Clinical Considerations in Transfusion Medicine Flashcards by Kyra Catedral

is essentially the monitoring system for blood transfusions.

It tracks the entire process,

from blood donation to the patient receiving the transfusion, to identify and prevent any problems.

Hemovigilance

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Model used to track, analyze and ultimately to improve transfusion outcomes

HEMOVIGILANCE MODEL (NHSN, AABB, CDC)

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problem that happens during or after a blood transfusion,

ranging from mild (fever, chills) to life-threatening.

There is an untoward reaction of the patient towards the blood of the donor

RECOGNITION OF A TRANSFUSION REACTION

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SIGNS OF TR

• Fever (> or equal to 1 degree Celsius
increase in body temp)
• Chills/Rigors
• Respiratory distress (wheezing, coughing, dyspnea, cyanosis)
• Hyper/Hypotension
• Pain - Abdominal, etc.
• Skin manifestations - urticaria, rasha flushing, edema
• Jaundice, Hemoglobinuria
• Nausea, Voming,
• Abnormal Bleeding
• Oliguria/ Aruria

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CATEGORIES of TRANSFUSION
REACTIONS

Hemolytic

Delayed Serologic

Febrile Non-hemolytic

Allergic

Anaphylactic

Transfusion-Related Acute Lung

Injury (TRALI)

Transfusion-Associated Graft-versus-Host Disease (TA-GVHD)

Bacterial Contamination

Transfusion-Associated Circulatory Overload (TACO)

Transfusion Hemosiderosis

Citrate Toxicity

Post-Transfusion Purpura

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ACUTE (<24 hours)

Immune mediated
(Ag + Ab complex formation)

Hemolytic
Febrile, nonhemolytic
Allergic
Anaphylactic
TRALI

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ACUTE (<24 hours)

Non-immune mediated
(Physical/ Mechanical Setup)

Sepsis
TACO
Physical hemolysis

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DELAYED (>24 hours)

Immune mediated
(Ag + Ab complex formation)

Hemolytic
Serologic RBC
HLA alloimmunization
TA-GVHD
Post-transfusion Purpura

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DELAYED (>24 hours)

Non-immune mediated
(Physical/ Mechanical Setup)

Hemosiderosis
Citrate toxicity

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Acute Transfusion Reactions (TR)

Febrile
Allergic
Pulmonary

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ATR

Febrile Reactions (3)

AHTR (Acute Hemolytic Transfusion Reaction)

TAS (Transfusion-Associated Sepsis)

FNHTR (Febrile Non-Hemolytic Transfusion Reaction)

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ATR

Allergic Reactions (2)

Mild Allergic Reaction
Severe Allergic Reaction (Anaphylactic)

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ATR

Pulmonary Reactions (2)

TACO (Transfusion-Associated Circulatory Overload)

TRALI (Transfusion-Related Acute Lung Injury)

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HEMOLYTIC TR (4)

• Acute
• Delayed
• Immune mediated
• Non-immune mediate

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Rapid destruction of red cells during, immediately after, or after 24 hours

Severity ranges from fever to death

d/t antibody mediated incompatibility;Wrong blood unit

ACUTE HEMOLYTIC TRANSFUSION REACTION

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How to manage Acute HTR?

Early and aggressive
(1) fluid resuscitation and
(2) control of blood

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Antibody + Antigen

Immune complexes

Release of vasoactive amines

Vasodilation
Hypotension
Immune complex deposition
Thrombus formation

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Antibody + Antigen

Immune complexes

Activation of MAC

Intravascular Hemolysis

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Antibody + Antigen

Immune complexes

Activation of MAC

Release of vasoactive amines

Activation of Coagulation
cascade

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Antibody + Antigen

Immune complexes

Activation of Coagulation
cascade

Disseminated
Intravascular Coagulation
Bleeding

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ACUTE HTR

As little as_____ of transfused incompatible unit can cause this cascade

In cases of Intravascular hemolysis,____ and ____ is present. (HALLMARK OF INTRAVASCULAR HEMOLYSIS)

10ml

Hemoglobinuria and Hemoglobinemia

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ACUTE HTR

•_______ → Targets the endothelial cells of the blood vessels

• Severe hypotension would lead to____ (Very low blood pressure;
cannot circulate well in the important organs; cannot deliver 02)

Immune complex usually gets stuck in the_____ - will now compromise the filtration capacity of the kidney → Can now lead to_____(Cannot concentrate urine well)

Thrombus formations can lead to_____ (Blocking of blood vessels because of thrombus) → Narrowing of the passages → The patient will have a hard time breathing.

Vasoactive amines

SHOCK

KIDNEYS -> Renal Failure

Bronchospasm

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ACUTE HTR

Since the Coagulation Factors are activated it will lead to unwanted clotting resulting to_______

Disseminated Intravascular Coagulation (DIC)

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ACUTE HTR

KNOWN CAUSES:

• Collection of blood from the incorrect patient
• Incorrect labeling of blood samples
• Misidentification of sample at blood bank
• Issuance of wrong unit from blood bank
• Transfusion of blood to incorrect patient
• Aliquoting a patient sample to improperly labeled test tube

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AHTR: NON-IMMUNE MEDIATED CAUSES:

• Chemical damage • Mechanical damage Improper shipping or storage temps • Incomplete deglycerolization of frozen red cells • Needles used for transfusion are of small bore size • Rapid pressure infuser or roller pumps • Improper use of blood warmers • Concurrent infusion of unapproved fluids • Bacterial contamination

DELAYED HEMOLYTIC TRANSFUSION REACTION Symptoms appear after_____ ***Less severe*** and require no treatment ____antibodies (Newly developed antibodies) Rapid decrease of hemoglobin to pretransfusion levels Presence of____

24 hours (7-10 days) IgG spherocytes

When suspecting for delayed HTR perform________ • Because we want to detect the IgG antibodies that were newly formed • Expect that in delayed HTR the test is_____

Direct Agglutination Test (DAT) POSITIVE

PATHOPHYSIOLOGY OF DELAYED HTR ______+______ Activation of______ System Release of_____ Activation of____ and _____

IgG + Red cell Antigen Reticuloendothelial system Cytokines T and B lymhocytes

HTR Clinical S&S Fever, chills, flushing, pain at site of infusion, tachycardia, tachypnea, lower back pain, hemoglobinemia, hemoglobinuria, hypotension; dramatic and severe; rapid onset

AHTR

HTR Clinical S&S >24 hours posttransfusion; fever temperature increase ≥1 deg C (or 2 deg F) with or without chills; unexplainable decrease in hemoglobin and hematocrit, occasional mild jaundice

DHTR

HTR Major complications No major complications; less severe reaction

DHTR

HTR Major complications DIC, renal failure, irreversible shock, death

AHTR

HTR Causes Complement activation, ABO incompatibility

AHTR

HTR Causes Anamnestic response to red tell antigen; alloantibody not demonstrating or missed

DHTR

HTR Laboratory Clerical check, visual inspection of post-transfusion sample; DAT-positive or negative, repeat ABO testing, tests for hemolysis;

AHTR

HTR Laboratory DAT-positive; posttransfusion antibody screen- positive; INCREASED hemoglobin/hematocrit; tests for hemolysis

DHTR

HTR Management AHTR

Treat hypotension and DIC; maintain renal blood flow

HTR Management DHTR

Provide antigen-negative donor units; no additional treatment necessary

HTR Prevention AHTR DHTR

Avoid errors of mislabeled samples and patient identification; design systems to decrease chances of technical error Check patient records

HTR: Non-Immune Mediated • Exposure of red cells to extreme _____ • Improper_____ of RBC unit •_____ destruction •_____ solutions •____ contamination of unit • ______defect

temperature deglycerolization Mechanical Incompatible Bacterial Intrinsic red cell

• Antibody development after 24 hours • Positive DAT • Antibody identification

Delayed Serologic Transfusion Reactions

• ***Most commonly observed*** REACTION • Increase if 1°C or 2°F • Cytokines • Transfused • In response to transfusion

Febrile Nonhemolytic Transfusion Reaction

What are other ways that we can do to the blood unit to ***avoid these cytokines?*** We can perform ______ Since WBCs are removed, there are no more source of cytokines

leuko-reduction.

FNTR Fevers are possible because of the_____ from the WBC transfused to the recipient • _____ are pyrogens meaning they can mediate interleukin production for fever • ______________ are given to patients before or during the transfusion process to address a fever that may arise during or after transfusion

cytokines; cytokines Antipyretics/ Acetaminophen

Clinical signs and symptoms Fever-temperature increase 21° C (or 2º F): chills; nausea: vomiting: headache; and back pain Major complications: Usually not life-threatening for recipient Causes: Recipient HLA antibodies to HLA antigens on donor lymphocytes Cytokines released by WBCs during blood product storage Clinical laboratory test: DAT-negative No visible hemolysis Management: Antipyretics-acetaminophen Prevention: Prestorage leukocyte reduction of blood products

FEBRILE NONHEMOLYTIC TRANSFUSION REACTION

• Ranges from minor urticarial effects to fulminant anaphylactic shock and death

Allergic and Anaphylactic Transfusion Reaction

Allergic and Anaphylactic Transfusion Reaction • Common with_____ transfusions _____→ mast cell degranulation (release of vasoactive amines) _____→ IgA-deficient patients

plasma IgE IgA

________- The S&S are usually limited to the skin and the GIT (Abdominal pain, urticarial rashes, hives) ________- Multi-organ failure, Shock, hypotension and even death

Allergic TR Anaphylactic TR

Clinical S&S Hives, erythema, itching within 15-20 minutes of transfusion (Cutaneous)

ALLERGIC

Clinical S&S Rapid onset and severe, after a small volume is transfused; wheezing, coughing, dyspnea, bronchospasm, respiratory distress, vascular instability; no fever

ANAPHYLACTIC

Major complications Shock, loss of consciousness; death

ANAPHYLACTIC

Causes Recipient antibodies to foreign ***plasma proteins*** or other substances such as drugs or food consumed by blood donor

ALLERGIC

Causes Associated with ***genetic IgA deficiency*** (Not always) in recipient; possesses IgG, complement-binding anti-lgA antibodies

ANAPHYLACTIC

Management Transfusion interrupted and ***antihistamine administered***

ALLERGIC

Management Transfusion terminated; ***epinephrine (Steroids)*** administered Oxygen administered and open airways maintained

ANAPHYLACTIC

Prevention ***Premedication with antihistamine*** if patient history reveals repetitive allergic reactions May necessitate ***washed cellular products***

ALLERGIC

Prevention Plasma-containing products from IgA-deficient donors Washed red cell and platelet products

ANAPHYLACTIC

Respiratory distress and pulmonary edema (1-2 hours post-transfusion) Infusion of antibodies to leukocyte antigens (Class I and I| HLA)

Transfusion-Related Acute Lung Injury (TRALI)

Transfusion-Related Acute Lung Injury (TRALI) Respiratory distress and pulmonary edema (______post-transfusion) Infusion of____ to leukocyte antigens (Class I and IIHLA)

1-2 hours antibodies

The donor has antibodies against the HLA antigens present within the recipient ***The most common cause of Transfusion Related Death***

TRALI

• Anti-HLA can activate the neutrophils: Epithelial damage Capillary leakage Pulmonary edema

TRALI

According to Harmening, the blood units that contain Anti-HLA antibodies came from MULTIPAROUS WOMEN (Many history of pregnancy) ; That is why recommended donors are male.

TRALI

Clinical signs and symptoms Marked respiratory distress; fever, hypotension, chills, cyanosis; rapid onset-occurs during transfusion or ***within 6 hours of completion***

Causes Interaction of granulocytes and HLA-specific donor antibodies, complement activation, aggregation of granulocytes that leads to ***blockage of pulmonary microvasculature;*** capillary damage, vascular leakage, pulmonary edema

TRALI Clinical laboratory test DAT-_____; no visible hemolysis; WBC antibody screen in donor and recipient

negative

Transfusion-Related Acute Lung Injury (TRALI) Management Respiratory support Prevention Defer implicated donor for_____ containing components; Avoid use of_____ components from_____

plasma plasma ; multiparous women

Rare but highly lethal ***(90% mortality rate)*** VERY immunocompetent donor lymphocytes (Particularly ***T-cells)*** _____ days post-transfusion

TRANSFUSION-ASSOCIATED GRAFT-VERSUS-HOST DISEASE 3-6 days

The Cytotoxic T-cells of the donor will attack the organs and tissues of the recipient The host is unable to destroy the transfused cell the donor lymphocytes will proliferate and respond to the HLA antigen in the host To prevent this from happening we either give the donor immunosuppressants or we irradiate the blood unit to kill of the T-cells