83 yo male - anwresidency.comanwresidency.com/hospitalists/case_conf/heme/transfusion...
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83 yo male PMH
Diverticulosis
HTN
DM II
Hyperchol
AVR 1997, EF 60% recently
CVA 1997, aphasia, R-sided
GI Bleeds
Meckel’s 1998
Hemicolectomy
UGIB 3mo PTA, 2mo PTA &
1mo PTA
Gastric erosions
DNR code status
HPI Hutch 2 wks ago w/ melena & Hgb
7.4, INR 2.4
FFP for reversal, 3u PRBCs
EGD= gastric erosions, Last
colonoscopy 1998
Hgb stable, coumadin resumed and
lovenox to bridge @ Discharge
Recurrent Melena on lovenox and
coumadin
Presented to Hutch INR 2.8 on lovenox and coumadin, Hgb
6.7
Pulse 110, 110/65, 98% RA
6u FFP, 2u prbcs given prior to transfer
transferred to ANW
83 yo male PMH
Diverticulosis
HTN
DM II
Hyperchol
AVR 1997, EF 60% recently
CVA 1997, aphasia, R-sided
GI Bleeds
Meckel’s 1998
Hemicolectomy
UGIB 3mo PTA, 2mo PTA & 1mo PTA
Gastric erosions
DNR code status
HPI Hutch 2 wks ago w/ melena & Hgb 7.4, INR
2.4
FFP for reversal, 3u PRBCs
EGD= gastric erosions, Last colonoscopy
1998
Hgb stable, coumadin reversed and lovenox
to bridge @ Discharge
Recurrent Melena on lovenox and coumadin
still
Presented to Hutch and transferred to ANW
INR 2.8 on lovenox and coumadin, Hgb 6.7
Pulse 110, 110/65, 98% RA
6u FFP, 2u prbcs given prior to transfer
Hgb 6.9, 2u PRBCs
ordered w/ lasix btwn
units
Difficulty matching, delayed
6 hours
Hgb 8.9, melanotic
diarrhea continues
Pulse 120s, BP 105/50
EGD negative
Plan prep for colonoscopy
in AM
Melena/diarrhea
increases
140 32101
3.9 21 1.1110
83 yo male
Hgb 8.4 still w Melena
1u prbc ordered
Needs leukoreduced units
for transfusions
Delayed secondary to
aby incompatabilities
Infusion started at
1pm
144 44108
3.9 18 1.699
PMH
Diverticulosis
HTN
DM II
Hyperchol
AVR 1997, EF 60% recently
CVA 1997, aphasia, R-sided
GI Bleeds
Meckel’s 1998
Hemicolectomy
UGIB 3mo PTA, 2mo PTA & 1mo PTA
Gastric erosions
DNR code status
HPI Hutch 2 wks ago w/ melena & Hgb 7.4, INR
2.4
FFP for reversal, 3u PRBCs
EGD= gastric erosions, Last colonoscopy
1998
Hgb stable, coumadin reversed and lovenox
to bridge @ Discharge
Recurrent Melena on lovenox and coumadin
still
Presented to Hutch and transferred to ANW
INR 2.8 on lovenox and coumadin, Hgb 6.7
Pulse 110, 110/65, 98% RA
6u FFP, 2u prbcs given prior to transfer
83 yo male 45min into infusion…
Patient shaky/cold
Temp 36.7
Resp rate to 40 acutely,
diffuse wheeze new,
labored breathing
Rapid response called
Blood pressure 160/110,
pulse 140s
Sats 92 > 80% on 100%
facemask over 10min
144 44108
3.9 19 1.699
PMH
Diverticulosis
HTN
DM II
Hyperchol
AVR 1997, EF 60% recently
CVA 1997, aphasia, R-sided
GI Bleeds
Meckel’s 1998
Hemicolectomy
UGIB 3mo PTA, 2mo PTA & 1mo PTA
Gastric erosions
DNR code status
HPI Hutch 2 wks ago w/ melena & Hgb 7.4, INR
2.4
FFP for reversal, 3u PRBCs
EGD= gastric erosions, Last colonoscopy
1998
Hgb stable, coumadin reversed and lovenox
to bridge @ Discharge
Recurrent Melena on lovenox and coumadin
still
Presented to Hutch and transferred to ANW
INR 2.8 on lovenox and coumadin, Hgb 6.7
Pulse 110, 110/65, 98% RA
6u FFP, 2u prbcs given prior to transfer
83 yo male Solumedrol 100mg IV
Benadryl 50mg IV
Lasix 40mg IV
Albuterol Neb
Bipap
MSO4
DNR confirmed
Developed abdominal pain
Transferred to ICU
PMH
Diverticulosis
HTN
DM II
Hyperchol
AVR 1997, EF 60% recently
CVA 1997, aphasia, R-sided
GI Bleeds
Meckel’s 1998
Hemicolectomy
UGIB 3mo PTA, 2mo PTA & 1mo PTA
Gastric erosions
DNR code status
HPI Hutch 2 wks ago w/ melena & Hgb 7.4, INR
2.4
FFP for reversal, 3u PRBCs
EGD= gastric erosions, Last colonoscopy
1998
Hgb stable, coumadin reversed and lovenox
to bridge @ Discharge
Recurrent Melena on lovenox and coumadin
still
Presented to Hutch and transferred to ANW
INR 2.8 on lovenox and coumadin, Hgb 6.7
Pulse 110, 110/65, 98% RA
6u FFP, 2u prbcs given prior to transfer
83 yo male Ntg gtt started
Lines placed
Lasix = brown urine
First 2 lab draws hemolyzed
3rd lab draw & Transf Rxn labs
Hgb 7.2 < 1u+8.4
INR 1.9 <1.2
Plts 102 < 235
PMH
Diverticulosis
HTN
DM II
Hyperchol
AVR 1997, EF 60% recently
CVA 1997, aphasia, R-sided
GI Bleeds
Meckel’s 1998
Hemicolectomy
UGIB 3mo PTA, 2mo PTA & 1mo PTA
Gastric erosions
DNR code status
HPI Hutch 2 wks ago w/ melena & Hgb 7.4, INR
2.4
FFP for reversal, 3u PRBCs
EGD= gastric erosions, Last colonoscopy
1998
Hgb stable, coumadin reversed and lovenox
to bridge @ Discharge
Recurrent Melena on lovenox and coumadin
still
Presented to Hutch and transferred to ANW
INR 2.8 on lovenox and coumadin, Hgb 6.7
Pulse 110, 110/65, 98% RA
6u FFP, 2u prbcs given prior to transfer
83 yo male Forced diuresis with
bicarb and lasix/ivf
Quick echo at bedside:
global hypokinesis-
severe
Repeat TTE after acidosis
improved with bolus
bicarb, EF 55%, no wma.
PMH
Diverticulosis
HTN
DM II
Hyperchol
AVR 1997, EF 60% recently
CVA 1997, aphasia, R-sided
GI Bleeds
Meckel’s 1998
Hemicolectomy
UGIB 3mo PTA, 2mo PTA & 1mo PTA
Gastric erosions
DNR code status
HPI Hutch 2 wks ago w/ melena & Hgb 7.4, INR
2.4
FFP for reversal, 3u PRBCs
EGD= gastric erosions, Last colonoscopy
1998
Hgb stable, coumadin reversed and lovenox
to bridge @ Discharge
Recurrent Melena on lovenox and coumadin
still
Presented to Hutch and transferred to ANW
INR 2.8 on lovenox and coumadin, Hgb 6.7
Pulse 110, 110/65, 98% RA
6u FFP, 2u prbcs given prior to transfer
83 yo male Cr 3.0 next morning
UA large blood, 2 rbcs
Off Bipap, sob resolved
Cr climbed to 4.6
Dialysis initiated, pulled line out
that night
Hgb dropped to 7.1 < 8.6
Colonoscopy: 2 avms in ileum
at anastamosis, clipped
Coumadin resumed
Cr climbed to 5.3 then leveled
out and started to fall
PMH
Diverticulosis
HTN
DM II
Hyperchol
AVR 1997, EF 60% recently
CVA 1997, aphasia, R-sided
GI Bleeds
Meckel’s 1998
Hemicolectomy
UGIB 3mo PTA, 2mo PTA & 1mo PTA
Gastric erosions
DNR code status
HPI Hutch 2 wks ago w/ melena & Hgb 7.4, INR
2.4
FFP for reversal, 3u PRBCs
EGD= gastric erosions, Last colonoscopy
1998
Hgb stable, coumadin reversed and lovenox
to bridge @ Discharge
Recurrent Melena on lovenox and coumadin
still
Presented to Hutch and transferred to ANW
INR 2.8 on lovenox and coumadin, Hgb 6.7
Pulse 110, 110/65, 98% RA
6u FFP, 2u prbcs given prior to transfer
83 yo male PMH
Diverticulosis
HTN
DM II
Hyperchol
AVR 1997, EF 60% recently
CVA 1997, aphasia, R-sided
GI Bleeds
Meckel’s 1998
Hemicolectomy
UGIB 3mo PTA, 2mo PTA & 1mo PTA
Gastric erosions
DNR code status
HPI Hutch 2 wks ago w/ melena & Hgb 7.4, INR
2.4
FFP for reversal, 3u PRBCs
EGD= gastric erosions, Last colonoscopy
1998
Hgb stable, coumadin reversed and lovenox
to bridge @ Discharge
Recurrent Melena on lovenox and coumadin
still
Presented to Hutch and transferred to ANW
INR 2.8 on lovenox and coumadin, Hgb 6.7
Pulse 110, 110/65, 98% RA
6u FFP given prior to transfer
Discharged to rehab
Blood Bank Path Report:
1. Probable ongoing delayed hemolytic
transfusion reaction
2. Possible component of acute
hemolysis without demonstrable
immunologic basis
INTERPRETATION
Of significance is that this patient
received multiple red blood cell
transfusions prior to his admission to
Abbott Northwestern Hospital on 8/21/07.
Serologic evaluation at Abbott
Northwestern Hospital and at American
Red Cross North Central Blood Services
revealed four red cell alloantibodies with
anti-e anti-Kell, anti-S, and anti-Duffy A
specificities. All three units transfused at
Abbott Northwestern Hospital were
negative for the corresponding red cell
antigens and all three units were
demonstrated to be crossmatch
compatible through the antiglobulin
phase in both saline and albumin media.
The patient's direct Coombs test was positive on the
pretransfusion specimen and the plasma free
hemoglobin was elevated on a pretransfusion
specimen to 46 mg/dl. Accordingly, ongoing hemolysis
was likely present prior to the transfusion of the
implicated unit, and presumably represents an
evolving delayed hemolytic transfusion reaction to the
units transfused at the outside facility. A post
transfusion plasma free hemoglobin, however, was
more significantly elevated at 177 mg/dl suggesting an
element of acute hemolysis with the third unit. This
correlates with a serum haptoglobin of less than 6
mg/dl. Nevertheless, a repeat serological evaluation
including complete crossmatch through the
antiglobulin phase in both saline and albumin did not
demonstrate evidence for serological incompatibility
with this third unit. Accordingly, the possibility of
nonimmunologic/mechanical hemolysis might also be
considered, possibly reflecting the presence of the
prosthetic heart valve.
An eluate from red cells in the post transfusion sample
demonstrates specificity for anti-S which would
support the diagnosis of delayed hemolytic
transfusion reaction associated with red cell units
transfused at the outside facility.
If additional transfusions are needed for this
individual, he should be cross matched with units
negative for the e, Kell, S, and Duffy-A antigens, and
complete crossmatch through the anti-globulin phase
will be necessary.
Transfusion Reactions
Staff Case Conference
2.1.2008
FEBRILE NONHEMOLYTIC REACTIONS
Most common
Clinically:
Fever, chills, mild dyspnea, muscle cramps
Time course:
1-6 hrs after transfusion
Cause:
Cytokines generated during storage
Donor leukocytes
FEBRILE NONHEMOLYTIC REACTIONS
Treatment:
Stop the transfusion and determine that a
hemolytic reaction is not taking place
Symptomatic tx:
Administration of antipyretics
Meperidine in patients with severe chills and
rigors
Prevention:
Leukoreduced transfusion
ACUTE HEMOLYTIC REACTIONS
Emergency
Etiology: pre-existing RBC antibodies in the
recipient to the donor erythrocyte: ABO (clerical error), preexisting antibodies not detectable:
Kell, Duffy, and Kidd
Signs and symptoms: Triad: fever, flank pain, and red or brown urine
(hemoglobinuria)
hypotension
Coomb’s Test: positive
Pink serum (hemoglobinemia) Plasma free hemoglobin
Complications: oliguria 33%, DIC 4%, death 20%
ACUTE HEMOLYTIC REACTIONS
Stop the transfusion
Maintain the patient's airway, blood pressure, and heart rate.
Begin an infusion of normal saline immediately to initiate a diuresis and avoid hypotension
From the other arm, obtain a sample for a direct antiglobulin test, plasma free hemoglobin, and repeat type and cross-match. Save a urine sample for hemoglobin testing
The blood bank should be alerted immediately, and a search for clerical error should be instituted.
This is of critical importance, since if blood samples or blood bags have been switched in error, there may be a second patient at risk for a similar event
Follow coagulation, plts, renal function
DELAYED HEMOLYTIC REACTIONS
2-10 days after transfusion
Aby against previously seen antigen
Usually Kidd, Rho system
Diagnosis is often made by the blood bank
new positive direct antiglobulin test and a new
positive antibody screen are found when more
blood is ordered
Slow decrease in Hgb, low grade fever,
spherocytes on smear
Treatment: none, unless brisk hemolysis
ANAPHYLACTIC REACTIONS
Associated with IgA Antibodies
Anti-IgA antibodies of IgG type that are
capable of binding complement
Selective IgA deficiency 1:300-500 persons
Treatment:
conventional anti-anaphylactic management
0.3-0.6cc 1:1000 Epi IM
0.5-1cc 1:10,000 Epi IV
Glucagon if on Bbl and refractory
1mg IV, can repeat up to 5mg qmin
URTICARIAL REACTIONS
Pre-existing IgE aby to substances in blood
Mast cells and basophils to release histamine,
leading to hives or urticaria
Only transfusion reaction in which the blood
product can be continued
Stop first and assure no further sx develop
Benadryl 25-50mg iv
Do not need to send to blood bank
TRALI – transfusion related acute lung injury
Clinical symptom spectrum:
Cough
Acute resp distress, hypoxemia, hypotension,
fever, and pulmonary edema
Donor aby to leukocytes
1:5000 transfusions (tip o’)
2-4 hrs after initiation of transfusion
Treatment: supportive
Usually fully recover in 48-72hrs
POSTTRANSFUSION PURPURA Patient antibodies directed against human platelet
antigens (developed through pregnancy or
previous transfusion)
Thrombocytopenia = hemorrhages in the skin and
mucous membranes, purplish spots or patches 5-
12 days following transfusion
Management:
avoid transfusion of plts
steroids, IVIG and possibly plasma exchange
washed cells or HPA-1a negative cells in the future
If untreated may persist for several weeks
Transfusion of Infectious DiseasesInfection
Hepatitis B
HTLV I
Hepatitis C
HIV I
Smoking 20 cig/d
Automobile driving
Soccer/Football
Canoeing
• Risk
1:205,000 transfusions
1:641,000 transfusions
1:1,935,000 transfusions
1:2,135,000 transfusions
1:200 risk of death/yr
1:5,900
1:25,000
1:100,000
<1:million = babesia, bartonella, borrelia, brucella,
leishmania, parvo, toxo, EBV, W. Nile, Malaria.
Types of PRBCs
Washed
Removes proteins left in small amt
of plasma
Used in: Patients with severe or recurrent
allergic reactions (eg, hives) associated
with red cell transfusion
Certain patients with IgA deficiency
when IgA deficient donors are not
available (although frozen
deglycerolized red cells may be the
component of choice; see below);
patients with IgA deficiency may have
circulating anti-IgA antibodies that react
with IgA in the donor plasma
In the rare patient with a complement-
dependent autoimmune hemolytic
anemia to prevent complement
infusion.
Irradiated red cells
Prevent the donor T lymphocytes from
dividing in the recipient
Used in:
patients who have hereditary
immune deficiency states
Prevents GVHD in
immunosuppressed pts and
related T-lymphocytes
Types of PRBCs
CMV Negative
Donors are CMV negative
Doesn’t pick up infected sero-negative “Window Period”
40-60% of donors are CMV positive
Used in: immunocompromised oncology patients,
individuals undergoing hematopoietic or solid
organ transplantation,
low birth weight CMV-seronegative neonates
Leukoreduced
Removes leukocytes
Prevents HLA alloimmunization, febrile
reactions
Used in:
Chronically transfused patients
Potential transplant recipients
Patients with previous febrile
nonhemolytic transfusion
reactions
CMV seronegative at-risk patients
for whom seronegative
components are not available
Transfusion reaction workup…
determine whether the correct unit of blood was
administered
repeat type, crossmatch, antibody screen, and
direct and indirect Coombs.
Other considerations with a hemolytic
transfusion:
Free serum hemoglobin appears as a pink color of the
serum in a clotted centrifuged specimen. This may be
observed with as little as 5-10 mL of hemolyzed blood.
Serum bilirubin level peaks in 3-6 hours as the free
hemoglobin is metabolized.