NON INFECTIOUS NON INFECTIOUS TRANSFUSION TRANSFUSION

REACTIONSREACTIONS

CLASSIFICATION CLASSIFICATION Transfusion reaction

acute delayed

Immunologic Nonimmunologic Immunologic Nonimmunologic

A. Hemolytic transfusion A. Hemolytic transfusion reactions (HTR)reactions (HTR) Accelerated clearance or lysis of red cells in the Accelerated clearance or lysis of red cells in the

transfusion recipient. Usually d/t immunological transfusion recipient. Usually d/t immunological incompatibility b/w blood donor and the recipient incompatibility b/w blood donor and the recipient

A. C LASSIFICATION WITH RESPECT TO TIME OF A. C LASSIFICATION WITH RESPECT TO TIME OF OCCURRENCEOCCURRENCE

AcuteAcute (AHTRs ) (AHTRs )During or within 24 hours of transfusionDuring or within 24 hours of transfusion

Delayed ( DHTRs )Delayed ( DHTRs )After 24 hours of transfusion.( 5-7 days )After 24 hours of transfusion.( 5-7 days )

Signs and Symptoms of Acute HTR

Inder GAInder GA

•Hypotension•Hemoglobinuria (This may be masked in patients undergoing GU surgeries due to hematuria)•Undue bleeding from surgical site

Abrupt onset Abrupt onset Nausea, Vomiting Nausea, Vomiting AnxietyAnxiety ShockShockFacial flushing Facial flushing Oliguria Oliguria Fever, chills Fever, chills HemoglobinuriaHemoglobinuriaPain in back or flanks Pain in back or flanks Bleeding Bleeding

DyspnoeaDyspnoea

Under GAUnder GA

Conscious patient

Complications of AHTRSComplications of AHTRSRenal failure :- 36 %Renal failure :- 36 %

Thrombus formation in renal Thrombus formation in renal arteriolesarterioles

DIC :- 10 %DIC :- 10 %

Immediate Mx of Immediate Mx of suspected AHTRssuspected AHTRs

A. Action for nursing staffA. Action for nursing staff

In presence of fever > 38 In presence of fever > 38 0 0 C and / or any S/s C and / or any S/s • Stop the transfusion Stop the transfusion • Check the pt identity and unit transfusedCheck the pt identity and unit transfused• Save any urine the pt passesSave any urine the pt passes• Monitor pulse, BP and temp at 15 min intervalMonitor pulse, BP and temp at 15 min interval

Immediate Mx of Immediate Mx of suspected AHTRssuspected AHTRs

B. Action for medical staffB. Action for medical staff

1. 1. Isolated fever / fever & shivering, stable Isolated fever / fever & shivering, stable observations, correct unit given observations, correct unit given :- :- FNHTR FNHTR = Paracetemol 1 g orally , = Paracetemol 1 g orally , observe P, BP and T every 15 min for 1 observe P, BP and T every 15 min for 1 hr, then hourly. If no improvement call hr, then hourly. If no improvement call hematology medical staffhematology medical staff

Immediate Mx of Immediate Mx of suspected AHTRssuspected AHTRs

2. 2. Fever with pruritis, urticaria :- Fever with pruritis, urticaria :- Allergic Allergic transfusion reaction transfusion reaction = Chlorpheniramine = Chlorpheniramine 10 mg iv10 mg iv

3. 3. Any other s/s, hypotension, incorrect Any other s/s, hypotension, incorrect unit :-unit :- AHTRAHTR = discontinue transfusion, N = discontinue transfusion, N saline to maintain urine output 1ml saline to maintain urine output 1ml /kg / h. full and continuous monitoring/kg / h. full and continuous monitoring

Mx of AHTRsMx of AHTRs Take immediate note and inform blood bank Take immediate note and inform blood bank Seek help immediately from skilled anaesthetist Seek help immediately from skilled anaesthetist

or emergency team or emergency team Complete the transfusion reaction form and Complete the transfusion reaction form and

appropriately record the followingappropriately record the following

• Type of transfusion reaction Type of transfusion reaction • Time after the start of transfusion to the occurrence Time after the start of transfusion to the occurrence

of reactionof reaction• Unit No. of component transfused Unit No. of component transfused • Volume of the component transfusedVolume of the component transfused

Send the following lab investigations:Send the following lab investigations:Immediate post transfusion blood samples (clotted and EDTA) Immediate post transfusion blood samples (clotted and EDTA) for:for:

Repeat ABO & Rh (D) grouping Repeat ABO & Rh (D) grouping Repeat antibody screen and crossmatch Repeat antibody screen and crossmatch Direct antiglobulin test Direct antiglobulin test Complete blood count (CBC)Complete blood count (CBC) Plasma hemoglobin Plasma hemoglobin Coagulation screen Coagulation screen Renal function test (urea, creatinine and electrolytes) Renal function test (urea, creatinine and electrolytes) Liver function tests (bilirubin, ALT and AST)Liver function tests (bilirubin, ALT and AST)

Blood culture in special blood culture bottles Blood culture in special blood culture bottles Blood unit alongwith BT setBlood unit alongwith BT setSpecimen of patient’s first urine following reactionSpecimen of patient’s first urine following reaction

Investigation of suspected AHTRs Investigation of suspected AHTRs

Other reactions Other reactions characterized by characterized by hemolysishemolysis

1. Pts with autoimmune hemolytic anemia1. Pts with autoimmune hemolytic anemia

2. Donor units m/b hemolysed due to 2. Donor units m/b hemolysed due to • Bacterial contaminationBacterial contamination• Excessive warmingExcessive warming• Erroneous freezingErroneous freezing• Addition of drugs or iv fluidsAddition of drugs or iv fluids• Trauma from extracorporeal devicesTrauma from extracorporeal devices• Red cell enzyme deficiencyRed cell enzyme deficiency

Maintain adequate renal perfusion by Maintain adequate renal perfusion by - Fluid challengesFluid challenges- Frusemide infusion Frusemide infusion - If hypovolumic – dopamine infusionIf hypovolumic – dopamine infusionTransfer to high dependency areaTransfer to high dependency area Repeat coagulation and biochemistry Repeat coagulation and biochemistry screens ever 2- 4 screens ever 2- 4

hrlyhrlyIf urinary output not maintained If urinary output not maintained seek expert renal adviceseek expert renal adviceHemofiltration or dialysis Hemofiltration or dialysis m/b required for acute tubular m/b required for acute tubular

necrosisnecrosisDIC development – DIC development – component therapy may be requiredcomponent therapy may be required

Mx of confirmed AHTRsMx of confirmed AHTRs

Due to secondary immune responses Due to secondary immune responses following re-exposure to a given red following re-exposure to a given red cell antigencell antigen

- Ab most commonly involved – Rh , Ab most commonly involved – Rh , Kidd, Duffy and KellKidd, Duffy and Kell

- No clinical signs of red cell destruction No clinical signs of red cell destruction but positive DATbut positive DAT

- Rarely fatalRarely fatal

DELAYED HEMOLYTIC DELAYED HEMOLYTIC TRANSFUSION REACTIONSTRANSFUSION REACTIONS

Sign and symptomsSign and symptoms - fever- fever- fall in Hb concentration- fall in Hb concentration- Jaundice and hemoglobinuriaJaundice and hemoglobinuriaMxMx- Requires no Tt.Requires no Tt.- Hypotension & renal failure – may Hypotension & renal failure – may

require expert medical advicerequire expert medical advice

DELAYED HEMOLYTIC DELAYED HEMOLYTIC TRANSFUSION REACTIONSTRANSFUSION REACTIONS

Diagnosis & Management Diagnosis & Management Routine examinationRoutine examination Stop Tx immediatelyStop Tx immediately Monitor vital signs, urine out putMonitor vital signs, urine out put Verify identification of the patientVerify identification of the patient IV line kept open with NSIV line kept open with NS Evaluate for evidence of HTR, septic shock, Evaluate for evidence of HTR, septic shock,

anaphylaxisanaphylaxisTRALI other D/D feverTRALI other D/D fever

Report and send transfusion set to B/BReport and send transfusion set to B/B Diagnosis of exclusion

Blood Bank:• Recheck the records for clerical error• check for identification error• Visual check for hemolysis, appearance of returned unit• Evidence of blood group incomparabilityPre Tx samplePre Tx sample Post Tx Post Tx

samplesampleABO,Rh groupABO,Rh groupDCTDCTICTICTRepeat CxMRepeat CxM

•Gram stain, culture•HLA, Plt, Granulocyte specific Abs in recipient

Treatment Treatment AntipyreticsAntipyretics

acetaminophen ; 325-650mg orally acetaminophen ; 325-650mg orally (adult) 10-15mg/kg (adult) 10-15mg/kg

(children)(children) MeperiedineMeperiedine

severe chills - 25-50mg IV severe chills - 25-50mg IV contraindication: renal failurecontraindication: renal failure Pts on MAO inhibitors Pts on MAO inhibitors

AntihistaminicsAntihistaminics: not indicated: not indicated Tx should not be restarted for 30 min. Tx should not be restarted for 30 min.

D. URTICARIAL AND D. URTICARIAL AND ANAPHYLACTIC REACTIONSANAPHYLACTIC REACTIONS

- Usually mild allergic reactions- Usually mild allergic reactionsTreatmentTreatment- Non systemic reaction Non systemic reaction = = focal urticaria / focal urticaria /

angioedema angioedema : Antihistamine: Antihistamine- Mild systemicMild systemic = = chest tightness, generalized chest tightness, generalized

urticaria / angioedema : urticaria / angioedema : Antihistamine, Antihistamine, salbutamol and / or inhaled steroidsalbutamol and / or inhaled steroid

URTICARIAL AND ANAPHYLACTIC URTICARIAL AND ANAPHYLACTIC REACTIONS REACTIONS

Moderate systemic Moderate systemic = = wheeze / wheeze / breathlessness / obstructive laryngeal breathlessness / obstructive laryngeal oedema oedema : All above including prednisolone : All above including prednisolone , consider adrenaline, consider adrenaline

Severe systemic Severe systemic = = Severe breathing Severe breathing difficulty, shock arrhythmias, loss of difficulty, shock arrhythmias, loss of consciousness consciousness : Adrenaline im and all : Adrenaline im and all aboveabove

E. BACTERIAL CONTAMINATIONE. BACTERIAL CONTAMINATION

Most common microbiological Most common microbiological complication of transfusioncomplication of transfusion

Higher incidence after platelet Higher incidence after platelet transfusiontransfusion

Apparent infrequency of Apparent infrequency of clinical events of baclinical events of bacterial cterial

contaminationcontaminationNon pathogenic bacteriaNon pathogenic bacteria- Insufficient no. of bacteriaInsufficient no. of bacteria- Premedication with steroidesPremedication with steroides- Pts already on antibioticsPts already on antibiotics- Immunosuppressed pts Immunosuppressed pts

underinvestigatedunderinvestigated

Clinical features Clinical features - - usually appear immediately during transfusionusually appear immediately during transfusion

- S/t symptoms delayed until after the end of S/t symptoms delayed until after the end of transfusion transfusion

- - fever ( inc > 2 - fever ( inc > 2 oo C ) C )- - chills / rigors- chills / rigors- Hypotension, collapse, shockHypotension, collapse, shock- Nausea, vomittingNausea, vomitting- DIC, intravascular hemolysis, renal failureDIC, intravascular hemolysis, renal failure

ManagementManagement- - Stop transfusionStop transfusion. Retain unit for . Retain unit for investigationinvestigation

- Give Give general supportive Tt general supportive Tt (iv fluids , (iv fluids , inotropic agents , diuretics to maintain inotropic agents , diuretics to maintain urine output )urine output )

- Broad spectrum Broad spectrum antibioticsantibiotics until blood until blood culture report comesculture report comes

- Assess need for Assess need for intensive care intensive care bedbed

How to Prevent Errors in the Transfusion Chain

Where in the process do errors occurWhere in the process do errors occur??

Who is making the errors?Who is making the errors? Why are the errors occuring – which elements Why are the errors occuring – which elements

of good transfusion practice are failing of good transfusion practice are failing

Sample ErrorSample Error Technical ErrorTechnical Error

Wrong BloodWrong Blood IssuedIssued Storage ErrorStorage Error

Patient Patient MisidentificationMisidentification

Administrative Administrative ErrorError

Error Prevention in the Transfusion Error Prevention in the Transfusion ServicesServices

Adherence to Standard Operating Procedures Adherence to Standard Operating Procedures (SOPs)(SOPs) for pre-transfusion testing for pre-transfusion testing

Antibody screenAntibody screen in patients at risk of in patients at risk of alloimmunization; preferably universal screenalloimmunization; preferably universal screen

Antibody identificationAntibody identification when required when required Appropriate storage and transfusion Appropriate storage and transfusion

instructions on labelsinstructions on labels Clerical checks prior to issueClerical checks prior to issue

Prevention of transfusion Prevention of transfusion reactionreaction

Education and training of nurses health care Education and training of nurses health care assistants, doctors at every level assistants, doctors at every level

Proper communication at all level should be Proper communication at all level should be appropriate, timely and effective.appropriate, timely and effective.

Promoting the knowledge in hospital, raising Promoting the knowledge in hospital, raising awareness by having more educational awareness by having more educational sessions and poster available to hospital sessions and poster available to hospital