Blood Transfusion in Dogs

Nuno Manuel Félix, DVM, MD, MSc, PhD, Hospital Distrital de Santarém, Santarém, Portugal

August 2018|Emergency Medicine & Critical Care|Peer Reviewed|Web-Exclusive

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Blood Transfusion in Dogs

Although veterinary transfusion medicine has developed significantly in the past 30 to 60 years,1 blood transfusions are not benign,2,3 with transfusion reactions occurring in up to 3% to 15% of patients.2,4,5 The safe administration of blood products requires precautionary measures, including careful sourcing of blood products; blood typing and crossmatching between donor and recipient; and adoption of appropriate blood collection, processing, storage, and administration techniques. In the event of a possible transfusion reaction, several corrective measures should be followed and the cause of the transfusion reaction should be identified.

This 3-part series covers what you need to know to ensure safe blood transfusion in dogs: blood collection and storage, patient selection, how to transfuse, and treating potential acute transfusion reactions.   


Part I: Collection & Storage

Blood Product Sourcing

Blood products are readily available from animal blood banks in many countries and can also be obtained in-house or from an external donor program.6,7 About 15 to 20 mL/kg of blood can be safely collected from a dog. There is no need to administer crystalloid solutions during blood collection from dogs. Blood products may also be acquired via cell salvage and autotransfusion techniques.8,9

Dogs rarely need sedation for blood collection; if sedation is elected, acepromazine should be avoided due to its effects on platelet function. Several other sedative agents can be used. One common combination consists of butorphanol at 0.2 mg/kg IV +/- dexmedetomidine at 1 µg/kg IV for nonsensitive MDR1 breeds, or methadone at 0.2 mg/kg IV +/- dexmedetomidine at 2 µg/kg IV for MDR1-sensitive breeds can be considered.  

Donor Criteria

Whether selected in-house or from external programs, dogs that are candidates to become blood donors must meet several conditions: 

  • Clinically healthy and assessed with annual examinations and testing (see Donor testing)
  • 1-8 years of age
  • Weigh >20 kg
  • Normal body condition 
  • Good temperament 
  • Updated vaccination status 
  • Packed cell volume (PCV) >40% 
  • Negative for dog erythrocyte antigen-1 (DEA 1)
    • Ideal canine blood should be DEA 1, DEA 3, DEA 5, and DEA 7 negative and positive for DEA 4.1
  • Readily accessible jugular vein 
  • No previous history of receiving blood product transfusions
  • No previous history of pregnancy
    • Pregnancy is known to lead to alloantibody formation against erythrocyte antigens.10 The few studies available about this issue in dogs did not demonstrate that these alloantibodies are associated with increased incidence of transfusion reactions. Nevertheless, until further research is available, it is advised to avoid previously pregnant female dogs as blood donors, except in emergency situations where no other source of blood products is available. 

Donor Testing

Although infectious disease testing should in part be based on the local and regional prevalence of infectious agents, several national and international societies have released guidelines regarding this subject. One of them is the 2016 American College of Veterinary Internal Medicine Consensus Statement on Infectious Disease testing for blood donors.11 This suggests that any canine blood donor should be tested for:   

  • Blood type
  • Complete blood count (CBC)
  • Serum chemistry panel
  • Fecal analysis (every 6 months)
  • Heartworm antigen
  • Babesia spp
  • Anaplasma spp
  • Ehrlichia spp
  • Bartonella spp
  • Mycoplasma spp 
  • Leishmania spp (geographic)
  • Trypanosoma cruzi (geographic)
  • Hepatozoon canis americanum (geographic)
  • Brucella canis 

Blood obtained from closed cavities can be safely used for autotransfusion if there is no evidence of septic, bile, intestinal content, and urine contamination; if the dwelling time in the cavity is fewer than 72 hours; and if no gross clotting is apparent. Neoplastic disease can also be considered as a contraindication to blood product autotransfusion, although the risk of metastatic spreading may be reduced by leukocyte depletion filters.9 Blood for autotransfusion can also be collected and processed with cell salvage devices.                                                                                 

Step-by-Step: Blood Collection

What You Will Need

  • Peripheral venous-inserted catheter
  • Cutaneous asepsis kit (ie, antiseptic solution, alcohol, gauze swabs, clippers)
  • Sterile gloves
  • Blood collection bags (simple for whole blood collection, or with a dedicated collection system with satellite bags if blood is going to be processed to produce blood components)

Step 1

Take the donor’s temperature, pulse, and respiratory rate before placing in lateral recumbency. Evaluate the quality and location of the jugular vein before shaving and sterilizing the skin around the jugular vein.

Step 2

Place the collection bag (available through Animal Blood Resources International) on a gram scale and zero the scale. Flush and fill the line tubing of the collection system and the connected needle with the bag’s anticoagulant. Most commercially available blood bags now use a citrate-phosphate-dextrose-adenine [CPDA-1] or citrate-phosphate-dextrose/adsol preservation solution as an anticoagulant. Avoid kinking or twisting the line tubing to prevent red blood cell (RBC) damage. Clamp the collection line 3 to 4 cm distal from the needle (use a plastic hemostat to avoid damage to the collection line).

Step 3

Have an assistant compress the thoracic inlet to increase jugular vein distension, then insert the needle in the jugular vein in a cranial direction and with the bevel up (Figure 1). Once blood enters the collection system, remove the hemostat clamp and let blood flow into the tubing and collection bag. 

For blood collection, the blood donor should be placed in lateral recumbency, with its neck extended. The needle is inserted in the jugular vein in a cranial direction with the bevel up.

Photo courtesy of Dr. Isabelle Goy-Thollot, SIAMU/ICU, VetAgro Sup, University of Lyon
 
For blood collection, the blood donor should be placed in lateral recumbency, with its neck extended. The needle is inserted in the jugular vein in a cranial direction with the bevel up.

Photo courtesy of Dr. Isabelle Goy-Thollot, SIAMU/ICU, VetAgro Sup, University of Lyon
 

Figure 1 For blood collection, the blood donor should be placed in lateral recumbency, with its neck extended. The needle is inserted in the jugular vein in a cranial direction with the bevel up. Photo courtesy of Dr. Isabelle Goy-Thollot, SIAMU/ICU, VetAgro Sup, University of Lyon  

Figure 1 For blood collection, the blood donor should be placed in lateral recumbency, with its neck extended. The needle is inserted in the jugular vein in a cranial direction with the bevel up. Photo courtesy of Dr. Isabelle Goy-Thollot, SIAMU/ICU, VetAgro Sup, University of Lyon  

AUTHOR INSIGHT

Consider diverting the first 10 mL of blood to a separate collateral bag to prevent contamination of the blood unit with skin microorganisms.12,13 This blood can be used for donor testing, if needed. 

Step 4

An assistant should carefully agitate the collection bag back and forth during collection to allow blood to mix with the anticoagulant. Once 405 to 480 g of blood is collected, have an assistant remove the pressure to the thoracic inlet.  (Figure 2). Remove the needle and perform compression over the puncture site for 1 minute. Wrap the jugular site with cohesive bandage wrap for at least 30 minutes to prevent bruising and hematoma formation.

Let the blood flow by gravity to the collection bag. An assistant should gently agitate the collection bag back and forth during collection to allow mixing of the blood with the anticoagulant.

Photo courtesy of Dr. Isabelle Goy-Thollot, SIAMU/ICU, VetAgro Sup, University of Lyon
Let the blood flow by gravity to the collection bag. An assistant should gently agitate the collection bag back and forth during collection to allow mixing of the blood with the anticoagulant.

Photo courtesy of Dr. Isabelle Goy-Thollot, SIAMU/ICU, VetAgro Sup, University of Lyon

Figure 2 Let the blood flow by gravity to the collection bag. An assistant should gently agitate the collection bag back and forth during collection to allow mixing of the blood with the anticoagulant. Photo courtesy of Dr. Isabelle Goy-Thollot, SIAMU/ICU, VetAgro Sup, University of Lyon

Figure 2 Let the blood flow by gravity to the collection bag. An assistant should gently agitate the collection bag back and forth during collection to allow mixing of the blood with the anticoagulant. Photo courtesy of Dr. Isabelle Goy-Thollot, SIAMU/ICU, VetAgro Sup, University of Lyon

Step 5

Hemoclip or heat seal the collection line at least 3 cm above the bag to imprint a unique identifying line number on the bag. Identify the collection bag with donor identification, date, time, and amount collected. Record the donation in the donor record, including its weight, vital signs, and PCV/total protein before and 30 minutes after transfusion. Include data about vessel and draw position used, and record any problems that occurred during donation.

AUTHOR INSIGHT

Blood removed from closed cavities for autotransfusion can be collected into a 60-mL syringe, empty sterile crystalloid bags, or blood collection bags.9 Anticoagulant (citrate-phosphate) may be added (0.05-0.14 mL for each mL of collected blood) to the syringe or the crystalloid bag. However, because blood becomes defibrinated when in contact with serosal surfaces for more than 1 hour,9 the amount of anticoagulant needs to be decreased if blood is present in body cavities longer than this period. Alternatively, the coagulation system status of the recipient should be carefully monitored after the transfusion, especially during the first 72 hours posttransfusion. 

Processing Blood Products

In the first 4-6 hours after blood collection, blood can be administered as FWB, be refrigerated and stored as WB, or refrigerated until processing for component therapy. If the latter option is chosen, the collected blood should be stored at 4°C to 6°C (39°F-42°F) until processing. Blood component therapy is commonly used in human medicine and is becoming more frequent in veterinary medicine. Its main advantage is that it permits the veterinarian to tailor therapy more appropriately while avoiding transfusion-related reactions, as it spares the patient exposure to unnecessary blood products. In addition, it makes transfusion medicine more efficient, because a single unit can be divided in multiple components, which can be used for more than one patient. Each blood component has its own indications, advantages, and disadvantages. A summary of all blood components available is described in Table 1.  

Table 1

Blood Products: Main Indications, Doses, and Additional Information1

Blood Product Definition Composition Indication Dose Additional Information
Fresh Whole Blood (FWB) Blood collected from donor without processing RBCs, WBCs, platelets clotting factors, all components of plasma Acute hemorrhage (especially trauma); need for multicomponent therapy; life-threatening thrombocytopenia

20 mL/kg raises recipient´s PCV by 1%

VT (mL) = BW (kg) x BV (mL/kg) x [(desired PCV-recipient PCV)/donor PCV]  

10 mL/kg of FWB is expected to raise the platelet count by about 10,000/μL Should be used in 4-6h because platelets and clotting factors lose activity  
Stored Fresh Blood FWB stored up to 4 weeks Same as FWB except without platelets and with decreased concentration of some clotting factors, in particularly the labile coagulation factors V and VIII Same as FWB (except in cases of thrombocytopenia); in hemophilia A, it is preferable to use FWB than stored FB, especially if the latter is stored > 24h Same as FWB Storage decreases factors V and VIII, especially if storage is longer than 24 hours and at temperature of 4ºC. Platelets do not survive refrigeration. For critically ill patients, preference should be to use younger units to prevent injury associated with storage lesions (see Blood Product Storage, below)
Packed Red Blood Cells (pRBCs) RBCs centrifuged with most plasma discarded RBCs, may have WBCs Anemia, in patients that are normovolemic, without the need of coagulation factors and/or that are susceptible to volume overload See Preparing to Administer Blood Products, in Part 3 For critically ill patients, preference should be to use younger units to prevent injury associated with storage lesions (See Blood Product Storage, below)
Leukoreduced pRBCs Same as pRBCs, but WBCs removed before storage   Same as pRBCs   Leukoreduction may decrease immunomodulation and nonhemolytic febrile transfusion reactions
Fresh Frozen Plasma (FFP) Plasma obtained from FWB and frozen in the first 8 hours and <1 year age Coagulation factors; anticoagulant factors such as antithrombin; albumin; immunoglobulins Inherited and acquired coagulopathies; prophylaxis before invasive procedure in patient known to have a specific coagulation factor deficiency 10-30 mL/kg (higher in vWD and hemophilia A) May be used in acute necrotizing pancreatitis and DIC; management of endothelial dysfunction in sepsis and hemorrhagic shock
Frozen Plasma (FP) Plasma obtained from FWB that was not frozen within the first 8 hours or is stored >1 and < 5 years Same as FFP, but without factors V and VIII Same as FFP except not hemophilia A. Rodenticide and warfarin-induced coagulopathy 10-15 mL/kg  
Cryoprecipitate The precipitate containing cold insoluble proteins, formed when FFP is slowly thawed and centrifuged (it can also be obtained through the use of plasma extractor) vWF, VIII, XIII, fibrinogen, and fibronectin Hemorrhage or prophylaxis before invasive procedures in deficiency of vWF and factor VIII 1 unit per 10 kg BW  
Cryoprecipitate-Poor Plasma Supernatant that remains after preparation of cryoprecipitate Stable coagulation factors II, VII, IX, X; anticoagulant, and fibrinolytic factors; albumin Coagulation deficiencies of factor II, VII, IX, or X resulting in active hemorrhage that does not require vWF 6-12 ml/kg IV over 1-2 hours (rate of administration should not exceed 4 ml/kg/hr in patients with cardiac or renal insufficiency)  
Platelet-Rich Plasma (PRP) Plasma and platelets separated from RBCs after centrifugation Platelets and plasma Hemorrhage or prophylaxis before invasive procedure in severe thrombocytopenic or thrombocytopathic disorders 1 unit per 10 kg BW  
Platelet Concentrate Further centrifugation of PRP to have a smaller volume or platelets obtained via plateletpheresis Platelets, small amount of plasma Same as PRP Same as PRP  
Frozen Platelets Platelet concentrate created by plateletpheresis and then frozen using DMSO for platelet stability Platelets Same as PRP Same as PRP  
Lyophilized Platelets Platelet concentrate created by plateletpheresis, followed by stabilization of platelets using aldehyde cross-linking, then lyophilization Platelets Same as PRP Currently under evaluation  
Lyophilized Plasma Plasma that is rapidly frozen, dried and maintained in low temperatures in vacuum Same as FFP Same as FFP; compared with FFP can be stored at room temperature, transported easily, and reconstituted rapidly in remote and austere environments   Studies have shown promise in human medicine; No studies available regarding its use in dogs with the recent products
Albumin Protein is extracted from pooled plasma Albumin Hypovolemia oncotic support Albumin deficit = 0.3 x BW (kg) x 10 (albumin desired - current albumin); 1.5 g/kg Human and canine albumin available; Administration of human serum albumin to dogs and cats is controversial due to safety concerns, in particular the possibility of developing type III hypersensitivity reactions  
Intravenous Human Immunoglobulin Pooled IgG extracted from multiple human donors Immunoglobulins Immune-mediated diseases 0.5 g/kg/day Type I and III hypersensitivity reactions possible
Specific Clotting Factors and Concentrates   Antithrombin; fibrinogen; factors VII, VIII and IX; prothrombin complex concentrates Several indications; mostly used in the management of coagulopathies Varies depending upon blood product used Not yet used or produced in veterinary medicine

 

BV-blood volume; BW-body weight; DIC-disseminated intravascular coagulation; FB-fresh blood; FFP-fresh frozen plasma; FP-frozen plasma; PCV-packed cell volume; pRBCs –packed red blood cells; PRP-platelet-rich plasma; RBCs-red blood cells; VT-volume transfused; vWD-von Willebrand disease; vWF-von Willebrand Factor; FWB-fresh whole blood; WBCs-white blood cells.

The different blood components are mainly obtained by centrifugation; each blood component needs its established times and speeds of centrifugation to obtain the correct blood product components (Figure 3).1

For example, to obtain packed red blood cells (pRBCs) and fresh frozen plasma (FFP), WB is first centrifuged and then, with the use of a plasma separator, separated into those 2 components (Figure 4). If any solutions are added to pRBCs, this should be clearly indicated in the blood product identification label, as various preservative solutions have different expiration dates. 

During the process of obtaining them, blood products should be handled with care and with aseptic technique to prevent mechanical damage and contamination (ideally in a laminar flow chamber; Figure 5).  

If possible, consider the use of leukoreduction before RBC product storage. Leukoreduction, the process where white blood cells (WBCs) are removed from an RBC unit, is normally performed by passing the blood product through specific filters. Leukoreduction may reduce storage lesions, transfusion reactions, transfusion-related inflammation, and disease transmission.1,8  Storage lesions consist of changes in RBC metabolism, protein activity and function, phenotype, and morphologic properties induced by storage. Storage lesions were associated with an increase in reactive oxygen species, pro-inflammatory mediators, and microvesicle concentration, with the potential to have deleterious side effects in the blood component transfusion recipient.1

Blood Product Storage

Stored blood products should be labeled with blood type, donor’s name, collection date, and expiration date (Figure 6). The ideal storage time that preserves the functional qualities of the blood product without significantly increasing storage lesions is still being studied. In the case of WB and pRBCs, although these blood components can be stored for longer periods, it has been suggested to use units with storage time no greater than 21 days (and no greater than 14 days if the recipient is a critically ill patient).1,3,8  Regarding FFP, whether using “younger” units has benefits to the recipient or not is currently unknown. Currently advised storage times and temperature for FFP are -30ºC to -20ºC (-22°F to -4°F) for 1 year (see Table 2).1,7

Blood products should be properly identified with blood type, donor’s name, collection date, and expiration date.

Photo courtesy of Dr. Isabelle Goy-Thollot, SIAMU/ICU, VetAgro Sup, University of Lyon
Blood products should be properly identified with blood type, donor’s name, collection date, and expiration date.

Photo courtesy of Dr. Isabelle Goy-Thollot, SIAMU/ICU, VetAgro Sup, University of Lyon

Figure 6 Blood products should be properly identified with blood type, donor’s name, collection date, and expiration date. Photo courtesy of Dr. Isabelle Goy-Thollot, SIAMU/ICU, VetAgro Sup, University of Lyon

Figure 6 Blood products should be properly identified with blood type, donor’s name, collection date, and expiration date. Photo courtesy of Dr. Isabelle Goy-Thollot, SIAMU/ICU, VetAgro Sup, University of Lyon

A dedicated refrigerator that records temperature fluctuations should be used for blood product storage. The importance of a dedicated refrigerator should not be underestimated, as a recent study associated the lack of a dedicated blood product refrigerator with the development of hemolysis in the blood product units, leading to 3 fatalities.14 

However, if a dedicated refrigerator is not available, a dedicated space may be acceptable. In this case, blood products should be kept separate from other products to avoid chemical and biologic contamination. Frozen products should be stored in a freezer set on manual defrost.

Blood products should be stored vertically, with airspace between each bag, and never in crisper drawers. Blood product storage refrigerators should be opened as infrequently as possible to prevent temperature fluctuations, as this can cause damage to RBC products. Blood products with RBCs should also be inspected and gently rotated every other day to allow mixture of RBCs with the anticoagulant.  

Table 2

Suggested Blood Product Storage Times

Blood Product Storage Time
Whole Blood 1⁰C to 6⁰C in refrigerator. 28 days when stored with CPDA-1 (citrate-phosphate-dextrose-adenine 1) or 30 days with ACD (acid-citrate-dextrose)
Packed Red Blood Cells 1⁰C to 6⁰C in refrigerator. 20 days when stored with CPDA-1; 35 days when stored with CPDA-1 with  Optisol® or Nutricel®, 37 days when stored with CPDA-1 and Adsol®
Leukoreduced Blood Cells 1⁰C to 6⁰C in refrigerator, 37 days when stored with CPDA-1
Platelet-Rich Plasma 5 days in gas-diffusible bags with constant agitation at 22⁰C
Platelet Concentrate Same as platelet-rich plasma
Frozen Platelets 6 months in freezer at -30°C to -20°C
Lyophilized Platelets 2 years in the refrigerator
Frozen Plasma 5 years in freezer at -30°C to -20°C
Cryoprecipitate-Poor Plasma 1 year from collection in freezer maintained at -30°C to -20⁰C
Cryoprecipitate 10 months when stored at -20°C or colder
Human Serum Albumin 3 years at 20°C to 24°C
Intravenous Human Immunoglobulin 36 months in refrigerator at 1°C to 6°C

 

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