Transcript transfusion_reactions_and_their_management

NON INFECTIOUS
TRANSFUSION REACTIONS
CLASSIFICATION
Transfusion reaction
acute
Immunologic
delayed
Nonimmunologic
Immunologic
Nonimmunologic
A. Hemolytic transfusion
reactions (HTR)

Accelerated clearance or lysis of red cells in the
transfusion recipient. Usually d/t immunological
incompatibility b/w blood donor and the recipient
A. C LASSIFICATION WITH RESPECT TO TIME OF
OCCURRENCE

Acute (AHTRs )
During or within 24 hours of transfusion

Delayed ( DHTRs )
After 24 hours of transfusion.( 5-7 days )
Signs and Symptoms of Acute HTR
Conscious patient
Abrupt onset
Nausea, Vomiting
Anxiety
Shock
Facial flushing
Oliguria
Fever, chills
Hemoglobinuria
Inder
GA
Pain in back or flanks
Bleeding
Dyspnoea
Under GA
•Hypotension
•Hemoglobinuria (This may be masked in patients
undergoing GU surgeries due to hematuria)
•Undue bleeding from surgical site
Complications of AHTRS
Renal failure :- 36 %
Thrombus formation in renal
arterioles
DIC :- 10 %
Immediate Mx of suspected
AHTRs
A. Action for nursing staff
In presence of fever > 38 0 C and / or any S/s
•
Stop the transfusion
•
Check the pt identity and unit transfused
•
Save any urine the pt passes
•
Monitor pulse, BP and temp at 15 min interval
Immediate Mx of suspected
AHTRs
B. Action for medical staff
1. Isolated fever / fever & shivering, stable
observations, correct unit given :FNHTR = Paracetemol 1 g orally ,
observe P, BP and T every 15 min for 1
hr, then hourly. If no improvement call
hematology medical staff
Immediate Mx of suspected
AHTRs
2. Fever with pruritis, urticaria :- Allergic
transfusion reaction = Chlorpheniramine 10
mg iv
3. Any other s/s, hypotension, incorrect unit :AHTR = discontinue transfusion, N saline to
maintain urine output 1ml /kg / h. full and
continuous monitoring
Mx of AHTRs

Take immediate note and inform blood bank

Seek help immediately from skilled anaesthetist or
emergency team

Complete the transfusion reaction form and
appropriately record the following
Type of transfusion reaction
Time after the start of transfusion to the occurrence of
reaction
• Unit No. of component transfused
• Volume of the component transfused
•
•
Investigation of suspected AHTRs
Send the following lab investigations:
Immediate post transfusion blood samples (clotted and EDTA)
for:
 Repeat ABO & Rh (D) grouping
 Repeat antibody screen and crossmatch
 Direct antiglobulin test
 Complete blood count (CBC)
 Plasma hemoglobin
 Coagulation screen
 Renal function test (urea, creatinine and electrolytes)
 Liver function tests (bilirubin, ALT and AST)
Blood culture in special blood culture bottles
Blood unit alongwith BT set
Specimen of patient’s first urine following reaction
Other reactions characterized
by hemolysis
1. Pts with autoimmune hemolytic anemia
2. Donor units m/b hemolysed due to
•
Bacterial contamination
•
Excessive warming
•
Erroneous freezing
•
Addition of drugs or iv fluids
•
Trauma from extracorporeal devices
•
Red cell enzyme deficiency
Mx of confirmed AHTRs
Maintain adequate renal perfusion by
- Fluid challenges
- Frusemide infusion
- If hypovolumic – dopamine infusion
Transfer to high dependency area
Repeat coagulation and biochemistry screens ever
2- 4 hrly
If urinary output not maintained seek expert renal
advice
Hemofiltration or dialysis m/b required for acute
tubular necrosis
DIC development – component therapy may be
required
DELAYED HEMOLYTIC TRANSFUSION
REACTIONS
Due to secondary immune responses
following re-exposure to a given red
cell antigen
- Ab most commonly involved – Rh ,
Kidd, Duffy and Kell
- No clinical signs of red cell destruction
but positive DAT
- Rarely fatal
DELAYED HEMOLYTIC TRANSFUSION
REACTIONS
Sign and symptoms
- fever
- fall in Hb concentration
- Jaundice and hemoglobinuria
Mx
- Requires no Tt.
- Hypotension & renal failure – may
require expert medical advice
Diagnosis & Management
Routine examination
 Stop Tx immediately
 Monitor vital signs, urine out put
 Verify identification of the patient
 IV line kept open with NS
 Evaluate for evidence of HTR, septic shock, anaphylaxis
TRALI other D/D fever
 Report and send transfusion set to B/B

Diagnosis of exclusion
Blood Bank:
• Recheck the records for clerical error
• check for identification error
• Visual check for hemolysis, appearance of returned unit
• Evidence of blood group incomparability
Pre Tx sample
Post Tx sample
ABO,Rh group
DCT
ICT
Repeat CxM
•Gram stain, culture
•HLA, Plt, Granulocyte specific Abs in recipient
Treatment
Antipyretics
acetaminophen ; 325-650mg orally
(adult) 10-15mg/kg (children)
 Meperiedine
severe chills - 25-50mg IV
contraindication: renal failure
Pts on MAO inhibitors



Antihistaminics: not indicated
Tx should not be restarted for 30 min.
D. URTICARIAL AND ANAPHYLACTIC
REACTIONS
- Usually mild allergic reactions
Treatment
- Non systemic reaction = focal urticaria /
angioedema : Antihistamine
- Mild systemic = chest tightness,
generalized urticaria / angioedema :
Antihistamine, salbutamol and / or inhaled
steroid
URTICARIAL AND ANAPHYLACTIC
REACTIONS
Moderate systemic = wheeze /
breathlessness / obstructive laryngeal
oedema : All above including prednisolone
, consider adrenaline
Severe systemic = Severe breathing
difficulty, shock arrhythmias, loss of
consciousness : Adrenaline im and all
above
E. BACTERIAL CONTAMINATION
Most common microbiological
complication of transfusion
Higher incidence after platelet
transfusion
Apparent infrequency of clinical
events of bacterial contamination
-
Non pathogenic bacteria
Insufficient no. of bacteria
Premedication with steroides
Pts already on antibiotics
Immunosuppressed pts
underinvestigated
Clinical features
-
-
- usually appear immediately during
transfusion
S/t symptoms delayed until after the end of
transfusion
- fever ( inc > 2 o C )
- chills / rigors
Hypotension, collapse, shock
Nausea, vomitting
DIC, intravascular hemolysis, renal failure
Management
-
-
- Stop transfusion. Retain unit for
investigation
Give general supportive Tt (iv fluids ,
inotropic agents , diuretics to maintain
urine output )
Broad spectrum antibiotics until blood
culture report comes
Assess need for intensive care bed
How to Prevent Errors in the Transfusion Chain

Where in the process do errors occur?
Sample Error
Wrong Blood
Issued
Patient
Misidentification
Technical Error
Storage Error
Administrative
Error

Who is making the errors?

Why are the errors occuring – which elements of good
transfusion practice are failing
Error Prevention in the Transfusion Services
 Adherence to Standard Operating Procedures (SOPs)
for pre-transfusion testing
 Antibody screen in patients at risk of alloimmunization;
preferably universal screen
 Antibody identification when required
 Appropriate storage and transfusion instructions on
labels
 Clerical checks prior to issue
Prevention of transfusion reaction
Education
and training of nurses health care
assistants, doctors at every level
Proper
communication at all level should be
appropriate, timely and effective.
Promoting
the knowledge in hospital, raising
awareness by having more educational sessions and
poster available to hospital