Transfusion Challenges - Transfusion Reactions - Do they need platelets? Dr. Eoghan Molloy Haem SpR 2016
Guidance on Transfusion Hospital transfusion guidelines and procedures Irish Blood Transfusion Service (IBTS) www.giveblood.ie E-Learning & Accreditation www.learnbloodtransfusion.org.uk British Committee for Standards in Haematology www.bcshguidelines.com
What kinds of transfusion reactions do you know? What transfusion reactions are common? What transfusion reactions are life threatening? Can transfusion reactions be avoided?
Types of Transfusion Reactions Immune mediated: Acute Haemolysis Febrile Non-Haemolytic Allergic (Urticarial, Anaphylactic) TRALI Delayed Haemolysis TA-GVHD Post Transfusion Purpura
Types of Transfusion Reactions Non-immune mediated: TACO Transfusion transmitted infection Coagulopathy (massive transfusion) Transfusion haemosiderosis Electrolyte abnormalities
Scenario 1 76 year old lady PMHx: CCF, CKD, T2DM Left flank pain, vomiting, MSU: ++bacteria Hb 7.0, WCC 19, PLT 343, Creatinine 300, CRP 240 Plan: IV Abx, IV fluids, 2 units RCC 1 hour after commencing 1 st RCC: Temp 38.5, HR 90, SpO2 98%, BP 125/79, RR 18 Complains of headache
Scenario 1 Clerical/ID/Component checks done, transfusion held, cannula kept patent MIOC attends to assess patient O/E: slightly anxious, vitals stable, no skin rash, left renal angle tender Pre-transfusion: Temp 37.5, HR 95 What do you do?
Scenario 2 66 year old man, elective admission for craniotomy PMHx; Anaemia, Thrombocytopaenia, B12 deficiency Hb 10.1, WCC 4.0, Platelets 90 Commences 1 unit of platelets the night before surgery 15 minutes later: erythema over face, neck and back, itchy Intern on call comes to assess
Scenario 2 Clerical/ID/Component checks done, transfusion held, cannula kept patent Temp 37.1, BP 115/75, HR 80, RR 16, SpO2 98% O/E: Appears well, not dyspnoeic, chest clear, raised erythematous rash What do you do?
Mild Transfusion Reaction Fever > 38⁰C and rise 1-2 ⁰ from baseline and/or pruritis or rash but with no other features Management: Restart transfusion, paracetamol if febrile, antihistamine for rash, slow rate of transfusion Careful observation
Severe Transfusion Reaction What is the differential diagnosis? Acute Haemolytic Transfusion Reaction Anaphylaxis TACO TRALI Bacterial contamination
Management of severe reaction Stop transfusion, disconnect giving set, administer IV NaCl 0.9% Check ABC High flow O2 if dyspnoeic If wheeze: salbutamol nebuliser If hypotensive; lie flat and elevate legs Consider the diagnosis and treat accordingly
Scenario 3 26 year old man post splenectomy, RTA Hb 7.3 postoperatively. Prescribed 2 units RCC 5 minutes into 1 st unit RCC: BP 80/40, HR 100, SpO2 85%, RR 24, Temp 36.5 O/E: critically unwell, wheeze, stridor, generalised rash
Shock/Hypotension with evidence of Anaphylaxis: ABC IM Adrenaline 0.5 ml of 1:1000 (repeated if necessary) Rapid fluid resusitation (crystalloid) IV Chlorpheniramine 10 mg IV Hydrocortisone 200 mg Inhaled/IV Salbutamol
Scenario 4 77 year old lady admitted with #NOF Hb 7.1 1 hour into 2 nd unit RCC, becomes unwell, short of breath BP 124/80, HR 95, RR 28, SpO2 80%, Temp 36.9 O/E: no signs of anaphylaxis, crackles throughout both lung fields, JVP elevated What is your differential diagnosis?
Severe dyspnoea without shock Differential Diagnosis: TACO (Transfusion associated circulatory overload) TRALI (Transfusion associated acute lung injury) Management: Discontinue transfusion, high flow O2, urgent Chest X-Ray TACO: Diuresis TRALI: Ventilatory support
Scenario 5 55 year old lady day 2 post right hemicolectomy for CRC Hb 7.1, prescribed 2 units RCC by SROC 1 st unit transfused uneventfully 2 nd unit commenced: After 5 minutes; complains of new flank pain, fever Call to SIOC: Temp is 39.1, should we stop the transfusion? Do you want to take blood cultures?
Scenario 5 SIOC attends immediately Patient acutely distressed, diaphoretic, bleeding from surgical wound and IVC site, urine reddish brown BP 90/50, HR 109, Temp 39.1, SpO2 96%, RR 18 What do you do? What is the differential diagnosis?
Shock/Hypotension with no evidence of overload or anaphylaxis Differential Diagnosis: Acute Haemolysis (ABO incompatibility) Bacterial contamination (sepsis) Management: Discontinue transfusion and manage as per all severe reactions If ABO incompatible, contact lab immediately If bacterial contamination suspected; take blood cultures and start Piperacillin/Tazobactam and Gentamicin
A quick word on platelets
What is a bag of platelets pool of platelets: a preparation of platelets derived from 4 units of whole blood, ie. 4 donors Apheresis platelets: single donor platelets, collected specifically from a platelet donor at the IBTS
Platelet practicalities One unit of platelets (pooled or apheresis) is sufficient for one Adult Therapeutic Dose (ATD) One ATD should increase the platelet count by 20-40 x 10 9 /L Platelet shelf life: 5 days, at room temp (22 degrees), on an agitator
Platelet practicalities Platelets are always in very high demand; be sensible All platelets must come from IBTS in Dublin. NONE stored in Cork Cost of one pool of platelets: 826 If platelets are ordered and subsequently they are not actually required/clinical scenario changes: Contact the blood bank immediately as these platelets could be used for transfusion to a different patient
Indications for platelet transfusion Prophylactic 1. Prevent spontaneous bleeding 2. Prior to an invasive procedure Therapeutic; in active bleeding
Prophylactic Transfusion Indication Stable patient 10 x 10 9 /L Febrile patient 20 x 10 9 /L Prior to invasive procedure 50 x 10 9 /L Prior to invasive procedure at a critical site 100 x 10 9 /L Target Platelet Count Patients taking antiplatelet medications who require urgent invasive procedures? Platelet transfusion has an undetermined role in this setting Each case should be considered individually
Invasive Procedures Procedure Non-critical site: Lumbar Puncture OGD & Biopsy Liver Biopsy Transbronchial Biopsy Epidural Anaesthesia Laparotomy Critical site: Intracranial Ophthalmic Spine 50 x 10 9 /L 100 x 10 9 /L Target Platelet Count
Therapeutic Transfusion Indications for platelets when bleeding: Active major bleeding e.g. haematemesis Platelets <50 x 10 9 /L Active CNS bleeding Platelets <100 x 10 9 /L Patients requiring massive blood transfusion: follow massive transfusion protocol Active major bleeding on antiplatelet treatment
Specific scenarios Idiopathic Thrombocytopaenic Purpura (ITP) Platelet transfusion rarely required, even in severe thrombocytopaenia Usually only require platelet transfusion in an emergency setting TTP, HUS, HIT, DIC Complex haematological disorders All associated with thrombocytopaenia, bleeding AND thrombosis Require specialist assessment prior to platelet transfusion Transfusion can be life-saving in major haemorrhage
Questions, comments, concerns? Please get in touch: Haemovigilance Blood Bank Haematology Team