transfusion reactions
DESCRIPTION
Transfusion Reactions. Lloyd O. Cook, M.D. Department of Pathology March 2005. Definition: Txn Rxn. Any adverse outcome attributable to transfusion of a blood component or components. Immediate Action to Take for Txn Rxn: 1. STOP THE TRANSFUSION 2. Keep IV open with Normal Saline - PowerPoint PPT PresentationTRANSCRIPT
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Transfusion Reactions
Lloyd O. Cook, M.D.Department of Pathology
March 2005
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Definition: Txn Rxn
• Any adverse outcome attributable to transfusion of a blood component or components.
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• Immediate Action to Take for Txn Rxn:• 1. STOP THE TRANSFUSION• 2. Keep IV open with Normal Saline• 3. Check all blood component(s) labels, forms,
Pt. ID for errors• 4. Notify Pt.’s physician as appropriate• 5. Treat rxn• 6. Notify Blood Bank; submit work-up
specimens; submit report forms
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Common Signs & Symptoms
• Abnormal bleeding• Chest/back pain• Chills• Coughing• Cyanosis• Dyspnea• Facial flushing• Fever (> 1 C )• Headache• Hemoglobinuria• Heat at infusion site
• Hypotension• Itching• Myalgia• Nausea• Oliguria/anuria• Pulmonary edema• Rales• Rash• Urticaria/hives• Wheezing• Uneasy feeling
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Selected Txn Rxns
Signs/SymptomsCause
ManagementPrevention
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Acute Hemolytic
• Note: Most dangerous immunologic complication of Red Cell unit transfusion.
• Usually due to clerical error: wrong Pt.; wrong blood component; etc.
• High risk for morbidity or mortality.
• Morbidity, e.g.: renal failure, DIC
• Mortality: about 1 per 100,000 txn pts per year (cases reported to FDA)
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Acute Hemolytic
• Signs/symptoms (usual)• Sudden chills• Increased temp of 1 C to 2 C -
fever• Headache• Flushing• Anxiety• Muscle pain• Hemoglobinuria• Low back apin• Tachypnea• Tachycardia• Hypotension
• Vascular collapse• Bleeding (N.B. surgical field in
an anesthetized pt.• Acute Renal Failure• Hemoglobinemia• DIC• DIC with bleeding• Shock• Cardiac arrest• DEATH
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Acute Hemolytic
• Cause• Transfusion of incompatible donor RBC’s
into Pt• Usually an ABO incompatibility• Antibodies in Pt plasma attach to antigens
on donor RBC’s causing RBC destruction intravasculary
• Antibodies fix complement causing RBC lysis
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Acute Hemolytic
• Management
• Treat hypotension, renal failure, DIC, etc.
• Submit blood samples for blood bank/laboratory tests
• Avoid, if possible, further transfusions till work-up complete and/or Pt recovered from rxn
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Acute Hemolytic
• Prevention• Meticulously verify and document Pt ID
from sample collection for compatibility testing through to blood component transfusion
• Follow precisely the proper transfusion procedures at bedside (usually found in Nursing SOP’s ) every time – NO SHORTCUTS !!!
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Febrile Rxn
• Signs/Symptoms• Nonhemolytic• Sudden chills• 1 C to 2 C temp increase• Headache• Flushing• Anxiety• Muscle pain
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Febrile Rxn
• Cause
• Pt immunologic sensitization to donor WBC’s, platelets or plasma proteins
• Common sources: prior transfusions, previous pregnancies, previous transplants
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Febrile Rxn
• Management
• Give antipyretics (e.g. aspirin – except children – Reyes Syndrome)
• Avoid aspirin in thrombocytopenic pt’s
• Do not restart transfusion
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Febrile Rxn
• Prevention
• Consider leukocyte poor blood components
• Two types of leukopoor RBC’s: filtered at time of donation and frozen/washed
• Can also use WBC filters at bedside
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Allergic Rxn
• Signs & Symptoms
• Flushing
• Itching
• Urticaria (aka hives)
• Rarely, angioedema – epiglottal edema; bronchial airway constriction, hypotension, dyspnea, rales
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Allergic Rxn
• Cause
• Pt sensitized to foreign plasma antigens
• Exact mechanism not known for sensitization
• Commonly caused by transfusion of plasma containing blood components, e.g.: FFP, Cryoprecipitate, Platelet Concentrates
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Allergic Rxn
• Management
• Premedicate Pt with antihistamines (e.g. Benadryl)
• If signs/symptoms mild &/or transient, restart transfusion after treatment
• Do NOT restart transfusion if pulmonary symptoms/signs, fever present
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Allergic Rxn
• Prevention
• Prophylactically treat with antihistamines
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Anaphylactic Rxn
• Signs & Symptoms• Note: very immediate type rxn• Anxiety• Urticaria• Wheezing• Severe dyspnea• Pulmonary/laryngeal edema• Shock • Cardiac arrest
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Anaphylactic Rxn
• Cause
• Infusion of IgA proteins into Pt with IgA antibodies
• IgA deficiency about 1 in 700
• Anaphylactic rxn rate about I per 1,000,000 pts.
• Why disparity not known
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TRALI
• Transfusion Related Acute Lung Injury• aka Noncardiogenic pulmonary edema• Signs & Symptoms• Severe dyspnea• Hypotension• Fever• Chills• Bilateral pulmonary edema
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TRALI
• Cause
• Donor antibodies activate Pt’s WBC’s which cause damage to blood vessels in lung tissue
• Then fluids and proteins leak into alveolar space/interstitium
• Mechanism similar to ARDS
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TRALI
• Management
• Steroids
• Aggressive ventilatory support
• Hemodynamic support
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TRALI
• Prevention
• Transfuse washed RBC’s from which plasma is removed
• Platelet units can also be washed, but platelet function is significantly reduced
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Circulatory Overload
• Signs & Symptoms• Cough• Dyspnea• Pulmonary congestion• Headache• Hypertension• Tachycardia• Distended neck veins
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Circulatory Overload
• Cause
• Iatrogenic – physician induced rxn
• Fluid(s) administered faster than Pt circulation can accommodate volume load
• Some at risk types of pt.’s: congestive heart failure, renal failure, hepatic cirrhosis, normovolemic anemia
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Circulatory Overload
• Management
• Place Pt in upright position, if possible, with feet in dependent position
• Diuretics
• Oxygen
• Morphine (if necessary)
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Circulatory Overload
• Prevention
• Adjust transfusion flow rate based on Pt size and clinical status
• Consider dividing unit(s) into smaller aliquot(s) to better space apart blood component(s) pace of transfusion
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Septic Rxn
• Signs & Symptoms
• Rapid onset of chills & fever
• Vomiting
• Diarrhea
• Profound hypotension
• Shock
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Septic Rxn
• Cause
• Transfusion of bacterially contaminated blood components
• Common problem for platelet concentrates stored at room temperature
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Septic Rxn
• Management
• Obtain blood cultures from Pt
• Return blood component bag(s) to blood bank for further laboratory work-up
• Treat septicemia with antibiotics
• Treat shock with fluids & vasopressors
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Septic Rxn
• Prevention• Collect, process, store, transport, and
transfuse blood components according to contemporary standards of practice (e.g. for FDA standards adhere to cGMP’s – current good manufacturing practices – found in Code of Federal Regulations)
• Transfuse blood components within 1 to 2 hrs – do not exceed 4 hrs
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Delayed Hemolytic Txn Rxn
• Signs & Symptoms
• Fatigue
• Malaise
• Declining hemoglobin/hematocrit
• Conjugated bilirubin may be elevated
• Falling hemoglobin/hematocrit usually noticed 3 to 14 days post transfusion
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Delayed Hemolytic Txn Rxn
• Cause• Anamnestic immune response in Pt to
antigen(s) present on transfused donor cells• Antibody attaches to transfused RBC’s and
RBC’s are removed from Pt’s circulation by reticuloendothelial system (liver/spleen)
• This process is called extravascular hemolysis
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Delayed Hemolytic Trn Rxn
• Management
• Send specimen(s) to Blood Bank for antibody identification work-up
• Provide good Pt history
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Delayed Hemolytic Trn Rxn
• Prevention• Transfuse RBC’s that are phenotype
negative for known clinically significant RBC antibodies in Pt
• Delayed Hemolytic Trn Rxn’s can not be predicted
• Good Pt records and Blood Bank records are essential
• Clinical treatment usually not necessary
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Txn Rxns Usual Incidence Rates
• Some Selected Rates:• Acute Hemolytic ~1:32,000• Febrile 1% to 2%• Allergic 1% to 3%• Anaphylactic ~1:170,000 to
~1:1,000,000• Circulatory Overload ~1:10,000• Delayed Hemolytic~1:11,000
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Infectious Risks of Transfusion(more common risk types)
• Viral:
• HIV 1 & 2 1:493,000
• HTLV-I/II 1:641,000
• Hepatitis B 1:63,000
• Hepatitis C 1:103,000
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Infectious Risks (cont.)
• Bacterial:
• Red Blood Cells (RBC’s) 1:500,000
• Platelets, random 1:1:10,200
• Platelets, pheresis 1:19,000
• Parasites:
• Chagas Dis. (T. cruzi) 1:42,000
• Malaria & Babesia <1:1,000,000
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Txn Rxns - Reminders
• Signs & Symptoms are usually nonspecific
• No predictive tests for when a particular Txn Rxn will occur
• Transfusion is an IRREVERSIBLE process – always benefits against risks
• Be Prepared! – a Txn Rxn can happen unpredictably at anytime !!
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Txn Rxns
The End