Transfusion Reactions

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1 Transfusion Reactions From A to T Provincial Blood Coordinating Program Daphne Osborne MN PANC (C) RN

2 We want you to know Definition Appropriate actions Classification Complete case studies

3 Transfusion Reactions Diverse group of adverse physiological reactions to the transfusion of blood component or product. Usually present during or shortly after transfusion. Acute: Within 24 hours. Delayed: Greater than 24 hours before symptoms appear.

4 Response Stop the transfusion Infuse 0.9% sodium chloride Assess vital signs Perform clerical check Confirm the recipient s identity and blood component or plasma product.

5 Response Physician assessment implement Rx if required. Notify Transfusion Medicine Laboratory (Blood Bank) May request return of un-transfused component or product. Serological testing may be ordered. Documentation Issue/transfusion card Facility Transfusion Reaction report form

6 Classification To differentiate, useful to use a classification system Presenting signs/symptoms Clusters (cutaneous, respiratory, GI, CVS, inflammatory, pain) Immune/non-immune Febrile/non-febrile

7 Febrile Reactions Temperature increase GREATER than 1 C above baseline and GREATER than 38 C. Febrile non-hemolytic Bacterial contamination Acute hemolytic reaction

8 Febrile Non-Hemolytic Most common reaction in NL recipients; 78 of 118 reactions in May also have chills/rigors N,V, H/A

9 Febrile Non-Hemolytic Non-life threatening prompt assessment required to r/o other causes of fever. Could be AHR, bacterial contamination, or TRALI. Fever should be investigated; may Rx with antipyretics. Transfusion may be restarted.

10 Fever and/or Chills/Rigors

11 Febrile Non-Hemolytic

12 Bacterial Contamination

13 Acute Hemolytic

14 Cutaneous Reactions

15 Minor Allergic

16 Severe Allergic

17 Anaphylactic Shock

18 Dyspnea/Hypoxic Reactions

19 TACO

20 AHR, Bacterial Contamination

21 TRALI

22 Adverse Transfusion Reaction SIGNS AND SYMPTOMS For all signs and symptoms: STOP TRANSFUSION IMMEDIATELY! Maintain IV access with 0.9% sodium chloride. Type of Reaction ACUTE ( < 24 hours) Minor Allergic Reaction Suspected Transfusion Reaction Signs & Symptoms Intensely pruritic localized/or widespread urticaria less than 2/3 of the body; generalized erythema or flushing Timing of Symptoms Actions & Suggested Treatment / Investigations During transfusion up to 2-3 hours from start Consult with Physician diphenhydramine hydrochloride mg PO/IM or IV; proceed with CAUTION Anaphylactic Hypotension Febrile Non-Hemolytic Acute Hemolytic (AHTR) Circulatory Overload Transfusion Related Acute Lung Injury (TRALI) Bacterial Contamination DELAYED (>24 hours) Delayed Hemolytic Transfusion Associated Graft Versus Host Disease Post Transfusion Purpura Angioedema localized non-pitting deep edema; upper airway obstruction laryngeal edema, hoarseness, stridor, lump in the throat; lower airway obstruction bronchospasm, wheeze, chest tightness, dyspnea, cyanosis; profound hypotension Abrupt onset of clinically significant hypotension facial flushing with or without mild respiratory symptoms Cold sensation, rigors, nausea, vomiting with/without temperature greater than 1 C above baseline. Temperature 39 C, hypotension, tachycardia, rigors/chills, anxiety, dyspnea, anemia, hyperbilirubinemia, hemoglobinuria/oliguria, bleeding at IV site, nausea/vomiting, DIC, pain back/chest/head/flank/abdomen/groin/iv site Dyspnea, orthopnea, cyanosis, hypoxemia, tachycardia, hypertension, pulmonary/pedal edema, elevated JVP Acute respiratory distress, dyspnea, cyanosis, severe hypoxemia, severe bilateral pulmonary edema, bilateral infiltrates on x-ray, hypotension unresponsive to fluid bolus Fever, chills, hypotension, shock, nausea/vomiting, tachycardia, hypotension 1-45 minutes after start of infusion; majority within 5 minutes Within 5 minutes after start of infusion Usually within 30 minutes after start of infusion; up to one (1) hour after completed Usually within first 15 minutes; up to 24 hours following transfusion. Within 1-2, up to 6 hours following start of transfusion Within 1-2 hours during transfusion or within 6 hours posttransfusion During or within 4 hours of transfusion Epinephrine mg S/C or IV (up to 3 doses); fluid bolus; vasopressors if intractable hypotension; DO NOT RESTART TRANSFUSION Supportive therapy; DO NOT RESTART TRANSFUSION Consult with Physician Acetaminophen mg PO; proceed with CAUTION Serologic testing: group and screen, cross-match, DAT, LDH, BUN, creatinine, TB; IV Fluids DO NOT RESTART TRANSFUSION Oxygen, diuretics; elevate head of bed. DO NOT RESTART TRANSFUSION Oxygen, intubation and ventilation, vasopressors DO NOT RESTART TRANSFUSION Treatment of shock, DIC, renal failure, product and recipient cultures, antibiotics broad spectrum initially; anti-pseudomonas if red cells implicated Weakness, unexplained fall in post-transfusion hemoglobin, elevated serum bilirubin Within 3-7 days post-transfusion and up to 21 days post-transfusion Provide antigen negative blood products for subsequent transfusions Fever, erythematous cutaneous pruritic rash which progresses to Within 2-50 days of transfusion Largely ineffective Immunosuppressive therapy, generalized erythroderma, watery/bloody diarrhea, pancytopenia, (usually 1-2 weeks) cyclosporine/okt3, cyclophosphamide/antithymocyte, liver dysfunction, anorexia, nausea/vomiting T cell monoclonal antibodies, HPC transplants, irradiated components. Mortality is greater than 90% Purpura, bleeding, platelet count less than 10x 10 9 /L 1-24 days post transfusion IVIG NL TMP Version 2.0 Effective Date:

23

24 Case Studies 81 year old male admitted to ER, diagnosed with renal failure and hematuria. Hgb 77: Transfusion 3 units of red blood cells ordered. During 3 rd unit, the patient experienced shortness of breath. Transfusion was stopped; the physician notified.

25 Case 1 Physician ordered to discontinue the transfusion. Direct anti-globulin test (DAT) performed. Unit and tubing checked for visible hemolysis; Clerical checks of the patient s specimen and the product completed.

26 Case 1 No visible hemolysis and the DAT was negative. Technologist noted the product and administration set with the fluids that were hanging; 5 % dextrose and 0.45% saline! The technologist noted visible hemolysis of the red blood cell product in the lines and filter. So what do you think was the adverse event was on this patient?

27 Review Elderly patient with reduced kidney function. Transfused 3 units of red blood cells in a little over 5 hours - no diuretics being given before or during the transfusion. Diuretics were immediately given to the patient after the transfusion was discontinued - the patient s breathing improved.

28 Review Blood components should not be infused with anything other than 0.9% saline. Therefore this complicated case was concluded as a Transfusion Associated Circulatory Overload and transfusion error.

29 Case 2 Seven (7) year old hematology/oncology patient Received one dose of platelets Urticaria, hives following infusion. V/S stable What is happening here?

30 Interpretation Minor allergic (transfusion) reaction. Rx with hydrocortisone and benadryl.

31 Case 3 50 year old oncology patient; Hgb 78 One unit RBC transfused. Approximately ¾ of unit transfused, c/o chills, rigors. VS pre: Temp 37.9, B/P 155/7, RR 22. VS post: T- 39.3, B/P 155/73, RR 38 DAT negative

32 Interpretation Febrile Non-Hemolytic

33

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