BLOOD TRANSFUSION reaction

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Published on March 21, 2014

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BLOOD TRANSFUSION REACTION Basic concept, prevention & management: BLOOD TRANSFUSION REACTION Basic concept, prevention & management Dr asgher niazi anesthesologist PowerPoint Presentation: Blood Therapy Indications for Transfusion Various blood groups & antibodies Blood Transfusion Reactions acute delayed Blood transfusion guidelines Summery& take home message Indication of blood transfusion benefits >>risk: Indication of blood transfusion benefits >>risk Symptomatic anemia Usually HB less than 7 G/dl More than 40 blood volume is lost due to hemmorage OBSTRETIC causes PPH remains the leading cause Causes of maternal mortality : Causes of maternal mortality PowerPoint Presentation: Blood Component Therapy Packed Red Blood Cells Platelet Concentrates Fresh Frozen Plasma Cryoprecipitate ABO Blood groups & their antibodies: ABO Blood groups & their antibodies Cross match: Cross match Relationship between blood group & antibodies: Relationship between blood group & antibodies Transfusion Reactions: Transfusion Reactions ANY unfavorable consequence is considered a transfusion reaction of blood TX The risks of transfusion must be weighed against the benefits CLASSIFICATION : CLASSIFICATION Transfusion reaction Acute <24 hours Delayed >24 hours Immunologic Nonimmunologic HEMOLYSIS TACO febrile reaction air embolism Urticaria hypothermia TRALI hypocalecemia Immunologic Nonimmunologic Hemolytic ; iron overload Graft vs. Host Disease; Posttransfusion Purpura PowerPoint Presentation: ACUTE REACTION <24 HOURS PowerPoint Presentation: Immunologic Hemolytic; Febrile-non hemolytic; Allergic; Anaphylactic; Transfusion Reaction of Acute Lung injury(TRALI) Nonimmunologic Volume overload; Hemolytic (Physical or Chemical destruction of RBC); Air embolus; Hypocalcaemia; Hypothermia Acute (<24 hours) Transfusion Reactions Acute Transfusion Reactions Immunologic: Acute Transfusion Reactions Immunologic Acute Hemolytic Transfusion Reaction Associated with Intravascular Hemolysis Etiology: Antibodies that activate complements in the vasculature: ABO antibodies are predominant / not the only ones. Prevention: Give ABO compatible blood. Acute Transfusion Reactions Immunologic: Acute Transfusion Reactions Immunologic May also occur due to ABO incompatible plasma in platelet products Very rare; less than 20 case reports, all involving group O platelets Usually occurs in group A patients or those with anti-A titers greater than 1:1000 Can prevent by removing plasma from platelets, or limiting number of incompatible group O platelets in a 24 hour period ( Archives 2007;131:909 ) Haemolytic transfusion reaction : Haemolytic transfusion reaction symptoms of: Dyspnoea Rigors Lumbar pain Flushing Urticaria Headache Release of vasoactive substances causes profound hypotension and shock, and renal tubular necrosis can cause acute renal failure. Release of tissue thromboplastin from lysed red cells can lead to disseminated intravascular coagulation (DIC). Death occurs in 15% of cases of ABO incompatibility and usually results from severe DIC or renal failure. Acute Transfusion Reactions Immunologic: Acute Transfusion Reactions Immunologic Febrile non-hemolytic TX Reactions An INCREASE in temperature of 1 O C during infusion of blood component Usually “mild & benign” = not life threatening Can have more severe symptoms, not usually Non-hemolytic Incidence of 0.1% of RBC transfusions, 0.1-1.0% of platelet transfusions Cause: Recipient antibodies to donor WBCs & Cytokines in the transfused blood component. Febrile Transfusion Reactions: Febrile Transfusion Reactions Seen in… Multiply transfused patients Multiple pregnancies Previously transplanted Must rule out… Hemolytic transfusion reaction Bacterial contamination of unit Prevention Leukocyte reduction ( pre-storage reduction may be more effective than post-storage reduction) or plasma removal is also helpful . Acute Transfusion Reactions Immunologic: Acute Transfusion Reactions Immunologic Allergic ( Urticarial -Hives) Transfusion Reactions Etiology: Form of cutaneous hypersensitivity triggered by recipient antibodies directed against: Donor plasma proteins or Other allergens (food, medicines) in donor plasma Begins within minutes of infusion Characterized by rash and/or hives and itching . Common (1 per 2000 transfusions) Usually involves release of histamine. PowerPoint Presentation: MUST be sure that the only reaction is the development of urticaria Must rule out more severe symptoms that could lead to anaphylaxis: angioneurotic edema laryngeal edema bronchial asthma Prevention: Can pre-treat recipient with anti-histamines before transfusion. ( Transfus Med Rev 2007;21:1 , Br J Haematol 2005;130:781 ) . Allergic (Urticarial) Reactions Acute Transfusion Reactions Immunologic: Acute Transfusion Reactions Immunologic Anaphylaxis Life threatening!! Etiology: Recipient is IgA deficient & has anti- IgA in serum Recipient anti- IgA can react to even small amounts of donor IgA in the plasma in any blood component Idiopathic & Haptoglobin deficiency Reaction may occur within minutes : Onset of symptoms is SUDDEN Prevention: Wash cellular components or blood products from IgA deficients Acta Anaesthesiol Scand 2002;46:1276 Shock/severe hypotension associated with wheeze or stridor: Shock/severe hypotension associated with wheeze or stridor Suggestive of anaphylaxis with airways obstruction, especially if examination reveals angioedema and/or urticaria . MUST STOP TX IMMEDIATELY Administer epinephrine 0.5 ml of 1:1,000 adrenaline (500mcg) into the anterolateral aspect of the middle third of the thigh. Uk resucitation guidelines 2008 Shock/severe hypotension associated with wheeze or stridor contd: Shock/severe hypotension associated with wheeze or stridor contd Intramuscular (IM) adrenaline is rapidly effective and prevents delay in attempting to get venous access in a patient with peripheral venous shutdown. It should not be prohibited in patients with thrombocytopenia or coagulopathy . Intravenous adrenaline should only be given by expert practitioners such as intensive care specialists or anaesthetists . Shock ,hypotension Supportive care of anaphylaxis : Shock ,hypotension Supportive care of anaphylaxis Rapid fluid challenge of 500-1000ml crystalloid Administration of 10 mg of chlorphenamine IM or by slow intravenous (IV) injection following initial resuscitation Administration of 200 mg of hydrocortisone IM or by slow IV injection following initial resuscitation If the patient has continuing symptoms of asthma or wheeze, inhaled or intravenous bronchodilator therapy should be considered Acute Transfusion Reactions Immunologic: Acute Transfusion Reactions Immunologic TX Reaction of Acute Lung Iinjury Etiology: Acute onset of hypoxemia and pulmonary edema on CX-RAY within 2- 6 hrs of TX without evidence of cardiac failure. Mechanism’s Primary Suspect: Donor antibodies to recipient WBCs Another cause: Biologically active lipids in the lungs causing edema Transfusion Reaction of Acute Lung Injury(TRALI): Transfusion Reaction of Acute Lung Injury(TRALI) Symptoms Chills, fever, cough, cyanosis, hypotension , increased difficulty breathing Treatment ventilatory support and general Icu care Acute Transfusion Reactions NONimmunologic: Acute Transfusion Reactions NON immunologic Transfusion associated circulatory overload TACO Etiology : Rapid increases in blood volume to patient . Risk factors: compromised cardiovascular function, current volume overload, small intravascular volume (elderly, young children), severe chronic anemia . Signs and Symptoms Dyspnea , cyanosis, severe headaches, hypertension or CHF (congestive heart failure ). Chest Xray : pulmonary edema, distended pulmonary artery, cardiomegaly Laboratory : elevated B- natriuretic peptide (BNP) is 81% sensitive and 89% specific ( Transfusion 2005;45:1056 ) Prevention: Slow Tx . Treatment : Stop infusion and place patient in sitting position. Archives 2007;131:708 Acute Transfusion Reactions NONimmunologic: Acute Transfusion Reactions NON immunologic Physically or Chemically Induced Red Cell Destruction Etiology: Destruction of red blood cells in the collection bag and infusion of free hemoglobin, etc. Improper temperatures: High or Low Microwave blood bag, malfunctioning blood warmer or water bath, inadvertent freezing of blood. Physically or Chemically Induced Red Cell Destruction: Physically or Chemically Induced Red Cell Destruction Osmotic Hemolysis Addition of drugs or hypotonic solutions (5% dextrose, deionized water, etc.) to transfusion. Mechanical Hemolysis Caused by rollers in blood pump Pressure infusion pumps Small bore needles Prevention: Adherence to procedures for all aspects of procuring, processing, issuing and administering red blood cell transfusions. Acute Transfusion Reactions NONimmunologic: Acute Transfusion Reactions NON immunologic Hypocalcemia Excess citrate : When infused at rate >100 mL /minute or individuals with impaired liver function: Citrate is broken down by liver. Seen more in pediatric and elderly patients Signs and Symptoms: Facial tingling, nausea, vomiting. Prevention: Slowing or discontinuing infusion & replace calcium Acute Transfusion Reactions NONimmunologic: Acute Transfusion Reactions NON immunologic Hypothermia Etiology: Drop in core body temperature due to rapid infusion of large volumes of cold blood. Symptoms: Decreased body temperature and ventricular arrhythmias. Seen in small infants or massive transfusion Prevention: Reduce rate of infusion or use blood warmers . Acute Transfusion Reactions NONimmunologic: Acute Transfusion Reactions NON immunologic Air Embolism Etiology: If blood in an open system is infused under pressure or if air enters the system while container or blood administration sets are being changed. Treatment: Place patient on left side with head down to displace air bubble from pulmonic valve. PowerPoint Presentation: Delayed (>24 Hours) Transfusion Reaction PowerPoint Presentation: Immunologic Hemolytic ; Graft vs. Host Disease; Posttransfusion Purpura Nonimmunologic Iron Overload Delayed (>24 Hours) Transfusion Reaction - Delayed Transfusion Reactions Immunologic: Delayed Transfusion Reactions Immunologic Delayed Hemolytic Transfusion Reaction ( Red blood cell alloimmunization ) Onset within days (>24 hours) Associated with Extravascular Hemolysis Etiology: Antibodies that usually do NOT activate Complements : Rh, Kell, etc . Prevention: Give antigen negative blood. Extravascular Hemolysis: Extravascular Hemolysis Signs may include: No release of free Hgb, or enzymes into circulation May be immediate (hours) or delayed (days) Bilirubinemia or bilirubinuria Characteristics Reaction within days Antibody attaches to RBC: RBC destroyed in spleen or liver, etc. Commonly IgG May or may not activate Complement Extravascular Hemolysis: Extravascular Hemolysis Signs & Symptoms continued… Fever or fever & chills Jaundice Unexpected anemia Some may present as an ABSENCE of an anticipated increase in Hemoglobin and hematocrit. Delayed Transfusion Reaction Immunolgic: Delayed Transfusion Reaction Immunolgic Graft vs Host Disease (GVHD) Etiology: Donor CD8+ T -Lymphocytes attack recipient (host) tissues. Very rare in blood stored 4+ days due to WBC inactivation ( Br J Haematol 2000;111:146 ) Groups at risk: Immunocompromised patients (Cancer, fetus, neonatal, bone marrow transplant). Signs: Fever, dermatitis, or erythroderma, hepatitis, diarrhea, pancytopenia, etc. Prevention: Irradiation of blood products. Osaka City Med J 1999;45:37 Delayed Transfusion Reaction Immunolgic: Delayed Transfusion Reaction Immunolgic Post-transfusion Purpura Etiology: Antibodies to platelet antigens ( HP1a ) causes abrupt onset of severe thrombocytopenia (platelet count <10,000/ l) 5-10 days following transfusion. Usually affects multiparous women . Signs: Purpura , bleeding, fall in platelet count . treatment : IVIG, plasmapheresis or corticosteroids; platelet transfusions usually NOT recommended Transfus Med 2006;16:69 Delayed Transfusion Reaction NONimmunolgic: Delayed Transfusion Reaction NON immunolgic Iron Overload Etiology: Excess iron resulting from chronically transfused patients such as hemoglobinopathies, chronic renal failure, etc. Signs: Muscle weakness, fatigue, weight loss, mild jaundice, anemia, etc. Treatment: Infusion of deferoxamine - an iron chelating agent has been useful. PowerPoint Presentation: Infectious Complications of Blood Transfusion (Viral is rare) Infectious Complication of Blood Transfusion: Infectious Complication of Blood Transfusion Bacterial Contamination Etiology: At time of collection: either from the donor or the venipuncture site. During component preparation, etc . Usually involves endotoxins Staph, Pseudomonas, E.coli, Yersinia Bacterial Contamination: Bacterial Contamination Components: Most often from platelet components (room temp). Red cell units will look dark. Symptoms: Rapid onset Fever, hypotension, shaking chills, muscle pain Vomiting, abdominal cramps, bloody diarrhea, hemoglobinuria , shock, renal failure, & DIC. PowerPoint Presentation: Transfusion must be stopped immediately Gram stain & blood cultures should be done on the unit, patient and all infusion sets . Broad-spectrum antibiotics should be given immediately intravenously Prevention: Maintain standards of donor selection, blood collection and proper maintenance of collected blood components. Bacterial Contamination PowerPoint Presentation: Transfusion Reaction Follow-up Transfusion Reaction Follow-up: Transfusion Reaction Follow-up Clinical Information Needed: Recipient diagnosis Medical history of pregnancy &/or transfusion Current medications Signs & symptoms during transfusion reaction How many mL’s of RBC’s or plasma were transfused? Clinical Information Needed: Clinical Information Needed Were rbc’s cold or warm when transfused? Were red cells infused under pressure? What was the size of the needle used? Were other solutions given through the IV line at the same time? If so what? Were any other drugs given at the time of transfusion? If so, what? What were pre- & post- transfusion vital signs? Transfusion Reaction Workup: Transfusion Reaction Workup CLERICAL CHECKS Correct identification of patient, specimen, and transfused unit. Agreement of records and history with current results Correct labeling of transfused unit SPECIMEN CHECKS Visual inspection of post-transfusion specimen Visual inspection of blood bag and lines Transfusion Reaction Follow-up Post Transfusion Reaction blood samples to be collected from the recipient:: Transfusion Reaction Follow-up Post Transfusion Reaction blood samples to be collected from the recipient: Clotted specimen EDTA specimen Clotted specimen 1st voided urine specimen post-tx’n Repeat ABO, Rh, IAT and Crossmatch. Visual check for hemolysis and compare with pre transfusion sample. DAT (Direct Antiglobulin Test) Collect 5-7 hours post transfusion to check for bilirubin Free hemoglobin determination Post Transfusion Lab Testing: Post Transfusion Lab Testing Direct Antiglobulin Test (DAT) Recipient post-tx’n spec. Positive: Perform eluate and identify antibody if the pre-TX spec negative. ABO Grouping and Rh Typing Recipient pre transfusion and post transfusion specimen Donor bag. Post Transfusion Lab Testing: Post Transfusion Lab Testing Indirect Antiglobulin Test (IAT) Recipient Pre- & post-transfusion reaction specimens Pre neg and post pos: Identify antibody and compare results of serum panel with eluate panel. PowerPoint Presentation: Guideline on the investigation and management of acute transfusion reactions British society of hematology 2012 British thoracic society guidelines on the management of asthma 2011 UKResucitation guidelines guidelines , 2008 Starting transfusion: Starting transfusion All patients should be transfused in clinical areas where they can be directly observed, and where staff are trained in the administration of blood components and the management of transfused patients, including the emergency treatment of anaphylaxis. Management of acute transfusion reaction: Management of acute transfusion reaction Whilst awaiting medical support manage the patient In all cases disconnect the component and giving set from the patient and retain for further investigation, maintaining venous access with intravenous physiological saline. If the patient is severely dyspnoeic , ensure the airway is patent and give high flow oxygen through a mask with a reservoir. If wheeze is present without upper airways obstruction, consider nebulising a short-acting inhaled beta-2 agonist such as salbutamol . Management of acute transfusion reaction contd…..: Management of acute transfusion reaction contd ….. Position hypotensive patients flat with leg elevation, or in the recovery position if unconscious or nauseated and at risk of vomiting. Further management is dependent on expert medical assessment and appropriate specialist support, such as the resuscitation team or critical care outreach team, Shock/severe hypotension without clinical signs of anaphylaxis or fluid overload: Shock/severe hypotension without clinical signs of anaphylaxis or fluid overload Consider ABO incompatibility or bacterial contamination. Both require supportive care with fluid resuscitation, expert evaluation for inotropic , renal and/or respiratory support, and blood component therapy for disseminated intravascular coagulation with bleeding. Isolated hypotension can occur in anaphylaxis and severe hypotension can occur in TRALI. In the latter the clinical picture is usually dominated by dyspnoea Acute transfusion reaction due to ABO incompatibility: Acute transfusion reaction due to ABO incompatibility If the identity check shows ABO incompatibility due to transfusion of a unit intended for another patient, contact the transfusion laboratory immediately to prevent a further wrong blood incident When suspecting bacterial contamination: When suspecting bacterial contamination If bacterial contamination is suspected, take blood cultures from the patient (peripheral vein and through central line, if present) start broad spectrum IV antibiotics (regime for neutropenic sepsis would be appropriate). Immediately notify the transfusion laboratory staff and haematologist to arrange culture of the implicated unit/units and contact with the blood service so that any other components from the implicated donation can be recalled . Severe dyspnoea without shock: Severe dyspnoea without shock Consider TRALI or TACO, Ensure the airway is patent and high-flow oxygen therapy started while urgent expert medical assessment is obtained. Initial investigation should include chest X-ray and oxygen saturation. However, the distinction is clinically important as the primary treatment of TRALI is ventilatory support and mortality/morbidity may be increased by loop diuretic therapy Moderate febrile symptoms: Moderate febrile symptoms Symptoms and signs are defined as a temperature > 39C or a rise of > 2C from baseline and/or systemic symptoms such as chills, rigors, myalgia , nausea or vomiting Bacterial contamination or a haemolytic reaction are very unlikely if the reaction is transient and the patient recovers with only symptomatic intervention. Moderate allergic symptoms: Moderate allergic symptoms Moderate angioedema & dypsnea with no life threatening symptoms Give CPM 10 mg IV or oral High flow oxygen Nebulize with SABA salbutamol (McClelland, 2007, BTS/SIGN guideline, 2011). Mild reactions : Mild reactions These are defined as having no or limited change in vital signs for example an isolated fever > 38 c and rise of 1-2 C from baseline and/or pruritus or rash but without other features In these cases it is reasonable to restart the transfusion with direct observation at low rate Recommendation 1 : Recommendation 1 If a patient develops new symptoms or signs during a transfusion, this should be stopped temporarily, but venous access maintained. Identification details should be checked between the patient, their identity band and the compatibility label of the blood component. Perform visual inspection of the component and assess the patient with standard observations. Recommendation 2: Recommendation 2 For patients with mild reactions, such as pyrexia (temperature of > 38 oC AND rise of 1-2oC from baseline), and/or pruritus or rash but WITHOUT other features, the transfusion may be continued with appropriate treatment and direct observation. (2B) Recommendation 3: Recommendation 3 Anaphylaxis should be treated with intramuscular adrenaline (epinephrine) according to UKRC guidelines. Patients who are thrombocytopenic or who have deranged coagulation should also receive IM adrenaline if they have an anaphylactic reaction (1A) Recommendation 4: Recommendation 4 If a patient develops sustained febrile symptoms or signs of moderate severity (temperature > 39oC OR a rise of > 2oC from baseline AND/OR systemic symptoms such as chills, rigors, myalgia , nausea or vomiting), bacterial contamination or a haemolytic reaction should be considered. Recommendation 5: Recommendation 5 Patients with mild isolated febrile reactions may be treated with oral paracetamol (500-1000 mg in adults). Patients with mild allergic reactions may be managed by slowing the transfusion and treatment with an antihistamine. (2C) Recommendation 6 : Recommendation 6 Patients with confirmed IgA deficiency and a history of reaction to blood should be transfused with components from IgA -deficient donors (first choice) or washed red cells (second choice) if time allows. Life-saving transfusion should not be denied or delayed if these are not immediately available but the facilities and skills to manage severe allergic reactions must be present. Evidence from studies Typical SHOT IBCT errors (SHOT, 2011) : Evidence from studies Typical SHOT IBCT errors (SHOT, 2011) The blood sample was drawn from the wrong patient. Patient details were recorded incorrectly on the blood sample label or the blood request form. The incorrect unit was collected from the blood refrigerator. The final formal identity check at the patient’s bedside, prior to transfusion, was omitted or performed incorrectly. Data from royal college of nursing .national audit report on SHOT ,2011 PowerPoint Presentation: In Summary : Always have large double IV line when transfusing blood Most of the hemolytic reaction are caused by BO incompatibility Disconnect the transfusion as soon as transfusion reaction is suspected PowerPoint Presentation: In Summery: Contact the clinician Give oxygen and rush IV saline from 2 nd cannula Check vital signs every 15 minutes Check labels,forms,and Ids Send bags &patient’s blood to BB PowerPoint Presentation: Don’t hesitate to give INJ ADRENALINE 0.5mg IM to patient who develops dyspnea hypotension with unconsciousness after blood transfusion Summary : Summary RCC should only be diluted in normal saline Avoid dilution of RCC with RINGER lactate,dextrose soultion Take home message: Take home message Give blood only when it is severely indicated after careful identification of patient & blood

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