Haemovigilance: Acute transfusion reactions. Paula Bolton-Maggs Medical Director Serious Hazards of Transfusion

Transcription

1 Haemovigilance: Acute transfusion reactions Paula Bolton-Maggs Medical Director Serious Hazards of Transfusion

2 SHOT Cumulative data: 18 years n=14822

3 Deaths related to transfusion reported in 2015 Total n=26 TANEC=transfusion-associated necrotising enterocolitis ABOi=ABO-incompatible transfusion

4 Adverse reactions associated Infection very rare with plasma Transfusion-associated circulatory overload one to watch for Transfusion-related acute lung injury - rare Allergic/febrile the most common Haemolysis

5 Transfusion-transmitted infections in UK (SHOT) Only 6 infection transmissions from FFP HIV in 1996 HBV in 2011 HEV 4 cases One HEV transmission from cryoprecipitate No bacterial transmissions Total infection transmissions 87 from 76 incidents to 2016

6 Bacterial transmissions reported to SHOT red cells platelets 5 Diversion pouch Bacterial screening 2010 Number of reports / / / / / /02* Changes to arm cleansing Year of report

7 Changing pattern of pulmonary complications

8 Transfusion-related deaths 2010 to 2015 n=93

9 Errors now account for the majority of reports

10 Critical points in the transfusion process Critical points: Positive patient identification essential

11 Wrong transfusions 2014 and 2015 Near miss 1466 detected Clinical errors Laboratory errors

12 Multiple errors are common incorrect blood components transfused

13 Serious Adverse Reactions WHEN? Immediate and life-threatening : ABO-incompatibility; anaphylaxis Hours: pulmonary complications, bacterial infections, transfusion reactions Days: haemolytic reactions Late (months or years): viral infections; iron overload

14 Acute transfusion reactions Allergic or anaphylactic reactions are unpredictable and usually occur early This is why all patients having blood products must be monitored Adrenaline (IM) is the treatment of choice and should be available in all areas where transfusions take place

15 Pathogen-inactivated FFP Recommended for those born after 1 January 1996 (BSE no longer in food chain) Methylene blue-treated single units Solvent detergent-treated pooled (recommended for plasma exchange in thrombotic thrombocytopenic purpura)

16 What about MB-FFP? Withdrawn in France (2012) because of concern about ATR For UK, updated statistical analysis for data no difference between MB-FFP and other components

17 ATR Platelets allergic type Reduction in reactions with platelets suspended in PAS

18 ATR Platelets - febrile

19 SD FFP is associated with fewer allergic reactions Incidence per 100,000 units issued Allergic reactions Febrile reactions Other reactions Standard FFP SDFFP 2010 to 2012: 863,847 units of standard FFP, and 198,370 units of SD FFP were issued by UK Blood Services. 132 acute reactions associated with transfusion of standard FFP and 5 with SD FFP

20 Allergic reaction to FFP Transfusion reaction during plasma exchange with 7 units of FFP with pyrexia, hypotension, chest pain and rash on the arms, trunk and neck with mild swelling around the lips and eyes. Reaction and rash resolved following administration of hydrocortisone and piriton. No harm caused. Chronic inflammatory polyneuropathy decided to use albumin in future

21 Immediate management Recognise patient experiencing adverse reaction Stop transfusion, keep line open, retain component Airway, Breathing, Circulation and Bag, Band, Blood How severe is this reaction? Minor- e.g. itch. Should you restart the transfusion? More serious. Do not restart the transfusion. Establish most likely cause Monitor urine output and observe for haemoglobinuria

22 How common are ATRs in the UK? A. 1 in 30 units? B. 1 in 100? C. 1 in 1000? D. 1 in 10,000? SHOT collects reports on moderate and severe ATRs Incidence varies according to component type Are all cases reported?

23 SHOT ATR reports, 2013

24 Fever

25 Fever, chills and rigors during or soon after transfusion: possible causes Febrile non-haemolytic transfusion reaction Acute haemolytic reaction Bacterial contamination Underlying condition

26 Case History A patient with myelodysplasia has a 2 unit red cell transfusion as a day case History of complex red cell antibodies With the second unit, she complains of feeling unwell, with mild nausea and chills Her temperature rises from 37.8 to 39 o C, BP and pulse both increase The transfusion is stopped and symptoms and signs improve within 30 minutes

27 What is this most likely to be? A. A haemolytic transfusion reaction due to complex red cell antibodies B. A haemolytic reaction due to incorrect component transfused C. A febrile transfusion reaction D. Bacterial contamination of the unit

28 This is most likely to be a non-haemolytic febrile reaction BUT Consider other causes

29 Case history Patient with haematuria being transfused with platelets 20 minutes into transfusion: 2.2 o C rise in temperature, vomiting, tachycardia, chest pain Hypoxia Rigors prevented BP measurement Urine positive for haemoglobin but patient has haematuria

30 Which investigations would you do? A. Blood cultures of the patient, send the platelet unit for culture B. Repeat group and antibody screen the patient C. All the above D. None of the above

31 Culturing the platelet unit: A. Perform culture in hospital lab, refer to blood service if positive result B. Contact nearest blood service to discuss next steps C. Perform culture locally but at the same time inform blood service

32 Learning point With a severe febrile reaction such as this, the most important step is to contact the blood service Any associated components can be withdrawn from issue Unit sampling and culture requires expertise

33 Learning points Febrile reactions are more commonly seen with red cell transfusions

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35 Learning points Febrile reactions are more commonly seen with red cell transfusions The incidence has been reduced since universal leucodepletion Less severe reactions can be treated with paracetamol or anti-inflammatory medication In severe reactions the most important differential diagnosis is transfusion-transmitted infection although very uncommon

36 Respiratory symptoms

37 TACO in relation to PEX 16 year old child with atypical HUS having plasma exchange with SD FFP developed acute hypoxia, rigors, chest crackles, fluid in the lungs following treatment Occurred on 3 separate days requiring CPAP 2500mL positive fluid balance Background of acute lymphoblastic leukaemia No more exchange

38 Case history 67 year old female with myelodysplasia Transfused 3 units of red cells as a day case Felt ill on her journey home and returned immediately to A and E Had respiratory arrest

39 Most likely cause? A. Transfusion Related Acute Lung Injury (TRALI) B. Allergic reaction C. Transfusion Associated Circulatory Overload (TACO) D. Unrelated to transfusion

40 Outcome Chest X ray appearances consistent with left ventricular failure Probable TACO Patient made a full recovery with treatment

41 TACO Acute respiratory distress, tachycardia, hypertension, acute or worsening pulmonary oedema, evidence of positive fluid balance At least 4 of the above features Occurring within 6 hours of transfusion Tends to be seen in over 70s Almost certainly under-reported Recent series of 8/247 transfusions in this age group (3%) Bartholomew and Watson, 2014

42 Learning points TACO is much more common than TRALI and it can be difficult to confirm the cause of acute respiratory symptoms Elderly patients are particularly at risk of TACO Even small transfusions may be enough All patients need careful monitoring and appropriate investigation

43 Reduction in TRALI with move away from female donors for FFP 139 cases 29 deaths No cases from FFP since case in 2014 associated with transfusion of cryo: 3 female donors

44 Respiratory symptoms 2

45 Case history Patient with PPH received a unit of FFP Previously, 3 units red cells and 1 FFP transfused without problems 8 minutes into transfusion, she began to cough and had swollen eyes, lips and throat Bronchospasm Oxygen saturation dropped Blood pressure unrecordable and briefly lost consciousness Responded well to treatment

46 What was the reaction likely to be? A. TRALI B. TACO C. Moderate allergic reaction D. Anaphylaxis

47 What was the reaction likely to be? A. TRALI B. TACO C. Moderate allergic reaction D. Anaphylaxis

48 What is the immediate management? A. Call the haematologist B. Hydrocortisone and antihistamine C. Dopamine D. Adrenaline

49 What is the immediate management? A. Call the haematologist B. Hydrocortisone and antihistamine C. Dopamine D. Adrenaline

50 Learning point Anaphylaxis is characterised by rash and/or mucous membrane involvement followed rapidly by respiratory and/or circulatory distress A medical emergency Treatment is adrenaline: IM unless you are an anaesthetist or intensivist

51 Acute transfusion reactions and anaphylaxis in relation to total SHOT reports Although anaphylaxis is rare, patients should only be transfused when and where there is the ability to recognise and manage a reaction Minor reactions excluded

52 Management of patients who have reacted before A female patient with bone marrow failure and epistaxis has regular (appropriate) platelet transfusions With last two transfusions, she complained of itch Now has urticaria

53 How can you avoid future reactions? A. Give HLA-matched platelets B. Give hydrocortisone premed C. Give washed platelets D. Give antihistamine premed

54 How can you avoid future reactions? A. Give HLA-matched platelets B. Give hydrocortisone premed C. Give washed platelets D. Give antihistamine premed And ensure appropriate transfusion

55 Learning points 25% of women, and at least 10% of multitransfused male patients have HLA antibodies No evidence that reactions are reduced with HLA-matched platelets Washed platelets do reduce reactions IV hydrocortisone takes 8 hours to act Little evidence for antihistamine but if washed platelets do not work, worth trying Appropriate use underpins everything we do

56 What have we learnt from review of ATRs? Adrenaline is the treatment of anaphylaxis and should be available wherever transfusions are given Widespread use of steroids and antihistamines without literature evidence of benefit Febrile reactions are uncommon with FFP Severe allergic or anaphylactic reactions more likely with FFP than other components

57 Haemolysis Group AB FFP has no ABO antibodies Group O FFP is only suitable for Group O patients

58 FFP use and abuse Plasma exchange in TTP is lifesaving Widely used with little evidence Systematic reviews* show no benefit either for prophylaxis or treatment of bleeding FFP transfusion practice is habitual, often rooted in tradition and associated with strong beliefs (Shih and Arnold, 2015) *Stanworth et al. 2006; Yang et al. 2012

59 Acknowledgements Hazel Tinegate, Helen New, Janet Birchall The SHOT team The vigilant reporters and hospital staff who share their incidents with us FOLLOW US ON #SHOTHV

60 SHOT Symposium 2017 Rothamsted Centre for Research & Enterprise, Harpenden, Hertfordshire, AL5 2JQ Wednesday 12 th July 2017 Keynote speaker: Dr Phil Hammond

61 Additional Information Following documents available on website Teaching slide set SHOT cases SHOT reporting definitions Clinical lessons Laboratory lessons SHOT Bites Also available: Previous SHOT reports SHOT summaries