August 5, 2015 - Transfusion Reactions

Question 1

The Patient’s Right to Decide

Answer 1

The patient needs to obtain informed consent prior to a blood transfusion, unless extenuating circumstances such as a loss of consciousness in which case consent is assumed.

Question 2

Benefits of Blood Transfusion

Answer 2

• Maintain oxygen carrying capacity in critical illness
• Help stop bleeding
• Facilitate high risk surgical and medical treatments
• Alleviate the symptoms of anemia, thrombocytopenia, and low levels of non-cellular blood components.

Question 3

Risks of Blood Transfusion

Answer 3

• Circulatory overload
• Immunological reactions to blood components
• Transmission of bloodborn pathogens

Question 4

Reporting a Transfusion Reaction

Answer 4

ALL transfusion reactions and transfusion-related errors MUST be reported to the blood bank.

Question 5

Most Errors in the Blood Transfusion Occur…

Answer 5

During blood sample collection from a patient on a ward, often by a clinical clerk. Very error prone step in the process.

Question 6

Blood Components

Answer 6

• Red Blood Cells
• Platelets
• Plasma

Question 7

Plasma Products

Answer 7

• Cryoprecipitate
• Immunoglobulin products
• Clotting factor concentrates
• Albumin

Question 8

Hemoglobin Threshold for Transfusion

Answer 8

Maintain hemoglobin over 70 g/L during active bleeding

Consider maintaining a higher level of 80-100 g/L for people with impaired pulmonary function, uncontrolled coronary disease, or uncontrolled bleeding.

Anticipate the need for a transfusion when hemoglobin drops below 80 g/L.

Patients with levels over 100 g/L are unlikely to benefit from a transfusion.

Question 9

Target Platelet Count

Answer 9

Platelets can be administered through a transfusion for patients with a decreased number (thrombocytopenia).

Target platelet count depends on the risk of bleeding. Factors that could influence this are the procedure, as well as concurrent anticoagulation.

Question 10

Frozen Plasma Indications

Answer 10

Most commonly used in restoring normal coagulation in patients with disordered clotting.

Usually 750-1000 mL for an average sized adult with an infusion time of 30-120 minutes.

A single dose should restore coagulation to normal.

Question 11

Vitamin K

Answer 11

A vitamin that is needed for complete synthesis of certain proteins that are required for blood coagulation.

Warfarin is an antagonist of Vitamin K.

Question 12

Warfarin

Answer 12

An anticoagulant (blood thinner) that antagonizes Vitamin K.

Question 13

Types of Transfusion Reactions

Answer 13

Acute: During or shortly after the transfusion

Delayed: Hours to days afterwards

Question 14

Bacterial Contamination in Blood Transfusion

Answer 14

Most common type of infectious hazard of transfusion.

Multiple components of the same donation may be contaminated.

Notify the blood bank.

Question 15

First Step for Any Transfusion Reaction

Answer 15

STOP THE TRANSFUSION

Question 16

Acute Hemolytic Transfusion Reactions

Answer 16

The one you NEVER want to see.

The immediate cause is the presence of antibodies in the red cell recipient that are incompatible with the red blood cells that were transfused. This is most often the ABO groups, but may occasionally be other blood group systems.

Usually due to clerical error or improper labelling.

The common clinical presentation for acute hemolytic transfusion reactions are red urine (hemoglobinuria), back pain, fever and chills. Management involves supportive care.

Question 17

Common Presentation for Acute Hemolytic Transfusion Reactions

Answer 17

• Blood in urine (hemoglobinuria)
• Back pain
• Fever and chills

Question 18

Febrile Non-hemolytic Transfusion Reactions (FNHTR)

Answer 18

The most common adverse effect affecting 1 in 10 transfusions of pooled random donor platelets, and 1 in 300 units of RBC transfusion.

Attributed to soluble factors released by white blood cells and platelets during storage. This can be reduced, but not eliminated by removal of WBC’s at the time of collection.

Management involves controlling the fever with acetaminophen.

For patients with a history of FNHTR, premedication may be utilized.

Question 19

Transfusion Reaction Flowchart

Answer 19

Question 20

Four Categories of Transfusion Reactions

Answer 20

1. Fever
2. Dyspnea
3. Cytopenias
4. Transmission of Infections

Question 21

Causes of Fever Symptoms

Answer 21

• Bacterial contamination
• Acute intravascular hemolytic transfusion reaction
• Febrile, non-hemolytic transfusion reaction

Question 22

Causes of Dyspnea Symptoms

Answer 22

• Transfusion-related acute lung injury
• Transfusion-associated circulatory overload
• Anaphylaxis

Question 23

Causes of Cytopenia Symptoms

Answer 23

• Delayed hemolytic transfusion reaction
• Transfusion-associated graft versus host disease (GVHD)
• Post-transfusion purpura

Question 24

Transfusion Related Acute Lung Injury (TRALI)

Answer 24

Syndrome of acute respiratory distress with hypoxia, bilateral pumonary edema, no evidence of congestive heart failure, hypotension and fever may occur.

The onset is 1-6 hours after transfusion (usually within 2 hours)

Occurs after transfusion of plasma-containing blood products.

Resolves in 24-72 hours. Treatment is supportive and most patients require mechanical ventilation. 5-10% of patients die.

Occurs because some blood donors have antibodies against foreign HLA or granulocyte proteins. If these antibodies bind to neutrophils in the recipient, they may induce adhesive molecules on the cell surface and the neutrophils may adhere to the pulmonary endothelial cells and enter the lungs. Degranulation of these white cells in lung tissue results in damage to the alveoli and pulmonary edema.

Question 25

Transfusion-Associated Circulatory Overload (TACO)

Answer 25

TACO results when the rate of transfusion is greater than what cardiac function can accommodate.

Patients commonly present with dyspnea, orthopnea, engorged neck veins and hypertension/tachycardia.

Management is to stop the transfusion, administer diuretics, utilize supplemental oxygen as required, and resume transfusion once the patient is stabiized.

Question 26

Orthopnea

Answer 26

Shortness of breath (dyspnea) which occurs when lying flat, causing the person to have to sleep or lay propped up in a chair. Commonly seen as a manifestation of heart failure.

Question 27

Dyspnea Flowchart

Answer 27

Question 28

Delayed Hemolytic Transfusion Reaction

Answer 28

Antibody-mediated destruction of transfused RBC’s 48 hours or more after the transfusion. The recipient has been sensitized by a prior transfusion or pregnancy, but the recipient antibody level was below the threshold of detection.

Antibodies are usually IgG. Rarely life threatening. May be clinically silent, but some common features are an unexpected fall in post-transfusion hemoglobin levels, failure to obtain the expected rise in hemoglobin post-transfusion, post-transfusion jaundice, or post-transfusion spherocytosis on blood film.

Question 29

Transfusion Associated Graft vs. Host Disease (TA-GVHD)

Answer 29

TA-GVHD occurs when transfused immune-competent cells mount an immune response to recipient tissues. Fatal in over 90% of cases.

Clinical presentation usually includes…

• Onset after about 10 days
• Fever, rash, diarrhea, liver dysfunction
• Overwhelming infection

Diagnosed via a biopsy where you are looking for donor lymphocytes. Risk is much greater for immunodeficient patients. For patients in any risk group, the blood pack is irradiated prior to transfusion to kill off the WBC’s.

Question 30

Post-Transfusion Purpura

Answer 30

Acute thrombocytopenia that occurs around 10 days post-transfusion. It involves the formation of antibodies against platelet antigens in which the donor platelets are destroyed.

Platelet count is usually < 10x10⁹ /L and is accompanied by fever, chills, or wheezing.

Mortality is around 8% and is caused mainly due to intracranial hemorrhage.