In The Name Of GOD The 7 th international and 12 th national congress on quality improvement in clinical laboratories ADVERSE REACTIONS OF TRANSFUSION By Mehdi Allahbakhshian, PhD, Hematology and Blood Banking Apr 18, 2014
the risks and complications of a blood transfusion Most blood transfusions go very smoothly. However, mild problems and, very rarely, serious problems can occur.
James Blundell, in the 1600's, they tried transfusions of animal blood into humans. World War II Russian syringe Modern transfusion
When a Reaction is Suspected
Signs & Symptoms GENERAL Nervous System Fever Chills Muscle ache,pain Back pain Chest pain Headache Heat at the site of infusion or along vein Apprehension, impending sense of doom Tingling, numbness Respiratory Tachypnea Apnea Dyspnea Cough wheezing
Signs & Symptoms Gastrointestinal Nausea Vomiting Pain, abdominal cramping Diarrhea (may be bloody) Renal Changes in urine volume Changes in urine color Cardiovascular Heart rate Blood Pressure Circulatory Bleeding Cutaneous Rashes, Hives(urticaria) Itching
Signs in an Unconscious Patient Weak Pulse Fever Hypotension Visible hemoglobinuria Increased operative bleeding Vasomotor instability Tachycardia, brachycardia, hypotension Oliguria/anuria
STEPS TO TAKE WHEN TRANSFUSION REACTION SUSPECTED Tranfusionist Functions (Patient related ) Stop Transfusion. Keep intravenous (IV) line open with saline. Contact treating physician for directions. Notify the transfusion service. Rule out clerical error by RECHECK of Unit, transfusion tag and patient identification. Order a transfusion reaction workup, collect transfusion reaction specimen. Complete Transfusion Reaction Report Form and send to laboratory. Send actual unit to laboratory only when directed to do so. Defer future transfusions until workup complete.
Transfusion Reaction Report Form
STEPS TO TAKE WHEN TRANSFUSION REACTION SUSPECTED Laboratory Functions Clerical lcheck: Bag, lbl label, paperwork, sample. Visual check of pre and post transfusion plasma (Reliable only when >50 mg/dl hemoglobin present). Perform direct antiglobulin test (DAT) on posttransfusion sample. Report findings to transfusion service manager and staff pathologist. Additional studies at direction of transfusion services physician.
RECOGNITION, MANAGEMENT, AND PREVENTION OF SPECIFIC TRANSFUSION REACTIONS Reactions by Type: Acute Transfusion Reaction: Reactions occurring at any time up to 24 hours following a transfusion of blood or components. Delayed Transfusion Reaction: Reactions occurring at any time after 24 hours following a transfusion of blood or components
Types of Transfusion Reactions Acute Delayed Hemolytic Allergic Anaphylactic Sepsis Transfusion Related Acute Lung Injury (TRALI) FNHTR Hemolytic Graft vs Host Disease Iron Overload Post Transfusion Purpura Transmissible Diseases
ACUTE IMMUNE INTRAVASCULAR HEMOLYTIC REACTION (AHTR) Detection Usually caused by ABOincompatible RBCs. Fever, chills, hypotension, pain along IV line, back or chest, hemoglobinuria or oliguria, and bleeding or oozing are signs and 1 in every 31000 and death occurs in approximately 1 of 30.
AHTR(INTRAVASCULAR ) The Most Common Causes? Failure to identify the patient with the donor unit at the time of administration Collecting pre transfusion specimen from the wrong patient
AHTR(INTRAVASCULAR ) Management Administration of Low dose dopamine. a diuretic (e.g., mannitol). If DIC develops, platelets, fresh frozen plasma, and cryoprecipitate may be required. Prevention Proper identification of the patient, from sample collection through blood administration, and assurance of proper labeling of samples and components.
Detection local or generalized symptoms, usually urticaria (hives) with or withoutitching itching or localized edema. Management Transfusion should be interrupted until symptomatic relief is achieved following antihistamine administration. Transfusion may be safely restarted in patients with hives alone who respond to antihistamine therapy. Prevention few patients with previous history of transfusion related urticaria, receive pre transfusion prophylaxis p antihistamines( but it is not Routine for all). Steroids can also be helpful in selected situations. Reducing the plasma content of cellular components (washing) and avoidance of plasma administration. Allergic reaction
ANAPHYLACTIC Detection Acute respiratory distress due to laryngeal edema and bronchospasm. Management & Prevention The patient should receive appropriate airway management. Epinephrine i may be indicated. d For IgA deficient recipients with anti IgA, transfusions should be with IgA deficient components, if possible. Washed cellular products. Premedication with antihistamines and steroids.
SEPTIC Detection Caused by bacteria introduced into the blood bag which multiply and may elaborate toxins. Most commonly associated with platelet transfusion; occasionally red cell transfusions; rare with frozen plasma and cryoprecipitate. p y p p Very high fever, rigors, profound hypotension, often complaints of nausea with or without diarrhea are key signs and symptoms; death.
SEPTIC Management immediate investigation to include a Gram stain and culture of remaining component in the bag (and occasionally of the intravenous fluid). If the patient is receiving antibiotics at the time of transfusion, blood cultures from the patient may be negative for the organism in question. Because of the high likelihood of fatality, broad spectrum antibiotics should be administered Supportive care for other symptoms associated with sepsis should also be undertaken immediately. Prevention Pre transfusion culture of all platelet units. Inspection for abnormal color, clots.
FEBRILE, NON HEMOLYTIC TRANSFUSION REACTION Detection characterized by fever (greater than one degree centigrade), Occurs during or within one to two hours after transfusion, especially following transfusions with platelets and granulocytes. Management Rule out acute hemolysis in RBC transfusions or of bacterial contamination of a component, transfusion must be suspended pending further evaluation. Prevention Use leukodepleted blood products.
TRANSFUSION RELATED ACUTE LUNG Detection acute respiratory distress fever. INJURY (TRALI) Symptoms often develop during transfusion and always within 6 hours of transfusion.. bilateral infiltrates. Resolution usually within no more than 2 3 days. Management oxygen administration and may require intubation and mechanical ventilation. Prevention Most cases of TRALI occur with blood from Multiparous donors. Plasma for infusion i is no longer collected from such donors.
TRALI Before Transfusion After Transfusion
DELAYED & LONG TERM EFFECTS (beyond the first 24 hours after transfusion) Delayed Hemolytic Graft vs HostDisease Iron Overload Post ttransfusion Purpura Transmissible Diseases
DELAYED & LONG TERM EFFECTS (beyond the first 24 hours after transfusion) RED CELLS ALLOIMMUNIZATION Detection positive antibody screen Positive DAT. patients experience an unexplained lack of therapeutic benefit. Management/Prevention Delayed Hemolysis: The only therapy required is to alleviate symptoms, including possible additional transfusions of antigen negative blood for persistent anemia. Prevention is not possible using current methods.
POSTTRANSFUSION PURPURA Detection purpuric rash, bruising, or bleeding It occurs 5 to 10 days after transfusion. Patients have developed an anti platelet antibody (usually against a platelet antigen called Pl A1). platelet levels often drop to <10,000/µl. Occurs particularly in parous women or in previously transfused recipients who lack the most common platelet antigen, HPA1a (formerly PL A1). Management Spontaneous platelet recovery occurs within two weeks. treatment with corticosteroids, plasma exchange, high dose IV immunoglobulin. donors of these patients are negative for the appropriate antigen.
TRANSFUSION ASSOCIATED GRAFT VERSUS HOST DISEASE (TA GVHD) Detection Rash, fever, or gastrointestinal symptoms and unexplained cytopenias between 4 and 10 days after. TAGVHD is likely when the donor is HLA homozygous haplotypeidentical with the patient or was a biologic family member, or the recipient's immune system was significantly compromised. Management the disease is virtually always fatal due to the profound bone marrow aplasiaand and management is not well defined and is rarely successful. The disease does not respond to treatment regimens used for ordinary GVHD in the transplant setting. Prevention ; gamma irradiation of cellular (and some advocate all) blood components to at least 25 Gy in the center of the bag will inhibit lymphocyte mitosis without affecting other cellular functions. Leukoreduction does not eliminate TA GVHD.
INFECTIOUS DISEASES HEPATITIS Hepatitis B and C are the most frequently implicated agents. Hepatitis A is rarely seen. HIV, TYPES 1 & 2 HTLVI/II CMV Detection Clinical examination serologic and nucleic acid tests. Prevention, checking to ensure donor suitability serologic and nucleic acid screening. proper donor testing using the most current version of an FDA approved screening test leukoreduced for CMV. Transmission of hepatitis B and C viruses by blood cannot be completely prevented using available methods
References 1. Hendrickson JE & Hillyer CD. Noninfectious serious hazards of transfusion. Anesth Analg 2009; 108:759 769. 2. Alter HJ & Klein HG. The hazards of blood transfusion inhistorical perspective. Blood 2008; 112:2617 2623. 3. Triulzi D. Transfusion Related Acute Lung Injury: Current Concepts for the Clinician. Anesth Analg 2009; 108:770 776 4. Bux J. Transfusion related acute lung injury (TRALI): a serious adverse g j y( ) event of blood transfusion. Vox Sanguinis 2005; 89:1 10
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