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BloodtransfusionsinthedogandcatPart2:Indicationsandsafeadministration

ARTICLEinINPRACTICE·APRIL1998

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ClareMKnottenbelt

UniversityofGlasgow

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AndrewMackin

MississippiStateUniversity

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Severe haemolytic anaemia(PCV=9 per cent) in a six-year-oldBichon frise. Although bloodtransfusion in patients withhaemolytic anaemia may result infurther haemolysis ('fuelling the fire'),this dog presented with signs ofsevere anaemia (collapse anddyspnoea) and transfusion was

X i required as a life-saving procedure

Blood transfusions in the dog and catPart 2: Indications and safeadministration CLARE KNOTTENBELT AND ANDREW MACKIN

TECHNIQUES for the collection of blood from donor dogs and cats were described in the last issue in thefirst part of this article (pp 110-114). Here, the indications for blood transfusions are reviewed and thesafe administration of blood and blood products discussed. The recognition and management oftransfusion reactions is also addressed.

INDICATIONS

Anaemia is the major indication for blood transfusion inveterinary practice (see box). In particular, patients withblood loss or non-regenerative anaemia will benefit fromtransfusion. In non-regenerative anaemia transfused redblood cells can have a normal lifespan (approximately120 days in dogs, 70 days in cats). Transfusion maytherefore stabilise the patient for two to three months,allowing further diagnostic tests or treatment to be insti-tuted. In haemolytic anaemia, blood transfusions aregenerally of transient benefit only, as transfused cells,like the patient's own cells, will often be destroyed bythe haemolytic process and transfusion may arguably be'adding fuel to the fire'. However, in patients with signsof severe anaemia such as dyspnoea, weakness or neuro-logical disturbances a blood transfusion may be life-saving and allow time for more specific therapy for theunderlying cause of the haemolysis to be commenced.

Since patients with haemolytic and non-regenerativeanaemia are normovolaemic at the time of transfusion,packed red cell transfusions, if available, are moreappropriate than whole blood (see later). In contrast,whole blood is usually the treatment of choice in patientswith hypovolaemia secondary to blood loss anaemia.

Animals with congenital and acquired coagulopathieswill benefit from the administration of fresh blood, freshplasma or fresh frozen plasma to replenish clotting fac-tors. Patients with severe thrombocytopenia may requiretransfusions of fresh blood or platelet-rich plasma inorder to prevent life-threatening blood loss. In particularcircumstances patients benefit from the use of specificplasma components such as albumin to maintain oncoticpressure, or antithrombin III as part of the managementof disseminated intravascular coagulation.

Maim indications for bloodtransfusions

* Anaemia- Blood loss- Haemolysis- Non-regenerative anaemia* Disorders of haemostasis* Deficiencies of specific plasma components

WHEN TO TRANSFUSE?

The most important factor in determining the need fortransfusion is the clinical condition of the patient.Transfusion is always indicated in an anaemic patientthat is exhibiting signs of clinical compromise such asweakness, dyspnoea and ataxia. However, many patientswith quite severe anaemia will exhibit minimal associat-ed clinical signs and often can survive for long periodsof time without transfusion. Many authors have recom-mended that transfusion automatically be performedwhenever a patient's packed cell volume (PCV) dropsbelow 20 per cent (Pichler and Turnwald 1985). Cats,however, are known to tolerate anaemia well; they mayshow only mild lethargy at a PCV of 10 to 15 per centand, provided they remain unstressed, can survive at avery low PCV for a number of days. Dogs are somewhatmore sensitive to the effects of anaemia, which is oftendetected earlier due to poor exercise tolerance, a clinicalsign rarely recorded in cats. Chronic anaemia in dogsand cats tends to be much better tolerated than acuteanaemia.

Clare Knottenbeltgraduated fromBristol in 1994. She iscurrently the ClinicalStudies Trust Fund(Petsavers) resident insmall animal internalmedicine at the Royal(Dick) School ofVeterinary Studies,Edinburgh. Shegained the certificatein small animalmedicine in 1997.Her interests includefeline blood types,transfusion medicineand haematology.

Andrew Mackin isa 1983 graduate ofMurdoch University.He has worked atveterinary schools inAustralia, Canada andthe UK, and hasobtained specialistlevel qualifications insmall animal medicinein North America,Australia and the UK.He recently left the'Dick' to take up thepost of assistantprofessor in smallanimal internalmedicine atMississippi StateUniversity.

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Pale mucous membranesmay be the only sign ofanaemia in patients withchronic anaemia. While dogscommonly present withlethargy and exerciseintolerance, thesesymptoms are rarelyrecorded in the cat. Thisparticular patient, withmoderate to severe chronicanaemia, showed only mildlethargy

Given these considerations, a sensible approachwould be to recommend transfusion if a patient isexhibiting significant clinical signs of anaemia, if thePCV is less than 10 per cent or if the PCV has fallenrapidly to less than 20 per cent in dogs or 15 per cent incats. When the bone marrow response is minimal orabsent the patient is unlikely to be able to replenish itsown cells (at least in the short term), and earlier transfu-sion may be indicated in order to prevent further deterio-ration in clinical condition.

In patients that do not require immediate life-savingtransfusions the following simple diagnostic tests shouldbe performed prior to blood transfusion, since the resultsmay determine the benefits of transfusion. In all cases,

Vt(K1

Microhaematocrit tube revealing severe anaemia.Measurement of PCV using microhaematocrit tubecentrifugation provides an indication of the degree ofanaemia and a baseline for continued monitoring. Bloodtransfusion is indicated if the PCV is below 10 per cent orhas rapidly fallen to below 20 per cent in dogs

blood should be collected from the patient prior toadministration of a transfusion as the results of thesetests may be important in formulating a prognosis.* PCV or haematocrit (determines the degree ofanaemia before transfusion, thereby providing a baselinefor continued monitoring).* Examination of blood smears to determine:- reticulocyte count (following new methylene bluestaining); ie, is anaemia regenerative or non-regenera-tive?- potential aetiologies; for example, Haemobartonellafelis (in cats), or the presence of leukaemia (abnormaldifferential white blood cellcount or abnormal whiteblood cells).* Feline leukaemia virus(FeLV) antigen and felineimmunodeficiency virus(FIV) antibody testing(although transfusions are notcontraindicated in retrovirus-positive cats, the poorerprognosis may influence thedecision to transfuse).* Evaluation of serum orplasma for the presence oficterus or haemoglobin-aemia.* Evaluation of haemostat-ic parameters, such asplatelet count, prothrombintime and activated partialthromboplastin time, if ableeding disorder is suspect-ed.* Performance of a slideagglutination and/or Coombstest if immune-mediatedhaemolysis is suspected.

Further tests may beperformed, as indicated, todetermine the underlyingcause of the anaemia (eg,routine clinical chemistry,radiography, bone marrowaspiration and biopsy).

In Practice 0 APRIL 1998

Microhaematocrit tuberevealing icteric serum. Thepresence of serum icterusindicates that an underlyinghaemolytic process may bethe cause of the anaemia

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BLOOD ADMINISTRATION

VOLUME REQUIRED BY RECIPIENTTransfusion to a normal PCV is unnecessary to alleviateclinical signs, and will remove the stimulus for thepatient to increase its own marrow red cell production.Usually a post-transfusion PCV of 20 per cent in catsand 25 to 30 per cent in dogs will be sufficient to reversethe signs of anaemia without significantly dampening theregenerative response. Transfusion of large volumes ofblood may be needed to achieve these ideal end-points inseverely anaemic patients. Fortunately, however, even asmall rise in recipient PCV is often sufficient to alleviatea life-threatening anaemic crisis.

To calculate the blood volume required by therecipient, the equation given in the box below is used(Pichler and Tumwald 1985).

How much to transfuse?

Blood volume to be transfused = k x Weight (kg) x (Required PCV - Recipient PCV)PCV of donated blood

k = 90 in dogs, 66 in cats

Examples* A cat weighing 4 kg, with a PCV of 10 per cent, receiving donated blood witha PCV of 35 per cent, requires 75 ml of blood to reach a target PCV of 20 percent, while a cat with a PCV of 5 per cent would require 113 ml of blood (whichwould need to be collected from two cats or a very heavy donor!)* A 15 kg dog with a PCV of 10 per cent, receiving donated blood with a PCV of40 per cent, would require at least 500 ml of blood to reach a target PCV of25 per cent

NB. Since the volume of blood required by the recipient is heavily dependent onthe donor's PCV, it is important, whenever possible, to choose donors with a PCVwithin the top half of the normal range.

ROUTE OF ADMINISTRATIONIdeally, blood should be given into a cephalic or jugularvein via an intravenous catheter. In severely hypotensiveor paediatric patients, the blood can be given into theproximal femur using an 18 to 20 gauge intravenousneedle or a spinal needle placed in the trochanteric fossa.Extraction of blood from the marrow cavity into thebloodstream is highly efficient and marrow transfusion istherefore almost as effective as direct intravenous infu-sion. Blood is absorbed from the marrow at a rate of onedrop per minute, but may be administered at a faster rate

by using an infusion pump.Intraperitoneal administration of blood is an ineffi-

cient method of administration, achieving only a 40 percent extraction rate (Turnwald and Pichler 1985)

METHOD OF ADMINISTRATIONBlood should be administered through a filtered givingset specifically designed for blood products, to reducethe risk of cellular aggregates and microthrombi enteringthe circulation and leading to pulmonary capillary dam-age and pulmonary oedema. This is particularly impor-tant when blood has been stored following collection.The filters present in standard giving sets are too smalland will tend to clog when blood is administered through

them. Blood should not be administered concurrentlywith (ie, through the same catheter as) intravenous fluidscontaining calcium or glucose.

Blood should be gently warmed to 37°C beforeadministration in order to reduce blood viscosity,prevent patient chilling and minimise vasoconstriction.If blood is overheated, clotting and haemolysis canoccur. If it is necessary to warm blood quickly, warmingof the tubing as the blood is administered is preferableto warming the blood collection bag excessively. Oncethe bag has been warmed it should be used within24 hours.

The speed of administration must take into accountthe condition of the patient (Tumwald and Pichler 1985).Normovolaemic recipients can be given 5 to 10 mlblood/kg/hour; this amount can be increased in hypo-volaemic patients, up to a maximum of 20 ml/kg/hour.Although a standard maximum transfusion volume of20 ml/kg/day is often recommended, much greatervolumes can safely be given in certain circumstances,such as in animals with severe ongoing haemorrhage.In patients suffering from cardiovascular dysfunctionor renal failure, the flow should be restricted to2 ml/kg/hour to avoid circulatory overload due to asudden expansion in blood volume. Vomiting duringtransfusion can be associated with flow rates which aretoo rapid.

The administration of bloodthrough a filtered giving setspecifically designed forblood products will reducethe risk of microthrombientering the circulation. Thisis particularly importantwhen blood has been storedprior to transfusion

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BLOOD PRODUCTS

In certain clinical conditions, such as chronic haem-orrhagic, haemolytic or non-regenerative anaemia,thrombocytopenia, clotting factor deficits or hypoalbumin-aemia, the administration of specific blood products maybe more appropriate than whole blood transfusions. Inchronic haemorrhagic, haemolytic or non-regenerativeanaemia the patient is normovolaemic and requires onlypacked red cells to resolve the symptoms associated withanaemia. Patients with thrombocytopenia or clottingfactor deficiencies often do not need red cells, and willbenefit from the administration of platelet-rich plasmaand plasma, respectively.

Since one unit of fresh whole blood can be separatedinto two or even three blood products, the use of appro-priate products for specific clinical situations ensuresthat maximum benefits are obtained from each individ-ual donation. Although blood products are not yetavailable commercially in the UK, separation of red cellsand plasma is often feasible in a practice environment atminimal expense.

PLASMAPlasma can be decanted from centrifuged or sedimentedwhole blood and stored in a freezer for several months.In order to decant plasma from whole blood, blood bags(dogs) or syringes (cats) of fresh whole blood may beplaced upright in a refrigerator for six to 12 hours. Insome patients, sedimentation of fresh red cells allowsextraction of a usable volume of supernatant plasma.Plasmalred cell separation via sedimentation, however,is never as consistent or as complete as that obtained byusing a blood bank centrifuge. Although such cen-trifuges are not usually available in general practice, theymay on occasion be available for use at local humantransfusion centres.

Fresh plasma contains albumin, clotting factors andimmunoglobulins and, as such, its administration isbeneficial in animals with hypoalbuminaemia or clottingdisorders (including disseminated intravascular coagula-tion), or in those in which transfer of passive immunityhas failed. Plasma is indicated in situations such ashypovolaemia or hypoalbuminaemia as it maintains theoncotic pressure of the blood. Patients with severehypoproteinaemia will benefit from a plasma transfusionprior to and during anaesthesia for diagnostic and thera-peutic procedures.

Plasma should be given in preference to whole bloodto patients with clotting defects unless the clotting disor-der has resulted in a major bleed and subsequent bloodloss anaemia. Since clotting factors are amenable tofreezing, plasma can be stored for prolonged periodsprovided it is freshly harvested from whole blood andfrozen within six hours of collection. Frozen plasma har-vested from whole blood more than six hours after col-lection may contain minimal amounts of many clottingfactors and is therefore not appropriate for the treatmentof conditions where transfusion of clotting factors isindicated, such as haemophilia A. In patients with vonWillebrand' s disease, plasma transfusions should beadministered prior to and during surgery. The sub-cutaneous administration of desmopressin (1 pg/kg)to the donor 30 to 60 minutes before blood collectionmay increase von Willebrand' s factor levels withinthe collected blood (Nichols and Hohenhaus 1994).

Antithrombin III (present in fresh plasma) should beadministered to patients suffering from disseminatedintravascular coagulation.

PACKED RED BLOOD CELLSTransfusion of packed red cells is the treatment of choicefor severe anaemia where the patient is normovolaemicat the time of transfusion. This is particularly useful inpatients with cardiac or renal disease which would be atrisk of circulatory overload from the administration ofwhole blood. Once plasma has been decanted from thewhole blood (as discussed above), the remainder of theblood bag can be administered as a packed cell transfu-sion. The red cell concentrate is usually mixed withsaline to improve the flow rates through the catheter; theaddition of saline does not result in the same volumeexpansion as would an equivalent volume of plasma,as saline is rapidly redistributed throughout both theintravascular and extravascular compartments. Crystalloidsolutions containing calcium should not be used, as theaddition of calcium can result in clot formation

PLATELETSImpractically large volumes of blood are typicallyrequired to restore platelet numbers in patients withthrombocytopenia. However, while whole blood is avery inefficient method of restoring platelet numbers,whole blood transfusions are indicated when bleedinghas resulted in hypovolaemia or marked anaemia. Lowspeed centrifugation produces a plasma supematantwhich is rich in platelets (platelet-rich plasma).Transfusion of multiple units of platelet-rich plasma maybe successful in reversing thrombocytopenia, at leasttemporarily, but requires access to multiple donors and ablood bank centrifuge. In general, it is severe blood lossanaemia that is most effectively treated with blood trans-fusions, while other therapy is directed at the cause ofthe thrombocytopenia.

TRANSFUSION REACTIONS

Provided a matched transfusion is given and blood hasbeen stored and administered appropriately, transfusionreactions should be rare. Patients receiving blood orblood products should, however, be monitored closelyduring the transfusion period. If symptoms associatedwith a potential transfusion reaction are recorded (seetable on page 198), the transfusion should be stoppedand the cause of the reaction investigated.

The most common types of specific transfusion reac-tions and complications are listed in the box below.

Transfusion ractionscmMpl cations

* Haemolysis* Acute hypersensitivity reactions* Pyrexia* Bacterial contamination of blood bag* Hypocalcaemia (citrate toxicity)* Vomiting* Circulatory overload* Transmission of infectious diseases

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S O *. S 0

Urticaria (especially in dogs)

Erythema or pruritus

Vomiting

Vocalisation (cats)

Pyrexia

Depression

Dyspnoea, tachypnoea or coughing

Tachycardia or bradycardia

Tremors or convulsions

Shock

Cardiopulmonary arrest

Anorexia (delayed)

Jaundice (delayed)

Although transfusion reac-tions can be due to poorstorage or administrationtechniques, most significantreactions are associated withthe administration of mis-matched transfusions. Someclinicians recommend slowflow rates (0.5 mllkglhour)during the first 30 minutes oftransfusion in order to detectunexpected transfusion reac-tions (Turnwald and Pichler1985). The administration ofeven small test volumesof blood to felinerecipients, however, isdangerous and can result inrapid and severe transfusionreactions.

HAEMOLYSISAcute haemolysis associated with mismatchedtransfusionsAcute haemolysis results from the destruction of donorerythrocytes by alloantibodies and occurs during or soonafter transfusion. Acute haemolytic reactions associatedwith mismatched transfusions are rare in first transfu-sions in dogs due to the low incidence of naturallyoccurring antibodies against dog erythrocyte antigens(DEA) 1.1 and 1.2. However, the risk is much greater insubsequent transfusions due to induction of these anti-bodies (Harrell and Kristensen 1995).

In cats, transfusion reactions associated with A/Bmismatched transfusions can be life-threatening when

Mismatched transusions in cats

Type B cats receiving type A bloodMassive intravascular haemolysis of type A (donor)cells occurs due to the presence of high-titred,naturally occurring anti-A antibodies. This earlyreaction, which may be fatal, can occur followingadministration of very small volumes of mismatchedblood (Callan and Giger 1994).

Practical guidelines for suspectehaemolytic transfusion ions

* Stop the transfusion* Maintain intravenous line and administer crystal-loid solutions* Watch for evidence of shock or disseminatedintravascular coagulation; monitor temperature;check serum and urine for evidence of haemo-globinaemia and haemoglobinuria, respectively* Treat shock with more aggressive fluid therapyand corticosteroids if required* Administer supportive therapy (eg, oxygen sup-plementation, antihistamines, adrenaline)* Check blood bag for evidence of lysis (by capil-lary tube centrifugation) and collect sample ofblood for culture and sensitivity* Check blood typing or cross-matching

even small volumes of mismatched blood are adminis-tered as a first transfusion, due to the presence of natu-rally occurring alloantibodies. Type B cats which receivetype A blood are at greatest risk of a haemolytic reactionowing to the high levels of naturally occurring antibodythat they possess (see box below).

In both dogs and cats the acute haemolytic reactionis characterised clinically by depression, recumbency,cardiac arrhythmia, apnoea, seizures or signs of shock.Patients may urinate, defecate, salivate or vocalise (cats)and subsequently become tachycardic and tachypnoeicfor a prolonged period. Haemoglobinaemia and haemo-globinuria can occur within hours of transfusion but areonly clinically apparent when large volumes of blood aretransfused. The rapid destruction of transfused red cellswill also result in a dramatic fall in the recipient's PCV.

Delayed haemolytic transfusion reactionsDelayed haemolytic reactions result in a reduction in thelifespan of the transfused red cells. In cats, they are asso-ciated with the induction of antibodies to red cell anti-gens other than the AB group or the induction of anti-Bantibodies in type A cats without naturally occurringalloantibodies. In dogs, delayed haemolytic reactionsoccur in association with the induction of antibodiesagainst DEA 1.1, 1.2 and other red cell antigens by afirst or previous transfusion; due to the absence or lowtitres of these antibodies at the time of first transfusion,they may not be detected by cross-matching techniques.Transfused red cells are removed one to three weeksafter transfusion.

Type A cats receiving type B bloodType A cats often have weak anti-B alloantibodies andhence transfused type B (donor) cells can have a meanhalf-life of as little as two days. Although haemolysisoccurs, it is extravascular and therefore clinical signsare much milder. The main clinical significance is thatthe PCV will fall to pre-transfusion levels within daysof the transfusion (Callan and Giger 1994).

In Practice * APRIL 1998

Jaundice: a signof a potential transfusionreaction

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Pre-transfusion haemolysisHaemolysis can also occur during storage of wholeblood, particularly if the blood is subjected to overheat-ing or freezing or has become contaminated withmicrobes (Harrell and Kristensen 1995). The concurrentadministration of blood and hypotonic solutions via thesame catheter can also result in red cell lysis throughosmotic 'cell bursting'.

ACUTE HYPERSENSITIVITY REACTIONSAllergic reactions to transfused allergens are rare, butcan occur during transfusion of whole blood and bloodproducts (Harrell and Kristensen 1995). They developwithin 45 minutes of the start of the transfusion and, insevere cases, can result in cardiopulmonary arrest. Anyevidence of anaphylaxis, such as urticaria, pruritus, ery-thema, anxiety, vomiting or dyspnoea, therefore warrantsdiscontinuation of the transfusion and treatment for ananaphylactic reaction (corticosteroids, antihistamines,oxygen as required and adrenaline in severe cases).

PYREXIATransfusion-related pyrexia is the most common transfu-sion reaction and is characterised by an increase in bodytemperature of 1°C or more within four hours of thetransfusion (Turnwald and Pichler 1985). Pyrexia maybe related to bacterial contamination of transfused bloodor an acute reaction caused by antibodies to platelets,white blood cells or plasma proteins which are notdetected by blood typing or cross-matching. The bloodbag should be evaluated for evidence of bacterial conta-mination (see below) and the patient should be examinedfor evidence of haemolysis. Fortunately, non-infectious,non-haemolytic pyrexia - the most common cause ofpyrexia - is usually transient and does not requiretreatment.

BACTERIAL CONTAMINATION OF BLOOD BAGIncorrect collection or storage of whole blood can resultin bacterial contamination of the blood prior to adminis-tration. Bacteria will survive refrigeration and start tomultiply if the blood is warmed. Pyrexia will developwithin 15 minutes of the start of blood administrationand may be accompanied by other signs such as shock,abdominal pain, vomiting and diarrhoea. If bacterial con-tamination is suspected, the bag should be checked forevidence of haemolysis (by spinning down the bag or asample of blood from the bag) and a sample of donatedblood submitted for culture and sensitivity. Antibioticsshould be administered and supportive therapy providedas necessary.

HYPOCALCAEMIAClinical signs of hypocalcaemia (tremors, vomiting andcardiac arrhythmia) are occasionally associated with therapid administration of large amounts of citrate anticoag-ulant (which chelates calcium) (Tumwald and Pichler1985). In practice, this is a rare problem unless inappro-priate amounts of anticoagulant have been used, thepatient has severe liver disease (causing failure of citratemetabolism) or very large volume transfusions are givenrapidly.

VOMITINGVomiting is common during and after transfusions andmay be associated with rapid administration of blood or

Steps for avoiding transfusionreations and compikations* Always blood type or cross-match feline donorand recipient. Ideally cross-match canine donor andrecipient or use a DEA 1.1- and 1.2-negative donor* Administer transfusion at an appropriate rateaccording to the patient's condition:- 2 ml/kg/hour for patients with heart disease orrenal failure- 5 to 10 ml/kg/hour for normovolaemic patients- up to 20 ml/kg/hour for hypovolaemic patients* Maintain sterility of blood bags when storingblood and avoid prolonged storage* Collect blood in an appropriate volume ofanticoagulant and use a filtered giving set foradministration* Watch the recipient closely during the first 15minutes of transfusion for any signs of a potentialreaction

feeding around the time of transfusion. If no other symp-toms of transfusion reaction or haemolysis are evident,the transfusion can be continued after 15 minutes at aslower rate.

CIRCULATORY OVERLOADCirculatory overload is a common transfusion complica-tion in small animals and is most often associated withrapid administration of whole blood to patients withcardiac disease, renal failure or normovolaemic anaemia(Turnwald and Pichler 1985). Circulatory overload withpulmonary oedema is characterised clinically by tachy-cardia, tachypnoea, dyspnoea and coughing. The use ofappropriate flow rates and packed red cell transfusionsrather than whole blood reduces this problem. If circula-tory overload is encountered, the transfusion should bestopped immediately and frusemide and oxygen given asnecessary to control the symptoms.

TRANSMISSION OF INFECTIOUS DISEASESThe risk of transmission of infectious disease via trans-fusion cannot be completely eradicated. However, inorder to minimise it all donors should be healthy andfully vaccinated. Feline donors should be indoor cats thathave been tested for FeLV, FIV and Hfelis. In endemicareas, canine donors should be tested for heartworm,rickettsial diseases and blood parasites such as Babesiacanis.

SUMMARY

Blood transfusions can be life-saving in a number ofclinical situations and, provided a few simple guidelinesare followed, there is little risk of associated complica-tions. The main problem in veterinary practice is findingan appropriate donor when blood is needed. If donors areidentified prior to the need for blood, blood collectionand administration can be performed within an hour ofidentifying a need for transfusion.

It is likely that blood transfusions will be used withincreasing frequency within veterinary practice.

ReferencesCALLAN, M. B. & GIGER, U.(1994) Transfusion medicine. In:Consultations in Feline InternalMedicine. Ed. J. R. August.Philadelphia, W. B. Saunders.pp 525-532HARRELL, K. A. & KRISTENSEN,A. T. (1995) Canine transfusionreactions and theirmanagement. Veterinary Clinicsof North America: Small AnimalPractice 25, 1333-1361NICHOLS, R. & HOHENHAUS,A. E. (1994) Use of thevasopressin analoguedesmopressin for polyuria andbleeding disorders. Journal ofthe American Veterinary MedicalAssociation 205, 168-173PICHLER, M. E. & TURNWALD,G. H. (1985) Blood transfusionin dogs and cats, Part I.Physiology, collection, storageand indications for whole bloodtherapy. Compendium onContinuing Education for thePracticing Veterinarian 7, 64-71TURNWALD, G. H. & PICHLER,M. E. (1985) Blood transfusionin dogs and cats, Part II.Administration, adverse effectsand component therapy.Compendium on ContinuingEducation for the PracticingVeterinarian 7, 115-122

In Practice * APRIL 1998 199

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 Clare Knottenbelt and Andrew Mackin 2: Indications and safe administrationBlood transfusions in the dog and cat Part

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