BLOOD TRANSFUSION BRI BUDLOVSKY R3 JANUARY 2015. OVERVIEW The process Blood components Testing...

BLOODTRANSFUSION

BRI BUDLOVSKY R3

JANUARY 2015

OVERVIEW

• The process

• Blood components

• Testing

• Consent

• Transfusion reactions

DONATION

DONATION

TEST SPECIFIC AGENTS TESTS

GroupABO,Rh

AlloantibodiesABO and Rh antigen testing

Virus

HIVHep BHep CHTLV

West Nile

Antibodies, nucleic acid testing

BacteriaSyphilis

Bacterial contaminationSerology

Bacterial Culture (plt only)

ParasitesChagas in

at risk donorsantibody

BLOOD COMPONENTS

CONSENT: HISTORY

CONSENT

• Time to think of alternatives

• Describe the product

• Describe benefits & risks

• Describe alternatives

• Answer questions/confirm understanding

• Complete consent form

• Document in chart

RISKS• Hep B: 1/ 153,000

• Hep C: 1/ 2.3 million

• HIV: 1/ 7.8 million

• Minor urticaria: 1/100

• Febrile non-hemolytic: 1/300

• ABO incomp/serious immune: 1/ 40,000

• Sepsis: 1/ 10,000 plts, 1/ 500,000 pRBCs

TESTING

TESTTIMIN

G(min)

Group 5 Patient tested for ABO and Rh antigen

Screen 45Patient tested for alloantibodies from prior

transfusion/pregnancy

Xmatch 45Incubate patient’s blood with donor blood, checks for

immune reaction due to alloantibodies

Computer Xmatch

2Computer picks appropriate unit based on patient and

donor testing. Blood is not actually mixed.

DAT45

RBCs from patient are washed, and then mixed with Coombs Reagent. If they stick together, it means they

have antibodies on their surface (+ for immune transfusion reaction)

TRANSFUSION REACTIONS

56F – POD#3

• L hemi-colectomy for diverticulitis

• Transfusion for low Hb

• You are called for FEVER

DDX: FEVER

• Usual post-op fever causes

• Transfusion specific:

• Febrile non-hemolytic• Hemolytic• Septic

FEBRILE TRANSFUSION REACTION

During or within 4 hours of transfusion:

• >38°C

• Increase by 1°C

MANAGEMENT

• STOP THE TRANSFUSION

• Maintain IV access

• Check patient ID and blood product

• Notify the blood bank

RED FLAGS

• T>39°C• Hypotension/shock• Tachycardia• Dyspnea• Back/chest pain• Oliguria/Hematuria• Nausea/vomiting• Bleeding from IV sites

NON-HEMOLYTIC

HEMOLYTIC BACTERIAL CONTAMINATION

BACTERIAL CONTAMINATION

• From:

• Donor skin/blood• Poor handling

• 10% of transfusion mortality

BACTERIAL CONTAMINATION

• Cultures

• Two patient sites• Bag/line lab

• Antibiotics

• Pip-tazo• Vanco

HEMOLYTIC REACTION

• ABO incompatibility

• ½ from proper labeling wrong patient• Others from improper labeling, testing

error etc.• Non-ABO incompatibility

• From pregnancy/previous transfusion

• >50%: No morbidity• <10%: Fatal

MANAGEMENT

• Check labels

• Call blood bank

• UA for Hb

• DAT

• Fluids

• Supportive

60F – VAGINAL BLEEDING

• Transfused 2U pRBC

• You are called for:

• SOB• SaO2

DDX: DYSPNEA

• Usual post-op SOB causes

• Transfusion specific:

• TACO• TRALI• Anaphylaxis

TACO

• Fluid overload

• Impaired cardiac function +/-• Fast rate of transfusion

• 1/700 transfusions

• Management

• Stop transfusion• Oxygen• Diurese

TACO

• Prevention is key

• Identify at risk patients• Diuretics between/after units• Slow speed (4 hours/U)• Divide products into smaller aliquotes

• Reduce speed without waste

TRALI

• Acute onset:

• Hypoxemia

• Bilateral lung infiltrates on CXR

• No cardiac cause

• No ALI before transfusion, and now ALI present

• DURING or WITHIN 6 hours of transfusion

• No other risk factors for ALI

ALI

TRALI

• Etiology

• Passive transfer of antibodies• Neutrophil reaction to biologically active

compounds in blood• Most common cause of transfusion

related death (up to 10% of TRALI)

• Usually 1-2 hours post (up to 6)

TRALI - MANAGEMENT

• Supportive care

• No evidence for steroids or diuretics

• Reducing risk:

• No plasma/plasma products from multip females• Platelets from males or nullip females• Pool platelets in male plasma• Testing of & deferral of donors with TRALI hx• 2/3 reduction

ANAPHYLAXIS

• Mechanism unclear

• Transfusing IgA / IgE• Antibodies to serum proteins• Transfusion an allergen consumed by donor

• Rare

• 1/40,000• 3% of transfusion fatalities

URTICARIA

• 1/100 transfusions

• Management:

• Interrupt transfusion• Benadryl 25-50mg IV• Resume if:

• Urticaria improving/mild• No associated symptoms

72M – DIALYSIS PATIENT

• Transfused 2U pRBC for chronic support

• Complaining of palpitations

HYPERKALEMIA

• Prolonged storage & irradiation K leakage

62F – LGIB

• 6U pRBC for massive LGIB in ER

• C/O:

• Anxiety• Foot and hand “cramping”• Peri-oral tingling

CITRATE TOXICITY

• Rare!

• Massive transfusion or plex only

• Replace PO or IV

• More common:

• Metabolic alkalosis

SUMMARY

• Know the risks

• Know the benefits

• Know the alternatives

• Document

• Have a high suspicion

• Stop the transfusion and investigate

TO STOP OR NOT?

• Sick or severe

• TRALI

• Hemolysis

• Lab/clerical error

• Sepsis

• Anaphylaxis

• Urticaria

• Febrile non-hemolytic

• TACO

• Fever• NHTR• Sepsis• HTR

• Dyspnea• TRALI• TACO• Anaphylaxis

• Allergic• Urticaria• Anaphylaxis

• Hypotension• Sepsis• Anaphylaxis• HTR

REFERENCES• Bloody Easy

• Rosen’s

• Up-to-date

• CMPA

• www.hemophilia.ca

• TRALI: A clinical review. The Lancet. Sept 2013. Vlaar et al.

EXTRA SLIDES

STORAGE