Transcript Blood Transfusion Transfusion procedures Acute

Ismail M. Siala
By the end of this talk you should be able to:
• 1- Understand the blood components and plasma
derivatives.
• 2- Indications of blood transfusion
• 3- Time limits of blood transfusion.
• 4- Preparing the patient for transfusion.
• 5- How to monitor blood transfusion.
• 6- Diagnosis and management of common
transfusion reactions.
Blood Products
Whole Blood
Plasma
Platelets
Packed
RBCs
Definition: Any therapeutic substance made from human blood.
•Coagulation factor concentrates
•Red Cell Components:
•Platelet concentrate
•Plasma
•Fresh frozen plasma FFP
•Cryoprecipitate
Factor VIII
Factor IX
•Intravenous immunoglobulin
•Non-specific immunoglobulins
•Specific immunoglobulins
•Hepatitis B, Tetanus, Varicella zoster
•Human albumin solution
The advantages of using blood products
instead of whole blood:
•More patients will benefit from one donation.
•Appropriate product for a particular clinical
situation.
•Better storage .
•Prolongation of the life span of donated
blood.
•Preserve the function of the blood product.
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Haemorrhage.
Anaemia causing severe symptoms.
Thrombocytopenic bleeding
Coagulation disorders
Hypofibrinogenemia
The donated blood should be tested for:
1- Blood Grouping (ABO, RhD)
2- Infection Screen (Safety Testing)
Hepatitis B
Hepatitis C
HIV
Others relavant to area
Syphilis
HTLV
Malaria
Etc…
Storage
Temperature
Shelf Life
Whole Blood and Red Cell Concentrate
2-6o C
35 days
Platelet Concentrate
22o C
5 days
Fresh Frozen Plasma
- 30o C
12 months
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Collect Blood
Screen for infection
Blood group
Store blood
Clinical Condition
Blood Product Type
Haemorrhage
Whole Blood/ packed cells + colloid
Symptomatic Anaemia
Packed Red Blood Cells
Bleeding due thrombocytopenia
Platelet Transfusion
Hypovolemia
Plasma
Coagulation Defects
Fresh Frozen Plasma/Cryoprecipitate
1-Fill the Transfusion Request
• Patient’s data
• Indication for transfusion.
• Type of blood product required
2- Extract Blood for grouping and cross matching
a) Positively identify the patient at the bedside
b) Label the sample tube with patient name /bed & file number
3- Send request and sample to the blood bank
• Attach the blood sample for grouping and cross matching with
the request.
• Send request immediately to the blood bank.
– Make sure that the patient’s blood and donors blood
groups are identical.
– This is performed between the
the
.
– Its aim are;
and
• Minimize any risk of error in blood grouping
• Avoid reactions due to mis-matched other blood groups as
Duffy, Kell, Kid etc
•
1- Check the blood unit pack information:
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2- Check the Cross-Matching label
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Donation data and expiry date
Donor Blood group
Screening tests
Patient’s Name
Patient’s Blood group
Make sure that the unit number in the cross
match label is the same as that on donor
label.
Date of cross match
3- Check for signs of damage or
contamination.
3- Check the blood unit for signs of
damage or contamination.
• Check for:
– Signs of haemolysis
– Discoloration of the RBCs darker, purple/black
– Leak in the pack
– Clots in the plasma
• Pack not mixed properly with anticoagulant
• Bacterial contamination
Start infusion
Complete infusion
Whole blood\
Red cells
Within 30 min of
removing pack from
refrigerator
Within 4 hours ( or
less in high
temperature)
Platelet concentrates
Immediately
Within 20 minutes
Fresh frozen plasma
Cryoprecipitate
immediately
Within 20 minutes
• Mismatched information on the unit.
• The blood pack appears abnormal or
damaged
• Blood pack has been out of the refrigerator
for longer than 30 minutes.
• Report to the blood bank immediately.
No Need to warm the blood, just keep
the patient warm, NOT the blood pack.
• Large volume rapid transfusions;
• Exchange transfusion in infants.
• Patients with clinically
significant cold agglutinins.
If warming is indicated you
should use blood warmer
• Positively identify patient at the bedside
• Check the blood pack again.
• Make sure that the iv line is patent and not infected
• Record in the patients file
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The indication of transfusion.
The type of blood product requested.
Number of units.
The time of start the transfusion
The patient vital signs before starting transfusion.
• Patient’s general appearance; conscious,
irritable, calm, dyspnic,…..
• Vital signs:
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0
15min
Pulse
Temperature
Blood pressure
Respiratory rate
1hr
2hr
3hr
4hr
• Monitor all patients closely for the first 15 minutes
• Severe reactions most commonly present during
the first 15 minutes of a transfusion.
• Complete transfusion of whole blood or packed
cells within 4 hours .
Acute
Complications
“Reactions”
Within 72 hours
Delayed
complications
After 72 hours
1. Acute Haemolytic transfusion reactions.
2. Non Haemolytic reactions:
• Febrile non-hemolytic transfusion reactions.
• Bacterial Contamination
• Allergic reactions
– Urticarial
– Anaphlactoid
• Circulatory overload
• Transfusion-associated acute lung injury (TRALI)
Symptoms
•Anxiety
•Chills
•dyspnea
•Pain
•chest pain
•back pain
•Headache
Signs
•Rigors,
•fever,
•restlessness,
•tachycardia,
•hypotension,
•Bleeding 
•Hemolytic reaction / DIC
• While transfusion is running, the patient
became anxious, dyspnic.
• His pulse is raised and he started running
fever.
• He suffered an acute transfusion reaction.
How to manage him?
Stop transfusion
Start oxygen and fluid support.
Send blood for:
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CBC
UCE
LFT
Blood Group and X match
Blood Culture
 Maintain adequate urine output.
 Goal of urine O/P 100 mL/hr. in adults for at least 18-24 hours
 Forced diuresis with frusemide or mannitol
Give:
 Broad spectrum antibiotics, if contamination is suspected.
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Paracetamol for fever.
Diuretics for heart failure.
100% oxygen in ICU + assisted ventilation for transfusion related injury.
Treat DIC
CBC.
Screening for hemolysis:
Urea/creatinine/electrolytes.
Repeat blood grouping and cross
matching.
Blood culture.
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LFT
LDH
Haptoglobin
Hemoglobinaemia
Coagulation screen
Urine for hemoglobinuria
Screening for heart failure and
transfusion related lung injury:
• Arterial Blood Gas sample
• Chest X ray
Acute
Hemolytic
Transfusion
Reaction
•Hemoglobinemia
•Hemoglobinuria
• LDH
• Bilirubin
• Haptoglobin
• BUN, Cr. in ARF
Contamination
Heart Failure
Transfusion
Related Lung
Injury
•Positive culture of
the blood pack.
•Raised JVP
•Chest X ray
suggesting
pulmonary edema.
•Hypoxia
•Normal/Low JVP
•Chest X ray
suggesting
pulmonary edema.
•Hypoxia
• What causes hemolytic transfusion reactions?
• ABO incompatibility
• Clerical and other human error
– most common causes of ABO-incompatible transfusion
• Error in request
• Wrong patient sample.
• Incorrect labelling
– Inadequate check before transfusion.
• Incompatibility of other groups; Kidd, Kell or Duffy
 Appear within minutes of commencing transfusion.
 Even a small volume (10-50 ml) of incompatible blood can
cause a severe reaction.
• Definition: ~1oC rise in temperature and/or chills
with no evidence of hemolysis.
• Common reaction
• Causes:
– Alloimmunisation to HLA antigens
– Bacterial contamination of blood component
Source of Contamination:
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Skin (staph)
Bacteraemia of the donors blood at time of collection
Improper handling in blood processing
Damage to plastic blood bag.
Risk of bacterial growth ↑ with the increase in time out of refrigerator
Risk in platelet concentrate is higher
• A 32 year patient
developed severe
itching during blood
transfusion.
• Associated with the
development of rash.
• There was no fever and
patient did not look ill.
What Happened?
• 1-3% of transfusions
• Signs/Symptoms
– Pruritis-itching
– Urticaria – upper trunk
and neck
• Management:
– Slow/Stop the transfusion rate
– Administer iv antihistamines
e.g chlorpheniramine 10 mg iv
slowly
– If no further progression after
30 mins transfusion may
proceed normally
• Prevention: prophylactic
antihistamines
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Rare
More likely to occur with:
– Rapid transfusion
– Fresh frozen plasma
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Occurs within minutes
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Clinical features;
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 Cardiovascular collapse 
hypotension
 Respiratory distress,
bronchospasm
 Angioedema
 Abdominal pain.
 NO fever
Fatal if not managed urgently and
aggressively.
Treatment/Prevention
– Stop transfusion, take down
blood and giving set and return
intact to blood bank.
– Give chlorphenamine 10 mg i.v.
– Start Oxygen.
– Salbutamol nebulizer.
– If sever hypotension  adrenaline
– Saline wash for the future
blood components.
• May occur when:
– Too much fluid is transfused
– Too rapid transfusion
– Impaired renal function.
• It is more likely to occur in;
– Chronic severe anaemia
– Cardiovascular disease
– Young children and elderly
• It will result in:
– Heart failure/pulmonary
oedema
• Prevention:
– Monitoring fluid
balance
– Diuretics with infusion
– Slow transfusion
• Usually 4 hours, can be
extended to 6 hours
• A 54 year old man, who received
blood transfusion for a
symptomatic anemia.
• He received one unit of packed
cells and was discharged
immediately after finishing the
transfusion.
• 2 hours later the patient was
brought in a serious condition with
sever dyspnea, he was cyanotic
and hypotensive.
• He was transferred immediately to
intensive care unit for
management.
• His chest X ray is shown.
• Unfortunately, the patient died 30
minutes after arrival to ICU.
Could you explain what
happened?
Is there a way to avoid it?
• Donor’s plasma Ab reaction with
patient’s leucocytes.
Clinical presentation
(“classic”, severe form)
• Presents within 1-4 hours from starting
transfusion.
• Onset of acute dyspnea
• Diffuse opacity on chest x-ray
•Acute respiratory distress
•Pulmonary edema
•Hypoxemia
•Hypotension
Treatment of TRALI
• Oxyegn 100%
• Treat as Adult Respiratory Distress
Syndrome (ARDS) in ICU.
• A 29 year old patient who has aplastic
anemia and is on regular blood
transfusion.
• He was admitted to receive blood and
he received 2 units of packed red cells
one from his sister and the other from
his brother.
• He was discharged in a good general
condition.
• Three weeks later he was brought to
the emergency room ill with fever,
diarrhea, vomitting and
maculopapular rash allover his body.
This was progressed to the lesions
shown on the picture.
What could be the problem
of this patient?
Transfusion Related
Graft Versus Host Disease
• Rare 0.1-1%
• Almost always fatal 80-90%
• May occure 4-30 days post
transfusion.
Mechanism:
• Immunocompetent T cells of the
donor are transfused into a host
incapable of eliminating these
foreign lymphocytes.
• The donor T cells initiate a cell
mediated immune response
directed at a host lymphoid
tissue.
Pateints Features:
at risk are
Clinical
– Congenital T cell immunodeficieny
•fever
– Hodgkin lymphoma
•erythematous
maculopapular rash
generalised erythroderma.
– Recipients of stem cell transplants
•toxic
epidermal
in extreme
– Donations
from necrolysis
1st degree relatives.
cases
– Neonates
•Other
symptoms: cough, abdominal pain,
vomiting, and profuse diarrhea .
– those treated with fludrabine.
Prevention:
• Gamma irradiation of blood
components prevents lympohctye
proliferation
Transfusion from 1st Degree relative
Homozygous for
HLA Haplotype
Hiterozygous for
HLA Haplotype
• A 46 year old female, previously healthy.
• No past history of any illness before.
• History of blood transfusion 18 years ago following a post partum
hemorrahge.
• Now presented with fatigue, abdominal distension.
• Clinically she has ascites
• Ultrasound examination: cirrhotic liver, portal hypertension and
ascites
• Her hepatitis C virus test was positive.
Could her hepatitis be explained by
her blood transfusion 18 years ago?
yes,
hepatitis could be a delayed
complication of blood transfusion.
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Hepatitis B
AIDS
Hepatitis c
others
• It can be early or late
• Risk of transmission is low with
pre transfusion screening but it
is not zero
• Bacterial contamination may
rarely occur causing very severe
and often lethal transfusion
reactions
• Test for contamination of
platelet units may reduce the
risk
• Transmission of infection
• Graft Versus Host Disease