نور رب بسم

Prevention & Management of

transfusion reaction

Dr.sh.sharifi

20-21 th feb 2008

Febrile Rxn

Management Give antipyretics (e.g. aspirin – except

children – Reyes Syndrome) Avoid aspirin in thrombocytopenic pt’s Do not restart transfusion

Febrile Rxn

Prevention;

Antipyretics Prestorage leukoreduced blood products

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

Allergic Rxn

Prevention

Prophylactically treat with antihistamines

TRALI

Management Steroids Aggressive ventilatory support Hemodynamic support

TRALI

Prevention Typically ,TRALI is adonor specific

phenomen so donor deferred from donating plasma products.

Transfuse washed RBC’s from which plasma is removed

Platelet units can also be washed, but platelet function is significantly reduced

Circulatory Overload

Management Slow rate of infusion Place Pt in upright position, if possible, with

feet in dependent position Diuretics Oxygen Morphine (if necessary)

Circulatory Overload

Prevention Vigilant assesment of patients input and

output Slow rate of infusion Pretransfusion and/or intratransfusion

diuretic adminstration

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

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

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

MANAGEMENT OF ACUTE HEMOLYTIC TRANSFUSION REACTION

1-Stop the transfusion and maintain intravenous access. 2-make initial rapid assessment of patient and requirements for

basic and advanced support. 3-notify transfusion service,collect transfused units(full or

partially),tubing,etc.,and return them to blood bank. 4-Reconfirm identity of blood units and patient. 5-collect appropriate patient blood specimens 6-pending results of initial evaluation,consider the following

supportive approches: A-IV fluid resuscitation to treat hypotension. B-maintenance intravenous fluids at 3000 ml/m2/day with

adminstration of sodium bicarbonate to keep PH>7.0

Continue….

C-diuretics:mannitol(20%),100 ml/m2 give over 30-60 min,then 30 ml/m2/hr for text 12 hours;furosemide(adults 20-80 mg;infants and children 1-2 mg/ kg to an adult dose)

D-low-dose dopamine,1-5 mcg/kg/min. E-replacement of procoagulant factors and fibrinogen

with fresh frozen plasma and cryoprecipitate and platelets with platelet concentrate.

F-heparin:50-100 u/kg,(unfractionated heparin)and infusion 15-25 u/kg/hr to keep heparin level 0.4-0.7 u/ml.

prevention

The best way to prevent AHTR is to avoid transfusion

Defining clear-cut and defendable indication for transfusion

Careful determination of the Hb or HCT level for ordering TRX

patient-donor identification Autologousblood safer than homologous

Serious Hazards of Transfusion Reporting Scheme

Overview of cases from 2004 Report (n=541)

Distribution of Errors in IBCT Category (2004 Report)

Serious Hazards of Transfusion Reporting Scheme

Requesting Procedure

Check the patient’s case note Transfusion history Special requirements

- e.g., irradiated, CMV negative

Complete request form or order com

Sampling ProcedureStep 1: Ask the patient to tell you their:

Full Name + Date of Birth

Be extra vigilant when checking the identity of the unconscious / compromised patient

Check this information against the patient’s ID wristband

Sampling ProcedureEXAMPLE REQUEST FORM

Step 2: Check the patient’s ID

wristband against documentation

e.g., case notes or request form for:

First name Surname Date of birth Hospital number

ANY HOSPITAL

MACDONALD MORAG

ITU

ANAEMIA

11/07/1956

NOT KNOWN

NOT KNOWN

100198E

Only bleed one patient at a time

Do NOT use pre-labelled tube

Hand write the sample tube beside the patient

Send the sample to the laboratory in the most appropriate way for the clinical situation, i.e. routine / emergency

Sampling Procedure

Labelling the venous blood sample

Hand written label to include:- Full name Date of birth Hospital number Gender Date Signature of person who has taken the sample

At the bedside By the person taking the sample

Component Red blood cells

Platelets

Fresh Frozen Plasma

Cryoprecipitate

Storage

• First name• Surname• Date of birth• Hospital number

Collection Procedure

Follow procedure for each blood component collected

Step 1: Complete the Blood Collection Form (or follow your local collection procedure) with the following information:

Collection Procedure

Ensure prompt delivery of the blood component to the clinical area

Step 2: Check the patient’s IDdetails against compatibility/traceability label attached to the blood bag

Step 3: Document removalof unit on blood fridge registeror electronic release system

LEAKSDISCOLOURATIONCLUMPING

EXPIRY DATE

If there is ANY discrepancy - DO NOT transfuse

Pre-administration Procedure

Step 3: Undertake visual inspection

Step 1: Check the blood component has been prescribed

Step 2: Undertake baseline observations

Pre-administration checks Personal checks:

- clean your hands- wear personal protective equipment

Equipment checks:- Personal protective equipment is available and is clean and sterile- A correctly completed prescription chart- Observation chart- Giving set- Disposable bags - Trolley

Administration Process

Equipment• Venous access devices

• Blood administration sets

• Infusion fluids

• Infusion devices

Administration Procedure

Be extra vigilant when checking the identity of the unconscious / compromised patient

Step 1: Ask the patient to tell you their:

Full Name + Date of Birth

Check this information against the patient’s ID wristband

Step 2: Check the patient’s First name Surname Date of birth Hospital number

on the compatibility/traceability label against the patient’s ID wristband

Administration Procedure

If there is ANY discrepancy - DO NOT transfuse

Administration ProcedureStep 3: Check the compatibility/traceability label with the blood bag label

BLOOD GROUP

DONOR COMPONENT

NUMBER

RhD GROUP

Documentation ProcedureEXAMPLE COMPATIBILITY REPORT FORM

COMPLETE DOCUMENTATIONEnsure that you sign the transfusion documentation to say you have checked the blood component against the patient’s wristband

EXAMPLE COMPATIBILITY/TRACEABILITY LABEL

Ensure donor component number is recorded on the transfusion documentation

Complete documentation for every blood component transfused

G101 602 597 229 N

MACDONALD

MACDONALD

MORAG

MORAG

11/07/19566FEMALE

25 HILL STREETTOWN CENTRE

100198E

100198E

G101 602 597 229 N

20/12/2006

Red Cells

Red Cells

O Rh POS

G101 602 597 229 N

Red Cells

Monitoring Procedure

• Communicate with patient

• Record vital signs

*Early Check*

• Each unit must be infused within four hours

• Complete documentation

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

Investigations of transfusion reaction are necessary for :

1. Diagnosis

2. Selection of appropriate therapy

3. Transfusion management

4. Prevention of future transfusion reaction.

Investigations should include correlations of clinical data with

laboratory result .

Important clinical data :

1. Diagnosis

2. Medical history of pregnancies, transplant, and previous transfusion.

3. Current medication

4. Clinical signs and symptoms of the reaction.

5. Question related to the transfusion:

Amount of blood transfused to cause the reaction.

How fast , how long ?

The use of blood warmer.

Any filter used ? Other solutions.

Any drugs given at the time of transfusion

2. As recquired procedures

•ABO grouping and RH typing, pre and post transfusion•Major compatibility testing , pre and post transfusion•Antibody screening test , pre and post transfusion•Alloantibody identification•Antigen typings•Free hemoglobin in first voidedurine post transfusion•Unconjugated bilirubin 5 – 7 hours post transfusion.

3. Extended procedures

•Gram stain and bacterial culture of unit

•Quantitative serum Hemoglobin.

•Serum Haptoglobin , pre and post transfusion

•Peripheral blood film.

•Coagulation and renal output study

•Urine hemosiderin

Inco

mp

atib

le T

rans

fusi

on

6 12 18 24 30

HoursHours

Plasma HEMOGLOBINPlasma HEMOGLOBIN

HaptoglobinHaptoglobin

Urine HemoglobinUrine Hemoglobin

SerumSerum bilirubinbilirubin

Delayed Hemolytic Trn Rxn

Management Send specimen(s) to Blood Bank for antibody

identification work-up Provide good Pt history

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

DHTR

In the futureDHTR may be prevented;

Artificial blood substitutes

More sensitive antibody screening method

In all cases in which transfusion is thought to be the cause of death,the FDA must be notified by phone within 24 h after discovery and this must followed up with a written report within 7 days(21 CFR 606 .170)