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BLOODTRANSFUSION
BRI BUDLOVSKY R3
JANUARY 2015
OVERVIEW
• The process
• Blood components
• Testing
• Consent
• Transfusion reactions
DONATION
DONATION
TEST SPECIFIC AGENTS TESTS
GroupABO,Rh
AlloantibodiesABO and Rh antigen testing
Virus
HIVHep BHep CHTLV
West Nile
Antibodies, nucleic acid testing
BacteriaSyphilis
Bacterial contaminationSerology
Bacterial Culture (plt only)
ParasitesChagas in
at risk donorsantibody
BLOOD COMPONENTS
CONSENT: HISTORY
CONSENT
• Time to think of alternatives
• Describe the product
• Describe benefits & risks
• Describe alternatives
• Answer questions/confirm understanding
• Complete consent form
• Document in chart
RISKS• Hep B: 1/ 153,000
• Hep C: 1/ 2.3 million
• HIV: 1/ 7.8 million
• Minor urticaria: 1/100
• Febrile non-hemolytic: 1/300
• ABO incomp/serious immune: 1/ 40,000
• Sepsis: 1/ 10,000 plts, 1/ 500,000 pRBCs
TESTING
TESTTIMIN
G(min)
Group 5 Patient tested for ABO and Rh antigen
Screen 45Patient tested for alloantibodies from prior
transfusion/pregnancy
Xmatch 45Incubate patient’s blood with donor blood, checks for
immune reaction due to alloantibodies
Computer Xmatch
2Computer picks appropriate unit based on patient and
donor testing. Blood is not actually mixed.
DAT45
RBCs from patient are washed, and then mixed with Coombs Reagent. If they stick together, it means they
have antibodies on their surface (+ for immune transfusion reaction)
TRANSFUSION REACTIONS
56F – POD#3
• L hemi-colectomy for diverticulitis
• Transfusion for low Hb
• You are called for FEVER
DDX: FEVER
• Usual post-op fever causes
• Transfusion specific:
• Febrile non-hemolytic• Hemolytic• Septic
FEBRILE TRANSFUSION REACTION
During or within 4 hours of transfusion:
• >38°C
• Increase by 1°C
MANAGEMENT
• STOP THE TRANSFUSION
• Maintain IV access
• Check patient ID and blood product
• Notify the blood bank
RED FLAGS
• T>39°C• Hypotension/shock• Tachycardia• Dyspnea• Back/chest pain• Oliguria/Hematuria• Nausea/vomiting• Bleeding from IV sites
NON-HEMOLYTIC
HEMOLYTIC BACTERIAL CONTAMINATION
BACTERIAL CONTAMINATION
• From:
• Donor skin/blood• Poor handling
• 10% of transfusion mortality
BACTERIAL CONTAMINATION
• Cultures
• Two patient sites• Bag/line lab
• Antibiotics
• Pip-tazo• Vanco
HEMOLYTIC REACTION
• ABO incompatibility
• ½ from proper labeling wrong patient• Others from improper labeling, testing
error etc.• Non-ABO incompatibility
• From pregnancy/previous transfusion
• >50%: No morbidity• <10%: Fatal
MANAGEMENT
• Check labels
• Call blood bank
• UA for Hb
• DAT
• Fluids
• Supportive
60F – VAGINAL BLEEDING
• Transfused 2U pRBC
• You are called for:
• SOB• SaO2
DDX: DYSPNEA
• Usual post-op SOB causes
• Transfusion specific:
• TACO• TRALI• Anaphylaxis
TACO
• Fluid overload
• Impaired cardiac function +/-• Fast rate of transfusion
• 1/700 transfusions
• Management
• Stop transfusion• Oxygen• Diurese
TACO
• Prevention is key
• Identify at risk patients• Diuretics between/after units• Slow speed (4 hours/U)• Divide products into smaller aliquotes
• Reduce speed without waste
TRALI
• Acute onset:
• Hypoxemia
• Bilateral lung infiltrates on CXR
• No cardiac cause
• No ALI before transfusion, and now ALI present
• DURING or WITHIN 6 hours of transfusion
• No other risk factors for ALI
ALI
TRALI
• Etiology
• Passive transfer of antibodies• Neutrophil reaction to biologically active
compounds in blood• Most common cause of transfusion
related death (up to 10% of TRALI)
• Usually 1-2 hours post (up to 6)
TRALI - MANAGEMENT
• Supportive care
• No evidence for steroids or diuretics
• Reducing risk:
• No plasma/plasma products from multip females• Platelets from males or nullip females• Pool platelets in male plasma• Testing of & deferral of donors with TRALI hx• 2/3 reduction
ANAPHYLAXIS
• Mechanism unclear
• Transfusing IgA / IgE• Antibodies to serum proteins• Transfusion an allergen consumed by donor
• Rare
• 1/40,000• 3% of transfusion fatalities
URTICARIA
• 1/100 transfusions
• Management:
• Interrupt transfusion• Benadryl 25-50mg IV• Resume if:
• Urticaria improving/mild• No associated symptoms
72M – DIALYSIS PATIENT
• Transfused 2U pRBC for chronic support
• Complaining of palpitations
HYPERKALEMIA
• Prolonged storage & irradiation K leakage
62F – LGIB
• 6U pRBC for massive LGIB in ER
• C/O:
• Anxiety• Foot and hand “cramping”• Peri-oral tingling
CITRATE TOXICITY
• Rare!
• Massive transfusion or plex only
• Replace PO or IV
• More common:
• Metabolic alkalosis
SUMMARY
• Know the risks
• Know the benefits
• Know the alternatives
• Document
• Have a high suspicion
• Stop the transfusion and investigate
TO STOP OR NOT?
• Sick or severe
• TRALI
• Hemolysis
• Lab/clerical error
• Sepsis
• Anaphylaxis
• Urticaria
• Febrile non-hemolytic
• TACO
• Fever• NHTR• Sepsis• HTR
• Dyspnea• TRALI• TACO• Anaphylaxis
• Allergic• Urticaria• Anaphylaxis
• Hypotension• Sepsis• Anaphylaxis• HTR
REFERENCES• Bloody Easy
• Rosen’s
• Up-to-date
• CMPA
• www.hemophilia.ca
• TRALI: A clinical review. The Lancet. Sept 2013. Vlaar et al.
EXTRA SLIDES
STORAGE