Recognition & Investigation of Transfusion Reactions The Postgraduate Medical Education Service Ms. Bríd Doyle, MSc., FAMLS . Intern Presentation @ Cork A/Haemovigilance Officer, C.U.H. University Hospital Ms. Emma O’Riordan. A/CNM2 (Haemovigilance) C.U.H. Date: 2016
EU Blood Directive 98/EC/2002 Article 10: Personnel --- “… personnel directly involved in collecting, testing, processing, storage and distribution of human blood and blood components shall be qualified to perform those tasks and be provided with timely, relevant and regularly updated training ’ Article 15: Notification of Serious Adverse Reactions and Events – “..mandatory notification of serious adverse reactions events ” and Based on NHO handbook, which lists reportable types of adverse events and reactions All transfusion reactions reviewed by consultant haematologist and hospital transfusion committee
Serious Adverse Reaction Unintended response associated with the transfusion of blood/components that is fatal, life threatening, disabling, incapacitation, or which results in or prolongs hospitalisation or morbidity Serious Adverse Event Any untoward occurrence associated with the distribution or transfusion of blood/components that is fatal, life threatening, disabling, incapacitation, or which results in or prolongs hospitalisation or morbidity Near Miss Event which undetected could have resulted in the determination of a wrong blood group or the issue/administration of incorrect/unsuitable/inappropriate component, but which was recognised before transfusion.
PPG-CUH-CUH-30 ‘Policy and Procedure on recognizing, investigating and managing a Suspected Transfusion Reaction’ Refers to suspected adverse reaction to a blood component transfusion occurring During the transfusion Within 24 hours of transfusion Prior to Transfusion Nurses/midwives/doctors must advise patients Of the possible signs & symptoms of a transfusion reaction The patient should immediately inform the nurse if experiencing any of those signs/symptoms
Form No.15 (Paediatric or Maternity)
Form 15 A (Adults Only)
Infusion Rates Product Start Infusion Transfuse within Rate Red Within 30 min 2-4mls/kg/hr 4 hours (usually 2-3 hours) Cells Plts Immediately 30 – 60 mins For immediate transfusion ( If not to be transfused immediately, leave in Blood bank for agitator storage ) OCTAPLAS Immediately 30 – 60 mins For maximum benefit, transfuse immediately. Recommended be used within 4 hours of thawing
Transfusions Patients should be transfused in clinical area where they can be readily observed Staff trained in administration of blood components in emergency treatment of anaphylaxis In as far as possible, it is recommended that transfusion are only undertaken during the routine day. Only emergency transfusions should take place at night.
Suspected Transfusion Reaction Documented on the final page of the prescription & transfusion record (form 15/15a) Complete form FULLLY!! Circle sign or symptom detected Advice on how to deal with suspected reaction is outlined here
Investigations Blood Transfusion Other Investigations recommended Complete the blood transfusion request form Full Blood Count - indicating a suspected Coagulation Screen transfusion reaction. Urea & Electrolytes, LFTs, LDH Ward Urinalysis/ haemoglobinurea Fluid balance Draw 1 x 6ml EDTA (pink) & 2 x clotted (red) Aerobic and Anaerobic specimens Blood Cultures on Send the specimens plus patient for febrile the implicated unit reactions immediately to the blood transfusion laboratory
Blood Bank Investigations The Blood Bank will Quarantine any Haemovigilance Review un-transfused units Event ?Rapid Alert to IBTS? Clinical status On PRE & POST samples Chest X-Ray, Fluid Balance Perform Clerical checks LFTs, LDH, Haptoglobin Repeat ABO & Rh groups Perform extra testing as required Repeat antibody screens Repeat crossmatches for that unit and Consultant Haematologist any as yet un-transfused units Review Direct Coombs Tests Future Transfusion Policy Report to Clinician Blood Cultures on Unit Report to NHO, if required (aerobic/anaerobic) on pack
Observing/Monitoring Patients Severe transfusion reactions most likely to occur < first 15mins/50mls patients require close monitoring during this period On-going visual observation essential to detect signs/symptoms of a suspected transfusion reaction / adverse event Unconscious, unresponsive, paediatric patients will require closer monitoring
Observations What Temperature Additional Pulse observations are Respirations discretionary Blood pressure O2 Sat depending on the patient’s When clinical condition Baseline before Commencement After commencement If there are signs of a At 15 minutes suspected transfusion At 30 minutes reaction At 60 minutes intervals until completion On Completion of the transfusion
Signs & Symptoms Fever Pain Related symptoms chills, flushing, rigors, Loin, chest, abdominal, infusion Generally feeling ‘unwell’ site, muscle, bone Nausea, diarrhea, vomiting, headache, collapse Angiodema Cutaneous symptoms Tachycardia, Urticaria, rashes, pruritis Hypotension, Hypertension Respiratory symptoms Dyspnoea, stridor, wheeze, hypoxia, coughing Bleeding Anxiety Haematuria Confusion, restlessness, 'impending doom’ Wounds etc A mild reaction may be the early stages of a severe reaction DON’T IGNORE IT!
Suspected Transfusion Reaction Nurse/midwife must immediately Temporarily stop the transfusion Maximum permitted cessation time: 15 Minutes Outside 15 minutes, transfusion MUST NOT be recommenced Contact a doctor to review the patient as a matter of urgency Check patient’s observations and oxygen saturation levels Check the Identification Details on the Unit and of the Patient Verify ABO and Rh group compatibility of the Patient and the Unit IMMEDIATELY contact Blood Bank if discrepancy Leave cannula in situ Document suspected reaction, fluid balance etc. Take laboratory tests as directed. Seal unit, place in re-sealable plastic bag for return to Blood Bank Inform Blood Transfusion Laboratory & Haemovigilance
Acute Intravascular Haemolysis Often noticed during first 15 minutes or first few mls Transfusion of wrong blood ABO incompatible transfusions ~ 1:50,000 to 1:80,0000 units Death from mis-transfusion 1:2.6 million (due to DIC and acute renal failure) ABO incompatibility Sample mis-labelling Patient mis-identification Failure of bedside checking procedure
Delayed Haemolytic Transfusion Reaction Signs and Symptoms: Unexplained fall in HB Rising LFTs Jaundice Dark urine 5-10 days or longer after the transfusion Development of an irregular antibody ( e.g. Anti Kell, Anti Duffy ) Importance of full transfusion history
Febrile Urticaria Non-Haemolytic Transfusion Reaction Rash Isolated fever >1.5 degrees Possible itch May also have chills/rigors More common with Platelets now taken from male- Platelets only donors Up to 1-3% Leuco-depletion of red cell transfusions units Can occur 2-3hours Frequency 0.05% of post Transfusion transfusions
Non- Severe Allergic Reactions May include rash, pruritus & urticaria Along with any of the following Localised angioedema Oedema of lips, tongue & uvula Peri-orbital pruritus, erythema and oedema Responds to symptomatic treatment (steroid and antihistamine)
Severe Allergic Reactions/Anaphylaxis Involve respiratory and cardiovascular systems Usually occurs during the transfusion or very soon after Cause not completely understood May be associated with patients who have IgA deficiency with anti-IgA antibodies Very rare ( approx 1:50,000 ) Life threatening
TACO ( Transfusion Associated Circulatory Overload) Development of acute pulmonary oedema secondary to CCF as a result of transfusion. Characterized by any four of the following: Acute Respiratory distress (dyspnoea, cyanosis) Tachycardia Increased Blood Pressure Acute or worsening pulmonary oedema chest x-ray Evidence of positive fluid balance Occurring within 6 hours of completion of transfusion. Acute left ventricular failure Caused by : Too much fluid or too rapid transfusion Risk: Infants, Elderly, low weight, Diminished Cardiac Reserve or/& Chronic Anaemia Preventable in at risk patients by close monitoring and transfusing smaller volumes at a slower rate May affect up to 1% transfusions in elderly: may be underdiagnosed Take chest X-rays
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