Boot Camp Transfusion Reactions Dr. Kristine Roland Regional - PowerPoint PPT Presentation

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

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.

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

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?

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

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

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?

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

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?

Transfusion and FEVER

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

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 Fever does • Presentation: Fever, chills, rigors NOT have to – Headache, N&V, mild ↓ in BP be present • Not associated with harm to patient but can be very distressing

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

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

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)

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

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 Gm- bacteria can be implicated) • Order the blood components with respect to frequency of bacterial contamination: – RBCs 2 – Plasma 3 – Platelets 1 – Albumin 4

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!

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.

Transfusion and SOB

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

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. http://www.phac-aspc.gc.ca/hcai-iamss/ttiss-ssit/ttiss-summary-ssti-summaire-2006-2012-eng.php#t_1a

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

Scenario • So what do I do now?

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

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

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

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

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

Example of Transfusion Reaction Form

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

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