Boot Camp Transfusion Reactions

Transcription

1 Boot Camp Transfusion Reactions Dr. Kristine Roland Regional Medical Lead for Transfusion Medicine, VCH

2 Objectives By the end of this session, you should be able to: Describe in common language the potential risks and adverse effects of transfusion of blood products. Recognize and respond appropriately to adverse transfusion events or transfusion reactions. Plan monitoring and follow up of transfusions to optimize patient safety.

3 Transfusion reactions Acute reactions (<24 h) Delayed reactions (>24 h) Febrile non-hemolytic Allergic minor, major Acute hemolytic TACO TRALI Bacterial sepsis Hypotensive Delayed hemolytic TA-GVHD TRIM PTP Viral and parasitic infections

4 Scenario 1 You are admitting a 69 y.o. woman with pneumonia. Upon review of her recent CBC, you note Hb 73 g/l. She c/o SOB. You decide to order a 1 unit RBC transfusion with the intended benefit of relieving her symptoms. She asks you what is the risk she could contract HIV?

5 Informed consent is required for all blood components and products: RBCs, plasma, platelets, cryoprecipitate Albumin, IVIG, factor concentrates, etc. There is no standardized script

6 Current rates of viral and parasitic infections in Canada Compare to: HIV HCV HBV HTLV Malaria WNV 1 in 8 million 1 in 2-6 million 1 in 150,000 to 1 in 1.7 million 1 in 4 million 1 in 4 million seasonal FNHTR 1 in 300 Mild allergic 1 in 300 TACO 1 in 700 DHTR 1 in 7000 TRALI 1 in 12,000 Anaphylaxis 1 in 40,000 vcjd? AHTR 1 in 40,000 Bacterial sepsis 1 in 50,000 Vox Sanguinis (2012) 103, 83 86

7 Scenario cont d You have ordered the single-unit transfusion and then you get called down to the ED to see another patient. What are some procedures performed by the nurse at the bedside to ensure a safe transfusion?

8 Blood administration Patient ID check Labels on blood bag and transfusion record must match with patient ID Sometimes two nurses are required to confirm ID Confirm blood group is compatible Check vital signs at start Transfuse slowly for first 15 min Monitor patient for first 15 min and re-check vitals Check vitals hourly until end Transfusion must be complete within 4 hours

9 Scenario cont d You are paged while in the ED: your patient has spiked a fever 30 minutes into the transfusion. What do you do now?

10 Transfusion and FEVER

11 Fever Most common Febrile non-hemolytic Acute hemolytic reaction Bacterial contamination Fever often dominant symptom Rare but can be deadly Others: TRALI, delayed hemolytic reaction fever due to underlying condition is very common!

12 Febrile non-hemolytic reaction Very common (incidence > 1:300 transfusions) Mediated by cytokines in stored product or recipient ab to white cells in donor blood Presentation: Fever, chills, rigors Headache, N&V, mild in BP Fever does NOT have to be present Not associated with harm to patient but can be very distressing

13 Management STOP transfusion and assess patient carefully! Check patient ID and send post-transfusion samples to lab Monitor vitals closely B.C. recommendation: do not restart; order a new unit if required If physician chooses to order a restart, they should attend at the bedside Treat FNHTR with acetaminophen Premedication hasn t been shown to prevent FNHTR but may be worth trying

14 Scenario cont d What can I do to reassure myself this is a FNHTR and not a more severe reaction?

15 Management cont d Patient usually starts to feel better quickly after transfusion stopped. Watch for warning signs! fever 39 C or 38 C plus 1 C from baseline drop systolic BP 30 mmhg dark urine (hemoglobinuria from intravascular hemolysis)

16 Follow up with blood bank investigations: Patient ID check within lab Post-reaction blood specimen: Visual check for free hemoglobin DAT Repeat ABO type Repeat Antibody screen normal hemolyzed

17 Further investigations If bacterial contamination is a consideration: Draw patient blood cultures Seal the product bag and return to blood bank for culture Consider broad-spectrum antibiotics (both Gm + and Gmbacteria can be implicated) Order the blood components with respect to frequency of bacterial contamination: RBCs Plasma Platelets Albumin

18 Further investigations If acute hemolytic reaction is a consideration, order hemolytic workup CBC, indirect bili, haptoglobin, LDH, (DAT) Send first voided urine to check for hemoglobinuria Alert blood bank immediately; a second patient may be at risk!

19 Scenario cont d You give the patient some Tylenol and order a new RBC unit for transfusion. It proceeds uneventfully, however 10 minutes after the transfusion you are paged again because the patient has worsened SOB.

20 Transfusion and SOB

21 Shortness of breath TACO TRALI SOB is a dominant symptom Others: TAD, anaphylaxis, bacterial sepsis, acute hemolysis

22 Canadian Hemovigilance Data: Rates of adverse reactions from 2006 to 2012 TRALI is the leading cause of death due to transfusion. TACO is a close second.

23 Transfusion associated circulatory overload Acute pulmonary edema secondary to CHF precipitated by transfusion Can occur after 1 unit! At risk: Very young, very old Diminished cardiac reserve Significant chronic anemia Most patients have: Respiratory distress Some patients have: Hypertension, tachycardia, cyanosis, dry cough, headache, chest tightness

24 Scenario So what do I do now?

25 Scenario cont d Initial Management: Stop transfusion and monitor vital signs Position patient in upright position; Supplementary oxygen Order a CXR Diuresis as appropriate

26 TRALI Acute onset lung injury Occurs within 6 hours of transfusion Bilateral CXR infiltrates No evidence of circulatory overload No other cause of lung injury Caused by donor antibodies that trigger lung injury in a susceptible patient No specific treatment; patients often require intubation but recover within 96 hours Can be fatal

27 TRALI cont d The reaction was probably volume overload but could it have been TRALI? Just report the signs and symptoms to the blood bank We will investigate further and report to CBS if required If possible TRALI then CBS will test for antibodies and recall companion products Confirmed TRALI: donor will be deferred

28 Allergic reactions Mild Incidence > 1:300 Hives, redness, pruritus, flushing Stop transfusion; assess; treat with Benadryl Can re-start Major (anaphylaxis) Cause often unclear Recipient allergy to donor allergen; severe IgA-deficiency with anti-iga antibodies Stop transfusion, treat with Epi/steroids/Benadryl Usually an isolated event and patient will not react to future transfusions We often suggest testing for IgA levels

29 Classifying a TR is not always easy Many symptoms are non-specific Dyspnea, fever, pain, etc Symptoms related to underlying disease Atypical presentations You don t necessarily need to classify the reaction at the bedside key recommendation: initial treatment of acute transfusion reaction is directed by symptoms and signs. Tinegate H, et al 2012

30 Example of Transfusion Reaction Form

31 Summary Management of acute transfusion reactions are guided by signs and symptoms Be able to generate a differential diagnosis and recognize the danger signs Report all reactions to the blood bank earlier rather than later Lab will do further workup and report to CBS as necessary To promote patient safety you should: Only transfuse when necessary, including single unit transfusions Avoid non-urgent transfusions overnight

32 You have help There is a lab pathologist on-call 24/7 for consultation! Questions?