When to intubate in GCS?

GCS ≤ 8 requires intubation for airway protection. The patient cannot protect their own airway at this level of consciousness. Motor score is the most prognostically important component.

What is the best initial fluid for sepsis resuscitation?

Lactated Ringer's (LR) is the preferred resuscitation fluid. The SMART trial (2018) showed balanced crystalloids reduced death, new renal failure, and persistent renal dysfunction compared to normal saline.

When to start vasopressors in septic shock?

Start norepinephrine (first-line vasopressor) if MAP remains < 65 mmHg after initial 30 mL/kg crystalloid resuscitation, or earlier if patient is profoundly hypotensive. Do not delay pressors to complete full fluid resuscitation.

Why can serum uric acid be normal during acute gout?

During acute inflammation, IL-6 increases renal urate excretion and redistributes urate from plasma to tissues. Up to 40% of acute gout flares have normal serum uric acid. Joint aspiration with polarized microscopy is needed for definitive diagnosis.

How do you distinguish lupus flare from infection in SLE?

Key clues: CRP is low/normal in flare but elevated in infection. Complement (C3/C4) drops in flare but is normal/elevated in infection. Procalcitonin is elevated in bacterial infection but normal in flare. Anti-dsDNA rises in flare, stable in infection.

What is the difference between DKA and HHS?

DKA features acidosis (pH 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

When to give tPA in acute ischemic stroke?

IV alteplase (tPA) can be given within 4.5 hours of last known well time in eligible patients. CT head must rule out hemorrhage first. For large vessel occlusion, mechanical thrombectomy can be performed up to 24 hours with favorable imaging.

What antibiotics for community-acquired pneumonia?

Inpatient non-ICU: ceftriaxone + azithromycin. ICU: ceftriaxone + azithromycin (add vancomycin if MRSA risk). Outpatient healthy: amoxicillin. Outpatient with comorbidities: augmentin + azithromycin or respiratory fluoroquinolone. Duration: 5 days if clinically stable for 48 hours.

How to interpret iron studies?

Iron deficiency: low ferritin (< 30), high TIBC, low iron, low transferrin saturation (< 20%). Anemia of chronic disease: normal/high ferritin (acute phase reactant), low TIBC, low iron. A ferritin of 50-100 in an inflamed patient may still represent iron deficiency.

What is the correction rate for hyponatremia?

Correct sodium no more than 8 mEq/L in 24 hours to avoid osmotic demyelination syndrome (ODS). For symptomatic severe hyponatremia with seizures, give 3% hypertonic saline 100-150 mL bolus over 10-20 minutes. If overcorrected, use D5W + DDAVP rescue protocol.

When to start antibiotics in meningitis?

Within 30-60 minutes. Do NOT delay antibiotics for LP or CT. Draw blood cultures, start empiric antibiotics (vancomycin + ceftriaxone ± ampicillin if > 50 or immunocompromised), then perform LP when possible. Dexamethasone should be given before or with the first antibiotic dose.

DOACs vs warfarin in antiphospholipid syndrome?

DOACs are contraindicated in APS. The TRAPS trial (2018) showed rivaroxaban was inferior to warfarin with more thrombotic events in triple-positive APS patients. Warfarin with INR target 2-3 is the standard for APS, indefinitely.

How to manage scleroderma renal crisis?

ACE inhibitors (captopril) are life-saving -start immediately and titrate aggressively. Do NOT hold for rising creatinine. Steroids > 15 mg prednisone per day precipitate scleroderma renal crisis. ARBs are NOT a substitute -evidence is only for ACEi.

What are the 4 pillars of heart failure treatment?

Guideline-directed medical therapy (GDMT) for HFrEF: (1) ARNI or ACEi/ARB, (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) MRA (spironolactone or eplerenone), (4) SGLT2 inhibitor (dapagliflozin or empagliflozin). All four should be initiated and titrated to target doses.

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Transfusion Medicine

When to transfuse, what products to use, and how to manage reactions. Restrictive is better for most patients. Know the thresholds and the reactions -you'll order blood products daily.

🩸 Transfusion Thresholds

Product	Threshold	Evidence
pRBCs -general RESTRICTIVE	Hgb < 7 g/dL	TRICC, 1999: restrictive (7) non-inferior to liberal (10) in ICU. TRICS-III, 2017: confirmed in cardiac surgery.
pRBCs -ACS	Hgb < 8 g/dL (or symptomatic anemia)	REALITY, 2021: restrictive (8) vs liberal (10) -non-inferior for 30-day MACE in MI.
pRBCs -active bleeding	Hgb < 7–8, but transfuse to symptoms/hemodynamics	MTP: 1:1:1 ratio PROPPR, 2015 (pRBC:FFP:platelets). Don't wait for lab values in massive hemorrhage.
Platelets -general	< 10,000 (prophylactic)	Higher thresholds for active bleeding (< 50K), neurosurgery (< 100K), or procedures.
FFP	Active bleeding + INR > 1.5	15 mL/kg. Or 4F-PCC for warfarin reversal (faster, less volume).
Cryoprecipitate	Fibrinogen < 100–150 (DIC, massive transfusion)	10 units raises fibrinogen ~50–70 mg/dL. Key product in DIC.

🔄 Updated Practice: Old teaching: transfuse when Hgb <10 ("10/30 rule"). Current evidence: restrictive strategy (Hgb <7) is as safe or safer than liberal (Hgb <10) in most ICU patients (TRICC, 1999; TRISS, 2014). Exceptions: active ACS (transfuse <8), symptomatic anemia, active hemorrhage. For upper GI bleed, restrictive transfusion (Hgb <7) actually IMPROVED survival (Villanueva, 2013).

💉 Blood Products

Product	Contains	Expected Effect	Special Considerations
pRBCs	Red blood cells in additive solution	↑ Hgb ~1 g/dL per unit	Type & screen required. Irradiate if immunocompromised (prevent TA-GVHD). CMV-negative or leukoreduced for transplant candidates.
Platelets	Platelets (apheresis or pooled)	↑ 30,000–50,000 per unit	ABO-compatible preferred. Room temperature storage (not refrigerated). 5-day shelf life. Highest bacterial contamination risk of all blood products.
FFP	All clotting factors	↑ factor levels ~20–30%	ABO-compatible required. Thaw time ~30 min. Volume ~250 mL/unit (risk of TACO).
Cryoprecipitate	Fibrinogen, Factor VIII, vWF, Factor XIII	↑ fibrinogen ~50–70 mg/dL per 10 units	Key for DIC, massive transfusion, factor XIII deficiency. Pooled (10 units = 1 dose).

⚠️ Transfusion Reactions

First step in ANY suspected reaction: STOP the transfusion. Maintain IV access. Check vitals. Send a clerical check + blood sample to the blood bank.

Reaction

Timing

Features

Management

Acute hemolytic (ABO mismatch)

Minutes

Fever, flank pain, dark urine, hypotension, DIC. Most dangerous. Usually clerical error.

STOP immediately. IVF (prevent renal failure), send direct Coombs + repeat type & screen. Supportive ICU care.

Febrile non-hemolytic (FNHTR)

1–6 hours

Fever, rigors. Most common reaction. Cytokines from donor WBCs.

Stop, rule out hemolytic. Acetaminophen. Leukoreduced products prevent recurrence.

Allergic (mild)

During

Urticaria, pruritus. No fever or hemodynamic changes.

Stop temporarily. Diphenhydramine 25–50 mg IV. Can resume slowly if mild.

Anaphylactic

Minutes

Hypotension, bronchospasm, angioedema. Often in IgA-deficient patients (anti-IgA antibodies).

Epinephrine 0.3–0.5 mg IM. IVF, steroids, bronchodilators. Future: washed or IgA-deficient products.

TRALI

≤ 6 hours

Acute respiratory distress + bilateral infiltrates + hypoxia within 6h. No volume overload. Caused by donor antibodies activating recipient neutrophils in lungs.

Supportive (O₂, ventilation). Diuretics do NOT help (not a volume issue). Usually resolves 48–96h. Report to blood bank.

TACO

≤ 6 hours

Volume overload → pulmonary edema, HTN, JVD. Distinguished from TRALI by: elevated BNP, response to diuretics, hypertension.

Diuretics. Slow transfusion rate for future products

🔍 Overview

Overview

Blood product transfusion is one of the most common inpatient procedures. Restrictive thresholds (Hgb < 7) are standard for most patients [TRICC, 1999; TRISS, 2014] -liberal transfusion does not improve outcomes and may worsen them. In acute coronary syndrome, threshold is Hgb < 8. Always transfuse 1 unit at a time and recheck before ordering more. Massive transfusion protocol (MTP): 1:1:1 ratio of pRBC:FFP:platelets + TXA 1g IV [CRASH-2, 2010; PROPPR, 2015]. Key reactions to recognize: TRALI (non-cardiogenic pulmonary edema, normal BNP, within 6h) vs TACO (volume overload, elevated BNP, responds to diuretics). Stop transfusion immediately for any suspected reaction.

🧪 Workup

Workup

Type & screen -ABO + Rh typing + antibody screen. Required before all transfusions. Valid for 72h in recently transfused/pregnant patients.
Crossmatch -for elective/non-emergent transfusion. Takes 30-60 min. In emergency: use O-negative (universal donor) while crossmatch pending.
CBC -Hgb (transfusion threshold), platelet count (threshold 10K for prophylactic, 50K for invasive procedure, 100K for neurosurgery)
Coagulation studies -PT/INR (FFP threshold: INR > 1.5 with active bleeding), fibrinogen (cryoprecipitate threshold: < 100-150 mg/dL)
Direct Coombs (DAT) -if suspected transfusion reaction or hemolytic anemia. Positive = antibodies coating RBCs.
Indirect Coombs (IAT) -detects circulating antibodies. Part of antibody screen. Positive → need antigen-negative units.
Post-transfusion Hgb -check 1-2h after transfusion. Expected rise: ~1 g/dL per unit pRBC. If less → consider ongoing bleeding, hemolysis, or hypersplenism.
For suspected reaction: stop transfusion → send bag + tubing to blood bank → direct Coombs → free hemoglobin (plasma/urine) → haptoglobin → repeat type & screen → UA for hemoglobinuria → chest imaging if respiratory symptoms

🚨 Management

Management

Transfusion thresholds (restrictive):
- Hgb < 7 -most hospitalized patients [TRICC, 1999; TRISS, 2014; FOCUS, 2011]
- Hgb < 8 -acute coronary syndrome, symptomatic anemia, acute GI bleed with hemodynamic instability
- Hgb < 10 -rarely indicated (active MI with ongoing ischemia, severe symptomatic anemia)
- Platelets < 10K -prophylactic (no bleeding)
- Platelets < 50K -active bleeding or invasive procedure
- Platelets < 100K -neurosurgery, ocular surgery
- FFP -INR > 1.5 with active bleeding. NOT for "correcting" INR without bleeding.
- Cryoprecipitate -fibrinogen < 100-150 mg/dL
Massive transfusion protocol (MTP): pRBC:FFP:platelets = 1:1:1 PROPPR, 2015. Activate early in hemorrhagic shock. TXA 1g IV within 3h of injury CRASH-2, 2010. Calcium gluconate 1g after every 4 units (citrate chelates calcium).
Transfusion reactions:
- Febrile non-hemolytic (most common): fever + rigors within 1-6h. Stop, rule out hemolytic. Acetaminophen. Resume with leukoreduced products.
- Acute hemolytic: ABO incompatibility. Fever, flank pain, hemoglobinuria, DIC. STOP immediately. Aggressive IVF. Send workup.
- TRALI: bilateral infiltrates + hypoxia within 6h. Normal BNP. Supportive care (no diuretics -not volume overload). Resolves 48-72h.
- TACO: volume overload. Elevated BNP. Responds to furosemide. Prevention: slow rate, furosemide between units in high-risk.
- Allergic: urticaria (minor → diphenhydramine, resume). Anaphylaxis (IgA deficiency) → epinephrine, stop, use washed products.
Special products: irradiated (prevent TA-GVHD in immunocompromised), CMV-negative (transplant recipients), leukoreduced (prevent febrile reactions + CMV), washed (IgA deficiency, severe allergic reactions)

📋 On Rounds

How do you distinguish TRALI from TACO?

Both present with respiratory distress + bilateral infiltrates within 6h of transfusion. TRALI: non-cardiogenic pulmonary edema (BNP normal or low, hypotension, no JVD, does NOT respond to diuretics). Caused by donor antibodies. TACO: cardiogenic volume overload (BNP elevated, hypertension, JVD, responds to diuretics). Risk factors: CHF, CKD, rapid infusion rate, multiple units. Key distinguisher: give furosemide. If they improve → TACO.

Why Hgb 7, not 10?

TRICC, 1999 randomized ICU patients to restrictive (Hgb 7) vs liberal (Hgb 10) transfusion. Restrictive was non-inferior for 30-day mortality and had fewer cardiac events. Multiple subsequent trials confirmed this across cardiac surgery TRICS-III, 2017, GI bleed Villanueva, 2013, and hip surgery FOCUS, 2011.

What is TRALI and how do you differentiate it from TACO?

Both present with respiratory distress during/after transfusion, but treatment is opposite. TRALI (Transfusion-Related Acute Lung Injury): non-cardiogenic pulmonary edema. Onset within 6h. Bilateral infiltrates on CXR. NO signs of volume overload (BNP normal/low, no JVD, no S3). Due to donor antibodies activating recipient neutrophils → capillary leak. Treatment: supportive (O₂, intubation if needed, NO diuretics).

What is the transfusion threshold for most hospitalized patients?

Restrictive threshold: Hgb < 7 g/dL for most hospitalized patients. TRICC, 1999 and TRISS, 2014: restrictive (Hgb < 7) was non-inferior to liberal (Hgb < 10) for mortality. Liberal transfusion did NOT improve outcomes and increased complications. Exception: Hgb < 8 for ACS/active cardiac ischemia (the MINT trial MINT, 2023 suggested possible benefit, though not definitive).

❓ How do you differentiate TRALI from TACO?

TRALI = non-cardiogenic pulmonary edema. Normal BNP, bilateral infiltrates within 6h, no fluid overload signs, does NOT respond to diuretics. Supportive care only -resolves 48-72h. TACO = volume overload. Elevated BNP, responds to furosemide, often hypertensive. Prevention: slow transfusion rate, furosemide between units in HF/CKD patients.

❓ What is the expected hemoglobin rise per unit of pRBC transfused?

~1 g/dL per unit in a 70 kg adult. If the post-transfusion Hgb rise is less than expected, consider: (1) ongoing hemorrhage, (2) hemolysis (check Coombs, LDH, haptoglobin), (3) hypersplenism, (4) volume overload diluting the measurement, (5) lab draw from a diluted line.

❓ When do you give cryoprecipitate and what does it contain?

Cryoprecipitate contains: fibrinogen (most important), Factor VIII, Factor XIII, vWF, and fibronectin. Give when fibrinogen < 100-150 mg/dL (DIC, massive transfusion, post-thrombolytics). Dose: 10 units (1 pool) raises fibrinogen ~70 mg/dL. In massive hemorrhage, check fibrinogen early and replace aggressively -it is the first factor to become critically depleted.

❓ What is a delayed hemolytic transfusion reaction (DHTR)?

DHTR occurs 3-14 days after transfusion due to anamnestic antibody response (patient was previously sensitized but antibody titer dropped below detection). Presents with: unexplained Hgb drop, new jaundice, dark urine, positive DAT. Especially dangerous in SCD patients -can cause hyperhemolysis (destruction of both transfused AND native RBCs). Prevention: extended phenotype matching.

❓ What does TXA do and when is it indicated in massive hemorrhage?

Tranexamic acid (TXA) inhibits fibrinolysis by blocking plasmin. Give 1g IV within 3 hours of hemorrhage onset -later administration may be harmful. Evidence: CRASH-2, 2010 -reduced mortality in trauma. WOMAN, 2017 -reduced death from postpartum hemorrhage. No benefit shown in GI bleeding HALT-IT, 2020. Include in all massive transfusion protocols.

Clinical Examples

📋 Case 1, Acute Hemolytic Transfusion Reaction

Patient: 62M receiving unit of pRBCs for Hgb 6.2. Within 15 min: rigors, fever 39.8°C, severe flank pain, dark urine. BP 82/48. Nursing notes: unit labeled "type A" but patient is "type O."

Key findings: ABO-incompatible transfusion, the most dangerous transfusion reaction. Patient (type O) has preformed anti-A antibodies → immediate intravascular hemolysis → DIC, shock, renal failure. Almost always a clerical/labeling error.

Management:

STOP transfusion immediately, do NOT continue even a drop
Maintain IV access with NS. Aggressive IVF to maintain UOP > 1 mL/kg/hr (prevent hemoglobin-induced AKI)
Send: DAT, repeat type and crossmatch, free hemoglobin, LDH, haptoglobin, fibrinogen, DIC panel
Return blood bag + tubing to blood bank for investigation
Monitor for DIC (fibrinogen, PT/PTT, D-dimer), replace products as needed

Teaching point: Acute hemolytic reactions are almost always human error, wrong blood to wrong patient. The bedside nurse check (patient ID + unit label + blood bank tag) is the last line of defense. Two-person verification at bedside prevents this lethal error.

📋 Case 2, TRALI vs TACO

Patient: 75F with HFrEF (EF 30%), received 2 units pRBCs for Hgb 6.8 (GI bleed). 4 hours after second unit: acute dyspnea, SpO₂ 84%, bilateral crackles, HTN (180/95). CXR: bilateral pulmonary infiltrates. BNP 2400.

Key findings: Elevated BNP + hypertension + responds to diuresis = TACO (transfusion-associated circulatory overload), NOT TRALI. TRALI would have normal BNP, hypotension, and would NOT respond to furosemide. This patient's underlying HF + rapid transfusion → volume overload.

Management:

Furosemide 40 mg IV (diagnostic AND therapeutic, TACO responds, TRALI does not)
Upright positioning, supplemental O₂, BiPAP if needed
If this were TRALI: supportive O₂ only, NO diuretics, may need intubation, resolves 48-72h
Prevention for future transfusions: slow rate (1 unit over 3-4h), furosemide 20 mg IV between units, limit to 1 unit at a time
Report to blood bank (both TACO and TRALI are reportable)

Teaching point: The BNP is the best discriminator: TACO = elevated BNP (volume overload). TRALI = normal BNP (capillary leak). When in doubt, give furosemide, if the patient improves, it's TACO. TACO is now more common than TRALI since leukoreduction reduced TRALI incidence.

📋 Case 3, Massive Transfusion Protocol

Patient: 32F with ruptured ectopic pregnancy, HR 140, BP 68/30, Hgb 4.2. Actively hemorrhaging. MTP activated.

Key findings: Class IV hemorrhagic shock (> 40% blood volume loss). Massive transfusion protocol (MTP) = ≥ 10 units pRBCs in 24h or ≥ 4 units in 1h. Goal: 1:1:1 ratio (pRBC:FFP:platelets) per PROPPR trial.

Management:

MTP packs: 6 pRBC + 6 FFP + 1 apheresis platelet (delivered as a cooler from blood bank)
1:1:1 ratio of pRBC:FFP:platelets PROPPR, 2015
TXA 1g IV within 3h of hemorrhage onset → 1g over 8h CRASH-2, 2010
Replace calcium: 1g calcium gluconate per 4 units pRBCs (citrate in blood products chelates calcium → hypocalcemia → cardiac dysfunction)
Check fibrinogen early, give cryo if < 150 (fibrinogen is the first factor to become critically depleted)

Teaching point: The biggest mistakes in massive transfusion: (1) giving crystalloid instead of blood (dilutes coagulation factors), (2) forgetting calcium replacement (citrate toxicity → cardiac arrest), (3) not checking fibrinogen early (depletes before other factors). Resuscitate with blood, not saline.

📣 Sample Presentation

One-Liner

"Mr. Davis is a 68-year-old who developed rigors, fever 39.2°C, and back pain 20 minutes into a pRBC transfusion. BP dropped from 130/80 to 88/52. Transfusion stopped immediately."

Key Points to Cover on Rounds

Suspected acute hemolytic transfusion reaction (fever + hypotension + back pain during transfusion). Immediate actions: (1) transfusion STOPPED, (2) IV access maintained with NS, (3) patient ID rechecked against blood product -mismatch identified (wrong unit hung). Reaction workup sent: repeat type & screen, direct Coombs (DAT), free hemoglobin, LDH, haptoglobin, UA (hemoglobinuria). Blood bank notified immediately. IVF resuscitation for hypotension. Monitoring for DIC (PT/INR, fibrinogen, D-dimer q4h). Plan: supportive care, if Hgb still needed → crossmatch new unit with correct sample.

💊 Medications

Blood Products & Transfusion Medications

Product / Drug	Indication & Threshold	Dose / Details
pRBCs (packed red blood cells)	Hgb < 7 (general, TRICC); Hgb < 8 (ACS / active cardiac ischemia)	1 unit at a time. Expected rise: ~1 g/dL per unit. Recheck Hgb after each unit before ordering more.
Platelets	< 10K (prophylactic, no bleeding); < 50K (active bleeding or procedure); < 100K (neurosurgery)	1 apheresis unit or 6-pack pooled. Expected rise: 30,000–50,000 per unit. Room temperature storage.
FFP (fresh frozen plasma)	INR > 1.5 with active bleeding. NOT for "correcting" INR without bleeding.	15 mL/kg (~4 units for 70 kg). ABO-compatible required. ~30 min thaw time. Consider 4F-PCC for faster warfarin reversal.
Cryoprecipitate	Fibrinogen < 150 mg/dL (DIC, massive transfusion, post-thrombolytics)	10 units (1 pool). Raises fibrinogen ~50–70 mg/dL. Contains fibrinogen, Factor VIII, vWF, Factor XIII.
Tranexamic acid (TXA)	Massive hemorrhage -within 3 hours of onset	1g IV over 10 min, then 1g over 8h. CRASH-2, 2010. Inhibits fibrinolysis. Include in all MTP activations.

Premedication

Premedication (acetaminophen 650 mg PO + diphenhydramine 25–50 mg IV/PO) is only indicated if the patient has had a prior febrile or allergic transfusion reaction. Routine premedication for all transfusions is NOT recommended -it delays the transfusion, adds cost, and does not prevent serious reactions (TRALI, hemolytic). Leukoreduction is more effective than premedication for preventing FNHTR.

⚡ Summary

Summary

Threshold

Hgb < 7 for most [TRICC]. Hgb < 8 for ACS. 1 unit raises Hgb ~1 g/dL. Check after each unit before ordering more.

Massive Transfusion

MTP: 1:1:1 ratio (pRBC:FFP:plt). TXA 1g IV within 3h [CRASH-2]. Ca²⁺ repletion (citrate in products chelates Ca). Warm products.

TRALI vs TACO

TRALI: non-cardiogenic edema, normal BNP, no diuretics. TACO: volume overload, elevated BNP, responds to furosemide. BNP is the differentiator.

Febrile Reaction

Fever + rigors during transfusion. Stop. R/O hemolytic reaction: send DAT, free Hgb, LDH, haptoglobin. Most are benign febrile non-hemolytic reactions.

Prevention

Irradiate for immunocompromised (prevent TA-GVHD). CMV-negative for CMV-seronegative transplant patients. Slow rate for CHF/elderly (1 unit over 2-4h).

Type & Screen

Always before transfusion. Emergency: O-negative pRBC (universal donor). Type-specific uncrossmatched next. Full crossmatch safest but takes time.

📄 One Pager

Transfusion Medicine -Quick Reference Card

Print this page (Ctrl/Cmd + P) for a condensed reference card. All tabs will print on the same page for a complete topic summary.

TRANSFUSION MEDICINE -AT A GLANCE

🩸 Thresholds: Hgb < 7 (general), < 8 (ACS). Platelets < 10K (prophylactic). FFP for INR > 1.5 + bleeding.
🧪 Workup: Type & screen, crossmatch, CBC, coags, post-transfusion Hgb 1h after → see Workup tab
⚠️ Reactions: STOP transfusion first. TRALI (normal BNP) vs TACO (elevated BNP) → see Reactions tab
💊 Products: pRBC, platelets, FFP, cryo, TXA → see Medications tab
📈 Monitor: Vitals q15min × 1h, watch for reactions, post-transfusion Hgb
📣 Present: Indication, product, reaction workup → see Rounds tab

📄 One Pager

Hematology · One Pager

Transfusion Medicine

Threshold Hgb < 7 for most. 1:1:1 for MTP. TRALI vs TACO: BNP differentiates. Stop + workup any suspected reaction. Type & screen before all transfusions.

🧪 Thresholds

Hgb < 7 for most patients [TRICC, TRISS]. Hgb < 8 for active cardiac ischemia. Massive hemorrhage: 1:1:1 ratio (pRBC:FFP:plt) + TXA [CRASH-2].

🚨 Reactions

Febrile non-hemolytic (most common): stop, workup, rule out hemolytic. Acute hemolytic: fever + hypotension + back pain → stop immediately, send DAT, free Hgb, haptoglobin. TRALI: non-cardiogenic edema (normal BNP). TACO: volume overload (high BNP → furosemide).

💊 Special Products

Irradiated: immunocompromised (prevent TA-GVHD). CMV-negative: CMV-seroneg transplant patients. Leukoreduced: prevent febrile reactions. Washed: severe allergic reactions (IgA deficiency).

💊 Key Drugs

pRBCs1 unit raises Hgb ~1 g/dL

FFP10-15 mL/kg (INR correction)

Platelets1 unit raises plt ~30-50K

TXA1g IV (massive hemorrhage)

⚠️ Pitfalls

Transfusing above threshold without indication
Not checking type & screen
Not recognizing TRALI vs TACO (BNP differentiates)
Rapid transfusion in CHF/elderly (slow rate, furosemide between units)