Transcript Transfusion Medicine III Complications and Safety of Transfusion Practices Salwa Hindawi

Transfusion Medicine III
Complications and Safety of Transfusion
Practices
Salwa Hindawi
Medical Director of Blood Transfusion Services
KAUH
4th year medical students 2nd
Feb,2008
Donor
Patient
The risks associated with transfusion can be reduced by:
- Effective blood donor selection.
- Screening for TTI in the blood donor population.
high quality blood grouping, compatibility testing.
- Component separation and storage.
- Appropriate clinical use of blood and blood products.
- Quality assurance
4th year medical students
2nd Feb,2008
Principles of Clinical Transfusion
Practices
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Avoid blood transfusion
Transfusion is only one part of the
patient’s management.
Prevention and early diagnosis and
treatment of Anemia & underlying
condition
Use of alternative to transfusion.
eg. IV fluids
Good anesthetic and surgical
management to minimized blood loss.
4th year medical students 2nd
Feb,2008
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Prescribing should be based on
national guidelines on the clinical use
of blood taking individual patient
needs into account.
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Hb level should not be the sole
deciding Factor Clinical evaluation is
important
4th year medical students 2nd
Feb,2008
– Consent form to be obtained from the patient
before transfusion.
– The clinician should record the reason for
transfusion clearly.
– A trained person should monitor the
transfused patient and if any adverse effects
occur respond immediately.
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Paid
Directed
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Volunteers
Blood Donation
• WB every 8 weeks, Hct > 38%
• Plateletpheresis every 3 days or 24 times
per year, Hct > 38%
• Autologous Blood
– WB every 3 days (twice/week)
– up to 3 days prior to surgery
– Hct > 33%
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Feb,2008
Donor Selection
Is Important
To Be Sure That The Donor Is Fit To Donate
The Required Amount Of Blood
Blood Donation Will Not Harm The Donor
The Donated Blood Should Be Safe And Free
From Transfusion Transmitted Infections TTI
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Donor Selection
I. Interview
II. Questionnaires
Donor safety
Patient safety
III. Physical examination
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Single Donation Testing
Different countries screen for different organisms.
Each country has to set its own policies for screening
of donors.
i. Serological screening
ii. Microbiological screening
HIV I & II (Ag-Ab), HBV, HCV, Syphilis
HTLV-I & II
HBcAb
Special donors for CMV
Malaria screen (in some countries)
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Feb,2008
Confirmatory tests
Any reactive donation should repeat testing in
duplicate. If any of the repeated tests is reactive,
a sample should be send to a reference laboratory
and the donation will be destroyed by autoclaving
or used for batch validation or quality control
purposes.
4th year medical students 2nd
Feb,2008
Complications of Blood Transfusion
Immediate
HTR
FNTR
TRALI
Bacterial
contamination
Allergic, Anaphylaxis
Delayed
GVHD
PTP
Iron overload
Infectious
diseases
Alloimmunization
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Feb,2008
Acute Hemolytic Transfusion
Reaction
• a clerical error (wrong specimen, wrong
patient)
• 1 in 6,000 to 25,000 transfusions
• back pain, chest pain, fever, red urine,
oliguria, shock, DIC, death in 1 in 4
• stop the transfusion
4th year medical students 2nd
Feb,2008
Work up of An AHTR
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start normal saline
treat patient symptomatically
send blood bag and tubing to culture
send red top and purple top tubes
urine specimen for hemoglobinuria
DAT is positive
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Feb,2008
Non Hemolytic Febrile
Transfusion Reaction
• NHFTR
(1:100)
• Recipient has WBC antibodies to Donor
WBCs contained within RBCs and
Plateletpheresis products
• DAT is negative
• rise in temperature by 2F or 1C
• other causes for fever are eliminated
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Feb,2008
Allergic (Urticarial) Transfusion
Reaction
• Recipient has antibodies to the Donor’s
plasma proteins (1 in 1000)
• offending protein is not identified
• urticaria, itching, flushing, wheezing
• this is the only transfusion reaction
where the blood that is hanging can be
restarted after treatment with Benadryl
• if symptoms continue then STOP
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Feb,2008
Anaphlyactic Transfusion
Reaction
• anaphylactic reaction (1 in 150,000)
• 1 in 700-900 people never made IgA
• occurs when exposed to normal blood
products which contain IgA
• bronchospasm, vomiting and diarrhea
and vascular collapse
• treat with Epinepherine, Solu-Medrol,
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Feb,2008
Circulatory Overload
• marginal cardiovascular status
• given blood components too rapidly
• develops acute shortness of breath,
heart failure, edema (1: 10,000)
• systolic BP increases 50 mm
• infuse slowly, not to exceed 4 hours
• split the unit of RBC and give half
4th year medical students 2nd
Feb,2008
Transfusion Related Acute
Leukocyte Lung Injury
• TRALI reaction (1:10,000)
• Donor plasma contains WBC
antibodies that when transfused to the
recipient cause agglutination of
recipient’s WBC in the pulmonary
capillary beds
• Chest X ray looks like ARDS
• Donor removed from donating blood
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Feb,2008
Transfusion - Related Acute Lung Injury
(TRALI)
A potentially fatal transfusion reaction
Manifested usually within 6hrs after transfusion
Characterised by
Hypoxemia PaO2/ FiO2< 300mmhg O2 sat <90%
on room air
Chest X-ray:Bilateral hilar infiltrates
Absence of evidence of circulatory overload
Toronto TRALI Concensus Conference 1 April 2004
Transfusion,44;1774-91 Dec 2004
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Feb,2008
Diagnosis
High Index of suspicion / Timing of Transfusion
Blood Gases
Chest X-ray
hypoxia and pulmonary oedema ; most
consistent findings.
Diagnosis of exclusion
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Feb,2008
TRALI Non-cardiogenic pulmonary oedema
(result of increased vascular permeability)
The first sign of the reaction can be
“Production of copious quantities of frothy
blood-tinged fluid” from the endotracheal tube
during intubation
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Differential Diagnosis
Other courses of pulmonary oedema
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Volume Overload
Congestive heart failure
Myocardial infarction
Response to diuretics?
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Other Differential Diagnosis
acute reaction
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Acute haemolytic transfusion reaction
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Bacterial infection(TTI)
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Acute anaphylaxis IgA def with anti-IgA
4th year medical students 2nd
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Management
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Adequate respiratory support
100% patients need O2 support
71% required mechanical ventilation
Steroids not beneficial
Important to distinguish TRALI from volume overload
Treatment with diuretics may have a detrimental
effect /reduced cardiac out put.
May need fluid support.
4th year medical students 2nd
Feb,2008
Sepsis from Bacterial
Comtamination
• Platelets:
– skin contaminants most common cause
– plateletpheresis 1 in 5000
– pooled platelets 1 in 1000
• RBC:
– Sepsis from RBC due to Yersinia,
Enterics or Gram Positive 1 in 3,000,000
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Feb,2008
Transfusion Transmitted
Disease (TTD)
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HBV
1 in 63,000
HCV
1 in 103,000
HTLV-I
1 in 641,000
HTLV-II 1 in 641,000
HIV-1
1 in 587,000
HIV-2
< 1 in 1,000,000
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Adverse Effects of Transfusion
Delayed Effects
Immunological
Etiology
* Delayed Haemolysis
RBCs Antibody Reaction
* Graft Vs Host
disease
Engraftment of
Functional Transfused
Lymphocytes
Anti platelet Abs
Exposure to Antigens of
Donor Origins
* Post-Transfusion
Purpura
* Alloimmunization
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Feb,2008
Adverse Effects of Transfusions
Delayed Effects
Non-Immunological
Etiology
Iron Overload
Multiple Transfusion
Hepatitis
AIDS
Protozoa
Infection
HVB, HCV, and Non-A,
Non-B, and Non-C
HIV -I / HIV-2
Malaria, Babesia
Trypanosomes
4th year medical students 2nd
Feb,2008
4th year medical students 2nd
Feb,2008