Boot Camp Transfusion Reactions Dr. Kristine Roland Regional - - PowerPoint PPT Presentation

Boot Camp Transfusion Reactions

• Dr. Kristine Roland

Regional Medical Lead for Transfusion Medicine, VCH

Objectives

By the end of this session, you should be able to:

• Describe in common language the potential

risks and adverse effects of transfusion of blood products.

• Recognize and respond appropriately to

adverse transfusion events or transfusion reactions.

• Plan monitoring and follow up of transfusions

to optimize patient safety.

Transfusion reactions

Acute reactions (<24 h)

• Febrile non-hemolytic
• Allergic – minor, major
• Acute hemolytic
• TACO
• TRALI
• Bacterial sepsis
• Hypotensive

Delayed reactions (>24 h)

• Delayed hemolytic
• TA-GVHD
• TRIM
• PTP
• Viral and parasitic

infections

Scenario 1

• You are admitting a 69 y.o. woman with
• pneumonia. Upon review of her recent CBC,

you note Hb 73 g/L. She c/o SOB.

• You decide to order a 1 unit RBC transfusion

with the intended benefit of relieving her symptoms.

• She asks you what is the risk she could contract

HIV?

• Informed consent is required for all blood

components and products:

– RBCs, plasma, platelets, cryoprecipitate – Albumin, IVIG, factor concentrates, etc.

• There is no standardized script

Current rates of viral and parasitic infections in Canada

HIV 1 in 8 million HCV 1 in 2-6 million HBV 1 in 150,000 to 1 in 1.7 million HTLV 1 in 4 million Malaria 1 in 4 million WNV seasonal vCJD ?

FNHTR 1 in 300 Mild allergic 1 in 300 TACO 1 in 700 DHTR 1 in 7000 TRALI 1 in 12,000 Anaphylaxis 1 in 40,000 AHTR 1 in 40,000 Bacterial sepsis 1 in 50,000

Vox Sanguinis (2012) 103, 83–86

Compare to:

Scenario cont’d

• You have ordered the single-unit transfusion and

then you get called down to the ED to see another patient.

• What are some procedures performed by the

nurse at the bedside to ensure a safe transfusion?

Blood administration

• Patient ID check

– Labels on blood bag and transfusion record must match with patient ID – Sometimes two nurses are required to confirm ID

• Confirm blood group is compatible
• Check vital signs at start
• Transfuse slowly for first 15 min
• Monitor patient for first 15 min and re-check

vitals

• Check vitals hourly until end
• Transfusion must be complete within 4 hours

Scenario cont’d

• You are paged while in the ED: your patient has

spiked a fever 30 minutes into the transfusion. What do you do now?

Transfusion and FEVER

Fever

• Febrile non-hemolytic
• Acute hemolytic reaction
• Bacterial contamination
• Others:

– TRALI, delayed hemolytic reaction – fever due to underlying condition is very common! Fever often dominant symptom

Most common Rare but can be deadly

Febrile non-hemolytic reaction

• Very common (incidence > 1:300 transfusions)
• Mediated by cytokines in stored product or

recipient ab to white cells in donor blood

• Presentation: Fever, chills, rigors

– Headache, N&V, mild ↓ in BP

• Not associated with harm to patient but can be

very distressing

Fever does NOT have to be present

Management

STOP transfusion and assess patient carefully!

• Check patient ID and send post-transfusion samples to lab
• Monitor vitals closely
• B.C. recommendation: do not restart; order a new unit if

required

– If physician chooses to order a restart, they should attend at the bedside

• Treat FNHTR with acetaminophen

– Premedication hasn’t been shown to prevent FNHTR but may be worth trying

Scenario cont’d

• What can I do to reassure myself this is a

FNHTR and not a more severe reaction?

Management cont’d

• Patient usually starts to feel better quickly after

transfusion stopped.

• Watch for warning signs!
• fever ≥ 39°C or ≥ 38°C plus ≥1°C from baseline
• drop systolic BP ≥30 mmHg
• dark urine

– (hemoglobinuria from intravascular hemolysis)

Follow up with blood bank investigations:

• Patient ID check within lab
• Post-reaction blood specimen:

– Visual check for free hemoglobin – DAT – Repeat ABO type – Repeat Antibody screen

normal hemolyzed

Further investigations

• If bacterial contamination is a consideration:

– Draw patient blood cultures – Seal the product bag and return to blood bank for culture – Consider broad-spectrum antibiotics (both Gm + and Gm- bacteria can be implicated)

• Order the blood components with respect to frequency of

bacterial contamination:

– RBCs – Plasma – Platelets – Albumin

1 2 3 4

Further investigations

• If acute hemolytic reaction is a consideration, order

hemolytic workup

– CBC, indirect bili, haptoglobin, LDH, (DAT) – Send first voided urine to check for hemoglobinuria – Alert blood bank immediately; a second patient may be at risk!

Scenario cont’d

• You give the patient some Tylenol and order a

new RBC unit for transfusion.

• It proceeds uneventfully, however 10 minutes

after the transfusion you are paged again because the patient has worsened SOB.

Transfusion and SOB

Shortness of breath

• TACO
• TRALI
• Others:

– TAD, anaphylaxis, bacterial sepsis, acute hemolysis

SOB is a dominant symptom

http://www.phac-aspc.gc.ca/hcai-iamss/ttiss-ssit/ttiss-summary-ssti-summaire-2006-2012-eng.php#t_1a

Canadian Hemovigilance Data: Rates of adverse reactions from 2006 to 2012

TRALI is the leading cause of death due to transfusion. TACO is a close second.

Transfusion associated circulatory overload

• Acute pulmonary edema secondary to CHF precipitated

by transfusion

• Can occur after 1 unit!

At risk:

• Very young, very old
• Diminished cardiac reserve
• Significant chronic anemia
• Most patients have:

– Respiratory distress

• Some patients have:

– Hypertension, tachycardia, cyanosis, dry cough, headache, chest tightness

Scenario

• So what do I do now?

Scenario cont’d

Initial Management:

• Stop transfusion and monitor vital signs
• Position patient in upright position; Supplementary
• xygen
• Order a CXR
• Diuresis as appropriate

TRALI

• Acute onset lung injury

– Occurs within 6 hours of transfusion – Bilateral CXR infiltrates – No evidence of circulatory overload – No other cause of lung injury

• Caused by donor antibodies that trigger lung injury in a

susceptible patient

• No specific treatment; patients often require intubation

but recover within 96 hours

• Can be fatal

TRALI cont’d

“The reaction was probably volume overload but could it have been TRALI?”

• Just report the signs and symptoms to the blood

bank

• We will investigate further and report to CBS if

required

– If possible TRALI then CBS will test for antibodies and recall companion products – Confirmed TRALI: donor will be deferred

Allergic reactions

• Mild

– Incidence > 1:300 – Hives, redness, pruritus, flushing – Stop transfusion; assess; treat with Benadryl – Can re-start

• Major (anaphylaxis)

– Cause often unclear

• Recipient allergy to donor allergen; severe IgA-deficiency

with anti-IgA antibodies

– Stop transfusion, treat with Epi/steroids/Benadryl – Usually an isolated event and patient will not react to future transfusions

• We often suggest testing for IgA levels

Classifying a TR is not always easy

• Many symptoms are non-specific

– Dyspnea, fever, pain, etc

• Symptoms related to underlying disease
• Atypical presentations

You don’t necessarily need to classify the reaction at the bedside

– key recommendation: initial treatment of acute transfusion reaction is directed by symptoms and signs.

Tinegate H, et al 2012

Example of Transfusion Reaction Form

Summary

• Management of acute transfusion reactions are guided

by signs and symptoms

– Be able to generate a differential diagnosis and recognize the danger signs

• Report all reactions to the blood bank earlier rather than

later

– Lab will do further workup and report to CBS as necessary

• To promote patient safety you should:

– Only transfuse when necessary, including single unit transfusions – Avoid non-urgent transfusions overnight

You have help…

• There is a lab pathologist on-call 24/7 for

consultation!

• Questions?