Thinking Twice About Transfusions: When TACOS and TRALIs Turn Treatment Into Tragedy. Megan Boysen Osborn, MD, MHPE

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1 Thinking Twice About Transfusions: When TACOS and TRALIs Turn Treatment Into Tragedy Megan Boysen Osborn, MD, MHPE

2 Let s TACO bout Transfusion Reactions Megan Boysen Osborn, MD, MHPE

3 Let s TACO bout Transfusion Reactions You TRALI Shouldn t Have Done that Transfusion Megan Boysen Osborn, MD, MHPE Megan Boysen Osborn, MD, MHPE

4 Objectives Review the most common complications of blood transfusion and their management.

5 Objectives Review the most common complications of blood transfusion and their management. Discuss the indications for ordering special blood components. Blood Transfusion Order Washed Irradiated Leukoreduced Antigen Negative CMV Negative Please Just Get Me Some Blood

6 Objectives Review the most common complications of blood transfusion and their management. Discuss the indications for ordering special blood components. Identify the indications for blood transfusion in acute and chronic anemia.

7 Which of the following are the most common complications of blood transfusion? TACO Febrile Non-Hemolytic Transfusion Reaction TRALI HIV

8 Which of the following are the most common complications of blood transfusion? Febrile TACO Non-Hemolytic TRALI HIV Transfusion Reaction

9 According to the FDA, how many deaths per year are directly attributed to blood transfusions?

10 According to the FDA, how many TRALI deaths per year are directly attributed to blood transfusions? TACO Hemolysis 40 Infection Allergy

11 Case #1 A 26 year-old female is undergoing transfusion for symptomatic anemia. During the transfusion, the patient develops severe pain in chest, back and right arm (IV site). Her temperature is 39 o C. Twenty minutes later, she starts oozing from her IV site and notices that her urine is very dark.

12 Case #2 A 40 year-old female with a history of chronic anemia was on vacation last week and required a blood transfusion at an outside hospital. She is complaining of worsening fatigue and dark urine. Her hemoglobin is 5 g/dl and her urine dipstick is positive for hemoglobin.

13 Case #2 A 40 year-old female with a history of chronic anemia was on vacation last week and required a blood transfusion at an outside hospital. She is complaining of worsening fatigue and dark urine. Her hemoglobin is 5 g/dl and her urine dipstick is positive for hemoglobin. Hemolysis

14 Case #1 A 26 year-old female is undergoing transfusion for symptomatic anemia. During the transfusion, the patient develops severe pain in chest, back and right arm (IV site). Her temperature is 39 o C. Twenty minutes later, she starts oozing from her IV site and notices that her urine is very dark. Acute (Intravascular) Hemolytic Transfusion Reaction (AHTR)

15 Case #2 A 40 year-old female with a history of chronic anemia was on vacation last week and required a blood transfusion at an outside hospital. She is complaining of worsening fatigue and dark urine. Her hemoglobin is 5 g/dl and her urine dipstick is positive for hemoglobin. Delayed (Extravascular) Hemolytic Transfusion Reaction (DHTR)

16 1 Acute (Intravascular) Hemolytic Transfusion Reaction (AHTR) DONOR RECIPIENT A A vs. A

17 2 Delayed (Extravascular) Hemolytic Transfusion Reaction (DHTR) DONOR RECIPIENT Duffy Kidd vs. Rh

18 1 Acute (Intravascular) Hemolytic Transfusion Reaction (AHTR) MANAGEMENT PREVENTION

19 2 Delayed (Extravascular) Hemolytic Transfusion Reaction (DHTR) TREATMENT PREVENTION Antigen Supportive Negative Units

20 Case #3 A 40 year-old previously healthy female is undergoing blood transfusion. Approximately 30 minutes later, the patient develops shortness of breath and hypoxia to 86% on room air. A chest x-ray shows new bilateral infiltrates and a normal heart size.

21 Case #4 A 65 year-old male with a history of congestive heart failure and chronic renal insufficiency is undergoing a blood transfusion for anemia of chronic disease. Shortly after the transfusion, he develops shortness of breath, hypoxia, JVD, and diffuse rales on examination.

22 Case #3 A 40 year-old previously healthy female is undergoing blood transfusion. Approximately 30 minutes later, the patient develops shortness of breath and hypoxia to 86% on room air. A chest x-ray shows new bilateral infiltrates and a normal heart size. Transfusion Related Acute Lung Injury (TRALI)

23 Case #4 A 65 year-old male with a history of congestive heart failure and chronic renal insufficiency is undergoing a blood transfusion for anemia of chronic disease. Shortly after the transfusion, he develops shortness of breath, hypoxia, JVD, and diffuse rales on examination. Transfusion Associated Circulatory Overload (TACO)

24 3 Transfusion Related Acute Lung Injury (TRALI) DONOR RECIPIENT vs. WBC Neutrophil Activation

25 3 Transfusion Related Acute Lung Injury (TRALI) TREATMENT PREVENTION Donor Deferral Programs

26 4 Transfusion Associated Circulatory Overload (TACO) DONOR RECIPIENT

27 4 Transfusion Associated Circulatory Overload (TACO) TREATMENT PREVENTION Rate 1 ml/kg/hr diuretic

28 Case #5 A 50 year-old female requires blood transfusion for a lower GI bleed. She initially refuses blood transfusion, but agrees if her sister can donate the blood (directed donation). Eight days later, she develops rash, elevated liver function tests, and worsening anemia, thrombocytopenia, and leukopenia.

29 Case #5 A 50 year-old female requires blood transfusion for a lower GI bleed. She initially refuses blood transfusion, but agrees if her sister can donate the blood (directed donation). Eight days later, she develops rash, elevated liver function tests, and worsening anemia, thrombocytopenia, and leukopenia. Transfusion Associated Graft vs. Host Disease (TA-GvHD)

30 Transfusion Associated Graft vs. Host Disease (TA-GvHD) DONOR RECIPIENT vs. Immunocompromised T & NK cells HLA Homozygosity HLA Heterozygosity

31 Transfusion Associated Graft vs. Host Disease (TA-GvHD) TREATMENT PREVENTION Irradiated Blood Products

32 Allergic Transfusion Reaction

33 Allergic Transfusion Reaction DONOR RECIPIENT IgA vs. Peanuts Anti-peanuts

34 diphenhydramine Allergic Transfusion Reaction TREATMENT PREVENTION Washed RBCs

35 Febrile Non-Hemolytic Transfusion Reaction (FNHTR)

36 Febrile Non-Hemolytic Transfusion Reaction (FNHTR) DONOR RECIPIENT WBC Cytokines vs. HLA WBC Leukocyte Specific Antigen Anti-Leukocyte Specific Antigen

37 Febrile Non-Hemolytic Transfusion Reaction (FNHTR) MANAGEMENT PREVENTION APAP Leukoreduction

38 Other Transfusion Badness Skin Flora - Pseudomonas Yersinia - Enterobacter Bacterial - CMV HIV Dengue Zika Hep C Hep B Viral/Prion - Infections Babesia Microti Parasitic SBP <80 Hypotensive Transfusion Reaction Post-Transfusion Purpura

39 What do the guidelines say? Transfusion Threshold* 7-8mg/dL *Carson JL, et al. Clinical Practice Guidelines from the AABB. JAMA 2016:

40 Transfusion thresholds for other populations? 7-10mg/dL 8-10mg/dL 8mg/dL Clinically Correlate Symptomatic Acute Coronary Syndrome Stable CAD Unstable Patients

41 Take Home Points It s not just HIV. TRALI and TACO are two of the most important complications of blood transfusion. A ACEP Scientific Assembly 2018 SAN DIEGO

42 Take Home Points It s not just HIV. TRALI and TACO are two of the most important complications of blood transfusion. Special populations Immunocompromised patients and the frequently-transfused may require special blood products. ACEP Scientific Assembly A 2018 SAN DIEGO

43 Take Home Points It s not just HIV. TRALI and TACO are two of the most important complications of blood transfusion. Special populations Immunocompromised patients and the frequently-transfused may require special blood products. Less is more Transfusion thresholds should be 7-8 mg/dl for most patients. ACEP Scientific Assembly A 2018 SAN DIEGO

44 Condition Blood Product Febrile Non-Hemolytic Transfusion Reaction Irradiated Leukoreduced Washed Antigen Negative

45 Condition Blood Product Febrile Non-Hemolytic Transfusion Reaction Allergic Transfusion Reaction Irradiated Leukoreduced Washed Antigen Negative

46 Condition Blood Product Febrile Non-Hemolytic Transfusion Reaction Allergic Transfusion Reaction Delayed Hemolytic XV Transfusion Reaction Irradiated Leukoreduced Washed Antigen Negative

47 Condition Blood Product Febrile Non-Hemolytic Transfusion Reaction Allergic Transfusion Reaction Delayed Hemolytic XV Transfusion Reaction Transfusion Associated Graft vs. Host Disease Irradiated Leukoreduced Washed Antigen Negative

48 Condition Blood Product Febrile Non-Hemolytic Transfusion Reaction Allergic Transfusion Reaction Delayed Hemolytic XV Transfusion Reaction Transfusion Associated Graft vs. Host Disease Irradiated Leukoreduced Washed Antigen Negative

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