Transporting Patients with Blood Transfusions

Transcription

1 Transporting Patients with Blood Transfusions Acknowledgement This training package was created by Bronwyn Cadd - ECP and NSQHS Standards Project Clinical Lead. Please direct any questions to your CSO or Team Leader. Offline Reading Download as PDF Welcome Introduction and Background Decision to Transfuse Preparing for the Transfusion Storage of Blood Administration of the Transfusion - PRIOR to SAAS Arrival

2 Continuing the Transfusion - SAAS Transfusion Reactions Recognise Transfusion Reactions Respond to Transfusion Reactions Summative Assessment Details Download Module as PDF

3 Section 1 of 12 Welcome All staff have a responsibility for the safe and appropriate use of blood and blood products, to ensure best patient outcomes and wise use of this precious resource. This elearning module focuses on the transfusion of red cells, but the principles are also applicable to other blood components. Materials are adapted from the BloodSafe elearning Australia Clinical Transfusion Practice course Staff can register with BloodSafe and complete the Clinical Transfusion Practice course or any other course for further information and professional development. Learning Objectives On completion of this module you should be able to: Be aware of a patient blood management approach to patient care. Identify the risks and benefits of a transfusion. Describe the information required on receiving clinical handover for a patient being administered a blood product. Explain why correct patient identification is important in the transfusion process. Comply with the 30-minute 4-hour rule to blood removed from storage. Apply and explain best practice for monitoring patients during and after a transfusion.

4 Recognise, respond and report appropriately in the event of a possible transfusion reaction. Document the transfusion process appropriately. Assessment There is a multiple choice quiz at the end of this module. For successful completion of the quiz you will need to achieve at least 80% correct responses. The quiz can be repeated up to three times. On successful completion, you will be issued with a certificate, which is confirmation that you can begin using the Transfer of Patients with Blood of Blood Product Infusion in Progress clinical practice guideline. The completion will also be automatically registered against your login details for reaccreditation records.

5 Section 2 of 12 Introduction and Background Every drop of blood is precious. The most valuable blood for your patient is their own blood, and as such it should be managed appropriately to optimise outcomes and decrease the need for donor blood. Transfusion is a complex process involving multiple steps and people, from the time blood is collected from a donor to when it is administered to your patient. As a healthcare worker involved in the transfusion chain, you have a dual responsibility to the patient who may receive the blood and to the person who donated it.

6 Blood is precious The Australian Red Cross Blood Service collects blood from volunteer donors who selflessly give their blood to help the community in a very practical way. The patients who receive this blood as part of their medical treatment do not pay for it. The collection, processing, storage and transportation of blood products incur significant costs. Each year all Australian governments provide more than one billion dollars to ensure a safe and

7 sustainable blood supply. Australia has one of the safest blood supplies in the world. It is essential that all clinical staff, laboratory staff and other healthcare professionals contribute to the sustainability of the blood supply, by ensuring responsible and appropriate handling and use of blood. The principles and requirements of this stewardship are outlined in the Australian Health Ministers Consensus Statement. Blood components All whole blood donations are processed into a number of blood components, each having specific indications for their use. This course focuses on red cells, the most commonly transfused product, but does provide some information on other products. Every blood donation is screened for syphilis, hepatitis B and C, HIV and HTLV prior to being released from the Australian Red Cross Blood Service. Red cells are transfused to alleviate signs and symptoms of anaemia due to blood loss, disease or treatment. Red cells are separated from donated whole blood by removing most of the plasma and suspending them in additive solutions to prolong their expiry. Platelets are used to treat, or prevent, bleeding in patients who have thrombocytopenia or abnormal platelet function (e.g. due to treatment with antiplatelet drugs). Platelets are collected from platelet donors by apheresis or produced as a pool of platelets from four units of donated Plasma contains proteins, clotting factors and antibodies and is separated or processed into a number of products, including: Fresh frozen plasma (FFP) which contains coagulation factors and plasma proteins and is

8 All red cells are filtered to remove leucocytes (leucodepleted). whole blood (pooled platelets). All platelets produced in Australia by the Blood Service are leucodepleted. used to treat bleeding or to reduce the likelihood of bleeding. Cryoprecipitate, which contains a number of clotting proteins and is most commonly used to treat bleeding or to reduce the likelihood of bleeding where fibrinogen is low. Other blood components, donated plasma is further fractionated (separated) into different components (eg albumin, clotting factor concentrates, immunoglobulins) that are used for specific indications. Other information Washing red cells

9 Washing red cells removes residual plasma (containing plasma proteins, which may be the cause of allergic reactions) as well as white cells and platelets. Washed red cells are only required in very specific clinical situations, and the indications for use should be discussed with a relevant expert. Washed red cells are indicated for those patients who have experienced: Reactions to transfused plasma proteins (e.g. patients with IgA deficiency). Severe allergic reactions of unknown cause. Severe reactions despite leucocyte depletion. Washed red cells need to be specifically ordered in advance. Washed red cells need to be specifically ordered in advance. Washing may reduce the shelf life or expiry of the product. Irradiation Irradiation of cellular blood components (red cells, platelets and granulocytes) prevents transfusion-associated graft-versus-host disease which is usually fatal. Irradiated blood components are used in certain patients or situations such as:

10 Intrauterine and exchange transfusions, including neonates who have previously received an intrauterine transfusion. Congenital cellular immune deficiencies. Hodgkin's lymphoma. Stem cell and bone marrow transplant recipients. Patients treated with certain immunosuppressive drugs such as purine analogues and related agents, or specific types of antibody therapies. Directed donations from blood relatives. Granulocyte transfusions or HLA-matched platelet transfusions. Note: In Australia all platelet packs are irradiated by the Blood Service. Cytomegalovirus (CMV) seronegative blood Cytomegalovirus (CMV) seronegative blood components minimise the risk of transfusion transmitted CMV infection a common virus typically carried by leucocytes which may lead to

11 severe or fatal disease in some patients. They should be considered for use in certain patient groups, for example: Neonatal, intrauterine and exchange transfusions. Pregnant patients. Haematology-oncology patients. Immunosuppressed patients such as transplant recipients. Their use may be dependent on the patient's CMV antibody status. If CMV seronegative units are not available, leucocyte depleted components can offer a high level of safety, although they are not universally believed to be equivalent. There are national guidelines that outline and prioritise the patient groups that require CMV negative blood components. Please consult your local hospital policy for further information or see the guidelines below. The cost of producing and manufacturing blood components is reviewed annually by the National Blood Authority (NBA) and published on their website The cost of providing

12 blood is shared by state, territory, and Commonwealth governments. In some states the budget for blood and blood products has been passed onto individual health services.

13 Section 3 of 12 Decision to Transfuse Although the decision to transfuse is not made by SAAS clinicians (excluding MedSTAR), it is still important to understand the decision processes. It is now recognised that transfusion should only be given when it is really necessary, due to its potential adverse effects. The focus of patient management has shifted from here is a blood component, when should it be used? to here is a patient, what is the best way to manage their condition, recognising that transfusion may be only one of the possible treatment options. The term for this approach is Patient Blood Management (PBM). There are three simple underlying principles in PBM. These are to: Optimise red cell mass Wherever possible, the patient s ability to produce their own blood cells should be optimised. This includes detection, investigation and management of anaemia, iron deficiency and other haematinic deficiencies. Minimise blood loss Limit or prevent blood loss wherever possible, including reducing iatrogenic blood loss. Optimise tolerance of anaemia

14 Includes supportive care such as oxygen therapy and fluid management and evidence based use of transfusion. If patient blood management strategies are used, and the patient s anaemia and blood loss is prevented or managed appropriately, the need to make a decision regarding transfusion may never arise. However, in certain clinical situations, blood transfusion may be necessary, though it will always come with associated risks to the patient. Each decision to transfuse needs to be based on a thorough assessment of the patient and their individual needs. Recommendation for transfusion should only be made where the benefits are expected to outweigh the risks. PBM Guidelines to help support decision-making processes and to assist with options for management of every patient s blood, there are PBM Guidelines covering six general patient groups. Clinicians who make decisions about the use of blood or blood products should be familiar with these guidelines and complete the associated elearning. Each of the PBM guidelines are available on the National Blood Authority website. Management of anaemia

15 Prevention and management of anaemia is one of the key components of patient blood management. Anaemia refers to a haemoglobin level below the reference range for gender, age and/or gestation, but is not a diagnosis in itself. In weighing up the risks and benefits of transfusion there are a range of clinical and laboratory factors to take into account. Coexisting conditions, ongoing blood loss, the risk to the patient of anaemia and the risk of transfusion must all be considered. Symptoms of anaemia Symptoms of anaemia may include chest pain, dyspnoea (particularly on exertion) and dizziness. However, these symptoms may not only be related to anaemia, other causes must also be considered. Volume of blood loss The rate and volume of the patient's actual or anticipated blood loss should be measured or estimated and used in the transfusion decision making process. Cause of bleeding Acute or chronic causes of bleeding, likelihood of ongoing bleeding and the potential for uncontrolled bleeding need to be assessed in the patient. Cause of anaemia

16 It is essential that the cause of anaemia is adequately investigated. It is particularly important to identify treatable causes, such as deficiency of iron or other haematinics, so that appropriate replacement therapy can be given and transfusion avoided. Treatment of the underlying cause also needs to be addressed concurrently. Cardiac dysfunction The possibility of cardiac disease or dysfunction needs to be considered. Red cell transfusion may be associated with either reduced mortality or increased risk of adverse events dependent upon the degree of anaemia and the nature of the cardiac condition. Atherosclerotic disease Critical arterial stenosis, such as acute coronary syndrome, may modify the threshold for the use of red cells. Bone marrow suppression Bone marrow suppression, as a result of disease or treatment, may affect the ability of the patient to replace lost red cells, and may also be the cause of the anaemia. Other relevant factors In any individual patient there may be other factors that influence the risk-benefit relationship and need to be taken into account in the decision to transfuse.

17 The guiding principle in the decision to transfuse is that blood components should only be given when the expected benefits are likely to outweigh the potential hazards. It should not be dictated by a haemoglobin concentration alone, but should be based upon a comprehensive assessment of the patient s clinical status. Hb concentration < 70 g/l Hb concentration g/l Hb concentration > 100 g/l Red cell transfusion may reduce mortality and is likely to be appropriate. However, transfusion may not be required in well-compensated patients where specific therapy is available to treat the cause of the anaemia, e.g. iron replacement. Transfusion of red cells is not generally associated with a reduction in mortality. The decision to transfuse should be based upon the need to relieve clinical signs and symptoms of anaemia and the patient's response to previous transfusions. Red cell transfusion is usually unnecessary and is often inappropriate as the risks outweigh the benefits. Risks vs benefit of transfusion Australia has one of the safest blood supplies in the world. However, like all medical procedures, transfusion is not risk free.

18 Human error risk Human error remains one of the biggest preventable risks for patients receiving a transfusion. When informing patients and prescribing transfusion it is important to understand potential risks and their frequency. It is important to remember that the greatest risk to the patient is that a mistake will be made somewhere in the transfusion chain that results in transfusion of the wrong blood to the patient. Transfusion reaction risk Many people believe the biggest risk associated with blood transfusion is contracting a disease such as HIV/AIDS. The more likely serious hazards include transfusion-associated circulatory overload (TACO), transfusion-related acute lung injury (TRALI), and haemolytic reactions due to blood group incompatibility. There is more on transfusion reactions in the transfusion reactions section. It is important to remember that the greatest risk to the patient is that a mistake will be made somewhere in the transfusion chain that results in transfusion of the wrong blood. Consent The patient should be involved in the decision to transfuse whenever possible. As part of this process the patient should be provided with: A clear explanation (using language the patient will understand) of the cause of their anaemia and reasons why transfusion is being considered. The nature of the proposed transfusion therapy and what is involved. The expected benefits as they apply to their particular case. The common and rare (but serious) risks. Any possible alternatives to transfusion (including the risk of doing nothing).

19 An opportunity to ask questions and clarify anything they do not understand. Health services providing transfusions must have a transfusion consent policy for adults and children. In SAAS, MedSTAR has a transfusion policy which includes how to acquire and document informed consent from patients, and processes for the appropriate decision and documentation for patients not able to consent due to emergency situations or when the patient is unconscious or anaesthetised. How much to administer Deciding how many units of red cells (or other blood component) a patient requires is as important as the decision to transfuse itself. Each individual unit of blood the patient receives carries an independent risk of adverse outcome. Red cells should be administered one unit at a time in non-urgent, non-bleeding settings. Don t give two when one will do. The dose of red cells prescribed should be sufficient to relieve signs and symptoms, and reduce the risk to the patient of anaemia, not to raise the haemoglobin to a certain level. In stable non-bleeding adults, a general rule is that one unit of red cells will increase the haemoglobin by approximately 10 g/l. However, this will depend on the pack volume (approximately 250 ml) and the patient's weight and hydration status. In paediatrics < 20 kg (excluding neonates) there is a specific formula for dose determined by age and weight. Transfusion volume (ml) = pt weight(kg) x (desired Hb patient s Hb) x transfusion factor (0.5)

20 Note: Based on a typical haematocrit for Australian red cell units, and assuming the estimated blood volume of the child is 70 ml/kg, a transfusion factor of 0.5 is suggested. Neonates, infants and small children are at risk of transfusion-associated circulatory overload. Blood components must be prescribed in ml rather than units. Duration of administration The rate of red cell transfusion will depend on the patient's blood volume, cardiac and haemodynamic status. If rapid transfusion is needed, blood can be given as rapidly as the patient's circulatory system will tolerate. In the non-urgent, non-bleeding setting, each unit is usually infused over 1 3 hours in adults, but always within 4 hours. A slower rate (maximum of 4 hours) should be considered for patients at risk of circulatory overload. The patient must be monitored and the clinician must be able to recognise and respond to possible adverse events. Typical duration times for other components In non-urgent, non-bleeding, stable patients, typical administration durations are: Platelets: minutes per unit. Fresh frozen plasma: 30 minutes per unit. Cryoprecipitate: min per adult dose (usually 8 10 units).

21 Documentation and communication The decision, along with reasons and supporting information, must be documented in the patient's medical record and should include: Indication for transfusion. Confirmation that informed consent has been obtained. Product type and quantity/volume. Any special requirements. The infusion duration and urgency. Premedication that may be required. Plan for post-transfusion assessment, including haemoglobin test.

22 Section 4 of 12 Preparing for the Transfusion In a healthcare facility, once the decision to transfuse has been made and all the appropriate consent and documentation has occurred, there must be laboratory testing to ensure the donor blood is compatible with the patient. These include: ABO and RhD blood grouping of the patient. An antibody screen of the patient's plasma to detect red cell antibodies. A compatibility test (crossmatch) between the donor blood and the patient if transfusion is required. In the majority of cases, these tests are straightforward, and typically will be completed in 30 to 60 minutes. Positive patient identification is mandatory prior to collecting a blood sample and labelling the specimen. The details on the request form must be correct and identical to those on the specimen.

23 It may be safe and appropriate to transport blood or other pathology specimens with a patient. The information on the specimen label and the laboratory request form should be checked with the clinician during handover, and confirmed against the patient being transported using standard active patient identification checks. Any specimen MUST be sealed in a zip lock bag and stored in the fleet where they will not be lost, overlooked or broken in the event of equipment or vehicle movements. Refer to the Transport of Pathology Specimens clinical practice procedure on the SAAS intranet for more details about transport of pathology specimens. Understanding ABO compatibility ABO incompatible transfusions can result in fatal haemolytic transfusion reactions. It is always the first preference that a patient received the same blood group as their own, but in certain situations, the blood group of the patient and the donated blood may be different, but still compatible (table below listed in order of preference for compatibility). Plasma compatibility is NOT the same as red cell ABO compatibility.

24 Rh group compatibility RhD negative red cells can usually be given to RhD positive recipients without any significant consequences. However, transfusion of RhD positive cells to an RhD negative recipient can result in formation of anti-d antibodies. In a female recipient this can have consequences for future pregnancies.

25 Section 5 of 12 Storage of Blood All blood products must be stored in a temperature controlled and monitored environment. Red cells must only be placed into a blood fridge that complies with Australian Standards. It must never be placed into a domestic fridge, vaccine fridge or medication fridge or any other fridge within the healthcare setting. Blood should only be removed from a blood fridge immediately before it is to be administered. Specific storage requirements R ED CEL L S PL AT EL ET S FRESH FROZAN PL ASMA (FFP) CRY OPR 2 to 6 C Outside this temperature can damage red cells. Warmth promotes bacterial growth.

26 R ED CEL L S PL AT EL ET S FRESH FROZAN PL ASMA (FFP) CRY OPR 20 to 24 C and must be continually agitated Cool temperatures (such as when refrigerated) can cause platelets to lose their function. The requirement for warm storage conditions makes platelets more susceptible to bacterial growth. R ED CEL L S PL AT EL ET S FRESH FROZAN PL ASMA (FFP) CRY OPR Frozen - 25 C for up to 12 months Takes 20 to 30 minutes to thaw. Once thawed stored at 2 to 6 C in a blood fridge for a limited time. Once thawed the activity of clotting factors reduces gradually over time.

27 R ED CEL L S PL AT EL ET S FRESH FROZAN PL ASMA (FFP) CRY OPR Frozen - 25 C for 12 months Takes 20 to 30 minutes to thaw. Once thawed stored at 20 to 24 C for a limited time. Once thawed the activity of clotting factors reduces steadily over time.

28 SAAS transport of blood products You may be asked to transport blood products with a patient. A validated transport container and packing procedure must be used different facilities have different methods. Ask staff during clinical handover if the blood products have been packed to ensure appropriate temperature control, however the pack IS NOT TO BE OPENED by SAAS paramedics/icps during transport. Any pack or container must be stored in the fleet where it will not be lost, overlooked or significantly agitated in the event of equipment or vehicle movements. If there are any concerns with the manner in which blood products are packaged, or the processes for safe transport, consult with the EOC Clinician who will liaise with a MedSTAR Nurse Retrieval Consultant. MedSTAR transport of blood products SAAS MedSTAR teams transport O negative blood for emergency transfusion.

29 The blood is transported inside an approved shipper and it is only opened by a MedSTAR Clinician once the decision has been made to transfuse. Unused red cells may be returned to a blood fridge or transfusion laboratory provided they have not been out of the blood fridge or temperature controlled transport package for > 30 minutes. All other blood that is not used must be returned to a transfusion laboratory for disposal. SAAS has an internal KPI to ensure less than 4% blood wastage as part of blood management and blood stewardship in SAAS MedSTAR.

30 Section 6 of 12 Administration of the Transfusion - PRIOR to SAAS Arrival SAAS clinicians (with the exception of MedSTAR) are not authorised to initiate the administration of any blood or blood products. However it is important to understand the rigorous processes and checks that occur prior to our involvement. Checks (patient prescription pack) A significant proportion of fatal transfusion events occur because of an identification error at the time of transfusion. To reduce these errors, there must be a check that takes place at the patient's side immediately prior to blood being transfused. This involves checking the three Ps, which are: Patient Prescription Pack

31 Although all the following steps are completed prior to SAAS commencing transport of a patient with a transfusion in progress, they are key parts of the information that should be included during clinical handover. Prior to collecting a red cell pack from a blood fridge or transfusion laboratory, the following is confirmed by the staff commencing the transfusion: The prescription is complete and informed consent is documented. The process of administration has been explained to the patient, including any possible reactions or symptoms they may experience. Intravenous access is inserted and patent. Baseline observations have been taken and recorded, and general patient status recorded, including pre-existing rashes. Circumstances/situation is appropriate to go ahead with transfusion, including staff availability. If prompt transport is required, only a Paramedic or ICP level crew can continue the transfusion during transport. If this crew level is not available, the transfusion will need to be completed prior to transfer or a transfusion qualified nurse escort provided. Any premedication prescribed for the patient has been administered in time to be effective. Resuscitation equipment is available and in working order (including oxygen and adrenaline). Final check

32 A final check at the patient s side, immediately prior to commencing the transfusion, is vital to ensure that the right patient receives the right blood. This check involves visual and verbal check of patient identification, the prescription details and the pack. If there are any discrepancies detected at any stage of the checking process, the transfusion should NOT PROCEED. Packs should be mixed by gentle inversion. Never shake a blood pack. Immediately after the preadministration checks at the patient s side, one of the staff involved in all the pre-administration checks can spike the blood pack. Red cells Red cells must be administered through an approved intravenous blood line incorporating a micron filter to remove clots and debris that form during collection and storage. The current SAAS administration set (giving set) is compatible for red cells. The administration set (giving set) may be primed with normal saline (0.9% sodium chloride) or the blood component. Blood components should not be infused with, or through, a line that has previously contained: Medications as they may interact with the anticoagulant, additive solutions or blood component. Dextrose containing solutions these may destroy red cells. Calcium containing solutions (eg Haemaccel, Hartmann's solution, lactated Ringer's solution and Gelafusal ) as these interfere with the citrate anticoagulant in the blood pack. Monitoring timeline As previously covered in the pre-administration checks, vital signs must be measured and recorded before the start of each pack. These are used as baseline measurements to assess the patient's clinical status, and they help determine whether any changes may be the result of a transfusion reaction.

33 First 15 minutes of transfusion Patients MUST be closely observed for the first 15 minutes after commencement of each pack. Vital signs must be measured and recorded at 15 minutes (or more frequently depending upon hospital policy) and compared with baseline observations. Signs of a transfusion reaction may include a rash, wheezing, increase in temperature of greater than 1 C above baseline, rigors, hypotension, hypertension, tachycardia, generalised oozing (due to disseminated intravascular coagulation (DIC) developing) and haemoglobinuria. Patients may also complain of chills, flank or IV site pain, itching or nausea. They may report feeling anxious, generally unwell or have a sense of impending doom. There is more on transfusion reactions later in the module.

34 Section 7 of 12 Continuing the Transfusion - SAAS A SAAS Paramedic or ICP can only accept handover of a patient for transport with the transfusion in progress AFTER: 1. The patient has been assessed by a Medical Practitioner or Registered Nurse at the 15 minute stage, AND; 2. Is found by the Medical Practitioner or Registered Nurse to have no signs of transfusion reaction. Refer to SAAS Clinical practice guidelines: For ICP's: CPG-119-ICP - Transfer of Patients with Blood of Blood Product in Progress For Paramedics: CPG-119-P - Transfer of Patients with Blood of Blood Product in Progress If requested to transport an unconscious or anaesthetised patient, any paediatric patient, or any other patient you are concerned about with blood or blood product transfusion in progress, consult to the EOC Clinician (who will liaise with a SAAS Medical Officer or MedSTAR Medical Retrieval Consultant).

35 Clinical handover A clinical handover using ISBAR must include all appropriate information, including: PAT IEN T PRESCRIPT ION PACK The principles of identifying the patient are always the same. Three patient identifiers must be used to ensure correct identification and matching of a patient to a procedure, the transport and the arranged destination. full name i.e. surname and given name(s) date of birth (DOB) patient address where applicable, note the medical record number (MRN). PAT IEN T PRESCRIPT ION PACK Check the blood product order and ask for a copy of all the documentation. Confirm the baseline observations and general patient status is recorded, including pre-existing rashes and all subsequent patient assessments. Ask for an estimated time of completion and confirm that this will be within 4 hours of the product removal from storage. 30-minute 4-hour rule Once a unit of blood is removed from the blood fridge, transfusion must: commence within 30 minutes

36 be completed within 4 hours If a unit of blood is collected from the laboratory or blood fridge and transfusion does not commence within 30 minutes, but is still required and will be completed within 4 hours from time of issue or removal from the blood fridge, it can proceed. If this time is greater than 4 hours, the prescribing Medical Practitioner should be contacted to consider whether a shorter transfusion time (based on the patient's haemodynamic and fluid status) would be appropriate. The Medical Practitioner may also choose to proceed at the originally prescribed rate, and at the 4 hour time point to discard any product not transfused. Ask if any other treatments are required or likely to be required during transport (e.g. pain relief). PAT IEN T PRESCRIPT ION PACK Confirm the current pack has been running for at least 15 minutes, the 15 minute patient checks have been completed and there are no signs of transfusion reaction. Ensure the start time of the transfusion is documented on a patient chart along with all patient observations. Obtain a hard copy of this information. Take any additional blood or blood products as required ask for them to be packed in an appropriate container to maintain temperature. Monitoring during transfer Monitor vital signs at the commencement of transfer, regularly during transfer (at least every 30 minutes) and at the completion of transfer. Observations must include temperature, pulse, respiration rate, oxygen saturations and blood pressure.

37 If a patient requires ongoing analgesia, this should be administered through a second IV line if at all possible. If the blood pack is completed during transport, the time of completion and volume infused must be recorded on the patient clinical record. A complete set of observations should also be taken at this time. No further blood products can be initiated by SAAS Paramedics or ICPs, even if it has been supplied by the sending facility and prescribed by the sending Medical Practitioner.

38 Section 8 of 12 Transfusion Reactions Every unit of blood has the potential to cause a transfusion reaction, however many transfusion reactions are preventable. The steps already outlined in this training package, that occur prior to commencement and during transfusion, aid in reducing the risk of a reaction. Transfusion reactions can occur at any time, however it is known that two-thirds of reactions occur within the first 30 minutes of a transfusion commencing. The rest occur after 30 minutes and sometimes after completion of the transfusion. The most common adverse events related to transfusion are mild febrile and allergic reactions. These are generally easily managed and unlikely to result in serious adverse outcomes. Significant acute reactions include: Severe febrile non-haemolytic transfusion reactions Cytokine accumulation during storage of cellular components (especially in platelet units) is thought to be the most common event leading to symptoms of FNHTRs. Cytokines are released by white cells and pre-storage leucodepletion has reduced this risk. FNHTR is also caused by the presence of recipient antibodies (raised as a result of previous transfusions or pregnancies) reacting to donor human leucocyte antigens (HLA) or other antigens. These antigens are present on donor lymphocytes, granulocytes, or platelets. This occurs in 0.1% to 1% of transfusions with leucocyte depleted products.

39 Severe allergic reactions (anaphylaxis) Usually begin within a few seconds or minutes after the start of the transfusion. The following mechanisms have been implicated in anaphylactic reactions: IgA-deficient patients who have anti-iga antibodies. Although IgA deficiency is not uncommon, fortunately most do not develop anti-iga antibodies. Patient antibodies to plasma proteins (such as IgG, albumin, haptoglobin, transferrin, C3, C4 or cytokines). Transfusing an allergen to a sensitised patient (for example, penicillin or nuts consumed by a donor). Rarely the transfusion of IgE antibodies (to drugs, food, etc.) from a donor to an allergen present in the recipient. This occurs in 1: to 1: of transfusions. Acute haemolytic transfusion reactions. Acute haemolytic transfusion reactions can be both immune mediated or nonimmune mediated. Immune mediated reactions are where the transfused red cells are destroyed, due to incompatibility of an antigen on transfused cells with an antibody in the patient s circulation. As little as 10 ml of incompatible blood can produce symptoms of an acute haemolytic reaction. Transfusion-associated circulatory overload (TACO)

40 TACO is cause by heart failure leading to pulmonary oedema as a result of rapid infusion or large volumes of blood products. Usually in patients with diminished cardiac reserve or chronic anaemia. Patients over 60 years of age, infants and severely anaemic patients are particularly susceptible. It is the 2nd leading cause of transfusion-related deaths reported to the FDA, accounting for 21% of all reported fatalities. It occurs in approximately 1% of older patients receiving transfusions. Transfusion-related acute lung injury (TRALI) The most widely held pathogenesis theory is that passive transfer of human leucocyte antigen (HLA) or human neutrophil antigen (HNA) antibodies found in the donor s plasma are directed against the recipient s leucocyte antigen. The antigen-antibody reaction activates neutrophils in the lung microcirculation, releasing oxidases and proteases that damage blood vessels and make them leak. Biological response modifiers, such as biologically active lipids can accumulate in some cellular components during storage and may also induce TRALI in susceptible patients. The true incidence is unknown but variably reported between 1:1200 to 1: transfusions with estimates around 1: most commonly reported. TRALI is thought to be the most common cause of transfusion-associated fatalities. Transfusion-transmitted infection (TTI) including sepsis from bacterial contamination of blood components. Bacterial infection is more common with platelets (as these are stored at room temperature), previously frozen components thawed by immersion in a water bath and red cell components stored for several weeks. Blood components may be contaminated by: Bacteria from the donor s skin during the collection procedure.

41 Unrecognised bacteraemia in the donor. Contamination from the environment. Contamination during the preparation of components. Contamination of ports during the thawing of frozen products in a water bath. Both gram-positive and gram-negative organisms have been implicated in transfusion transmitted bacterial infection with serious morbidity and mortality occurring most frequently with gram-negative bacteria. Organisms capable of multiplying at low temperatures and those using iron as a nutrient are most often associated with red cell contamination, especially Yersinia enterocolitica. For clinically apparent reactions, bacterial infections are reported to occur in at least 1: platelet transfusions and at least 1: red cell transfusions.

42 Section 9 of 12 Recognise Transfusion Reactions In the first instance, you may not be able to identify the type of transfusion reaction that is occurring that may take time but it is important to recognise that a reaction is occurring and take the appropriate action. Some transfusion reactions may become evident in the days after transfusion or in the longer term. These include delayed haemolytic transfusion reactions (DHTR), iron overload in chronically transfused patients and, very rarely, viral infection. The management of these reactions is not included in this course. Transfusion reactions generally present as clusters of symptoms and signs. Any significant alteration in the patient's vital signs, symptoms or condition (including pain along IV site, feeling generally unwell, or a sense of something not being right) could indicate a transfusion reaction. Click on the markers below to see possible reactions:

43

44 1. Central nervous system Anxiety, sense of unease or something going wrong, general feeling of being unwell

45 2. Skin Mild allergic Localised urticaria/rash, pruritis. Severe allergic Flushing, wheezing, hypotension, anaphylaxis, generalised urticarial rash

46 3. Cardiovascular Tachycardia, hypotension, hypertension

47 4. Temperature Temperature rise to > 38 C or > 1 C above baseline if baseline over 37 C which may be accompanied by chills and rigors

48 5. Respiratory Shortness of breath, wheeze, decreased O 2 saturation.

49 6. Gastrointestinal Nausea Vomiting

50 7. Pain Pain along IV site, chest/back pain Bleeding Uncontrolled bleeding or generalised oozing from IV sites or wounds

51 8. Urinary Haemoglobinuria Oliguria

52 Section 10 of 12 Respond to Transfusion Reactions If a transfusion reaction is suspected: IMMEDIATELY STOP THE TRANSFUSION ASSESS the patient MANAGE signs and symptoms as required STOP the transfusion DO NOT flush the giving set line. Close the blood administration giving set line. Disconnect from the IV bung. Retain the blood product pack and line in a zip lock bag (for further investigation). CHECK vital signs and continue to monitor. INITIATE any relevant SAAS clinical practice guideline (CPG) as needed. MAINTAIN IV access. RE-CHECK the three Ps the patient, prescription and pack details.

53 CONSIDER priority transfer, most appropriate destination and consult to the EOC Clinician, who will liaise with a SAAS Medical Officer or MedSTAR Medical Retrieval Consultant for advice. NOTIFY the receiving facility, and include details of reaction and actions in clinical handover. Assist with reporting to SA pathology at the receiving facility if required. DOCUMENT a detailed summary of events on the patient clinical record (PCR). REPORT the incident into the Safety Learning System (SLS). Click on each reactions below for more information: Severe febrile non-haemolytic transfusion reactions Signs & symptoms Unexpected temperature rise 38 o C. Increase 1ºC above baseline (if baseline 37ºC). Possibly fever, chills, rigors and headache (these also occur in other more serious reactions). What to do Stop the transfusion. Consider urgent transport and most appropriate destination it can be difficult to exclude more serious reactions. Mild allergy Signs & symptoms Localised urticaria/rash, pruritis What to do Stop the transfusion. Initiate Allergy CPG.

54 Severe allergy (anaphylaxis) Signs & symptoms Sudden onset of severe hypotension, cough, bronchospasm (respiratory distress and wheezing), laryngospasm, angioedema, urticaria, nausea, abdominal cramps, vomiting, diarrhoea, shock and/or loss of consciousness. What to do Stop the transfusion. Maintain open airway and intravenous line, support blood pressure. Initiate Anaphylaxis clinical practice guideline. Consider urgent transport and most appropriate destination. Acute haemolytic transfusion reactions Signs & symptoms Increase in temperature and pulse rate. Possibly chills, rigors, dyspnoea, chest and/or flank pain, discomfort at infusion site, sense of dread, abnormal bleeding and may progress rapidly to shock. What to do Stop the transfusion. Consider urgent transport and most appropriate destination. Maintain blood pressure and renal output. Transfusion-associated circulatory overload (TACO) Signs & symptoms Any of the 4 of the following within 6 hours of transfusion: Acute respiratory distress Tachycardia

55 Raised blood pressure Acute or worsening pulmonary oedema on CXR Evidence of positive fluid balance Can often be confused with TRALI. Hypertension is a constant feature in TACO whereas it is infrequent and transient in TRALI. What to do Stop the transfusion. Consider urgent transport and most appropriate destination. Position the patient upright and treat with oxygen and other cardiac failure therapy. Transfusion-related acute lung injury (TRALI) Signs & symptoms Dyspnoea, respiratory failure, non-cardiogenic pulmonary oedema, hypotension, chills, fever. Within 6 hours of transfusion: Acute onset of fever, chills, dyspnoea, tachypnoea, tachycardia, hypotension, hypoxaemia and noncardiogenic bilateral pulmonary oedema leading to respiratory failure. What to do Stop the transfusion. Consider urgent transport and most appropriate destination. Provide cardiovascular and airway support. Administer supplemental oxygen and employ ventilation as necessary. Diuretics are not beneficial. Transfusion-transmitted infection (TTI) including sepsis. Signs & symptoms Clinical features may include rigors, high fever, severe chills, hypotension, tachycardia, nausea and vomiting, dyspnoea, or circulatory collapse during or soon after transfusion. In severe cases, the patient may develop shock with accompanying renal failure and disseminated intravascular coagulation (DIC).

56 What to do Stop the transfusion. Consider urgent transport and most appropriate destination. Provide cardiorespiratory support. Keep the blood bag and giving set (sealed) for further investigation.

57 Section 11 of 12 Summative Assessment Details Successful completion of the online package will require at least 80% correct responses to the 15 MCQs. You are allowed three attempts for the quiz. Please speak to your team leader if you have used up all three attempts. Once you have passed the quiz, you can obtain your certificate of completion by returning to your portal. Go to quiz

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