plasma and no leukocytes, However, inadequate synthesis, as seen in severe liver disease and
febrile and allergic reactions are less likely to occur. severe malnutrition, or excessive loss, as seen in nephrotic syndrome
and protein-losing enteropathy, can lead to significant hypoalbumin-
emia with intravascular volume depletion, anasarca, ascites, and
ALBUMIN pleural effusions. Hypoalbuminemia is associated with poor clinical
outcome in some studies, yet correction of low serum albumin levels
Albumin, an important plasma protein, contributes primarily to the in critically ill patients does not improve outcome measures such as
maintenance of plasma colloid oncotic pressure; it is also involved in mortality, duration of intensive care unit (ICU) and hospital stay, or
the transport of numerous substances, such as unconjugated bilirubin, mechanic ventilation. Historically, albumin had a broader use (i.e.,
various hormones, and drugs. Albumin also has an established role nutritional support, correction of hypoalbuminemia, volume replace-
in acid-base function, free radical scavenging, is antiapoptotic, anti- ment), but recent studies support its benefit in fewer situations,
thrombotic, and has positive and negative effects on vascular integrity. including nephrotic syndrome resistant to potent diuretic therapy,
The human body content of albumin is 4 to 5 g/kg, and is responsible after large-volume paracentesis, and in ovarian hyperstimulation
for 80% of the osmotic pressure of human plasma. Albumin is clini- syndrome (OHSS) (Table 115.3).
cally available in four forms: 5% solution in saline; 25% solution in
distilled water; albumin conjugated with polyethylene glycol; and
purified protein fraction, which is 5% total protein (88% albumin Intravascular Volume Expansion
and 12% globulins). These products are heat-treated and albumin
has not been documented to transmit infectious diseases (single As noted, albumin provides the majority of plasma colloid oncotic
outbreak occurred with albumin transfusion-associated hepatitis B pressure. Infused albumin provides colloid oncotic pressure; however,
with purified protein fraction in 1973). 50% of the infused protein is lost to the extravascular fluid