TRANSFUSION REACTIONS AND COMPLICATIONS

09/10/2014 CME TeachingEmma McVeigh

CASE REPORT

68 year old lady background of CML referred to Emergency Department from the Transfusion Day Ward. She was receiving 2nd unit RBC when became febrile and increasingly dyspnoeic.

O/E:

Pyrexic 38.7ocOxygen Sat 90% R.A. RR28HR104BP101/68

INVESTIGATIONS

CXR:

MANAGEMENT

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BLOOD TRANSFUSION IN ED

BLOOD TRANSFUSION REACTIONSFebrile non-haemolytic transfusion reactionBacterial Infection reactionAllergic/ Urticarial transfusion reactionAnaphylactic/ Immunologic transfusion reactionTransfusion Associated Acute Lung Injury (TRALI)Transfusion Associated Circulatory Overload (TACO)Iron OverloadAcute Haemolytic ReactionDelayed Haemolytic ReactionTransfusion Associated Graft – VS – Host Disease

FEBRILE NON-HAEMOLYTIC REACTION

BACTERIAL TRANSFUSION REACTION

ALLERGIC / URTICARIAL REACTION

ANAPHYLACTIC REACTION

T.R.A.L.I.

CANADIAN CONSENSUS CRITERIA FOR TRANSFUSION-RELATED ACUTE LUNG INJURY TRALI:

1. Acute onset during or within 6 hours of transfusion

2. Hypoxemia

3. Bilateral infiltrates on chest x-ray

4. No evidence of volume overload

5. No preexisting lung injury

6. No alternative risk factor for ALI

Possible TRALI:

1. Criteria for TRALI, as stated above in criteria 1-5

2. Alternative risk factor for ALI identified (ie, sepsis)

Abbreviations: ALI, acute lung injury; TRALI, transfusion-related acute lung injury.

T.A.C.O.

IRON OVERLOAD

ACUTE HAEMOLYTIC REACTIONClinical Features Pathophysiology

Emergency!! ABO incompatible blood, eg group A, B or AB red cells to a group O patient

Haemolysis Human error

Fever

Back pain

Haemoglobinuria

ARF

DIC

Note: Difficult to assess patients – intubated/ ICU setting

DELAYED HAEMOLYTIC REACTION

TRANSFUSION ASSOCIATED GRAFT-VS-HOST DISEASE (GVHD)

MANAGEMENT OF TRANSFUSION REACTION1. Stop the transfusion immediately

2. Check and monitor vital signs

3. Maintain intravenous (IV) access (Do not flush existing line and use a new IV line if required)

4. Check the right pack has been given to the right patient

5. Notify Lab

2014 Australian Red Cross Blood Service

SCGH GUIDELINES

http://chips/departments/transfusionservices/pdf/PolicyManual/Transfusion%20Reaction%20Algorithm.pdf

http://chips/departments/transfusionservices/pdf/PolicyManual/Transfusion%20Reaction%20Algorithm.pdf

INVESTIGATIONS Immediate post transfusion blood samples (clotted and EDTA)

Repeat ABO & Rh (D) grouping G+XM Direct antiglobulin test FBC Haptoglobin Coagulation screen RFT LFTSs (BR) DIC (DD/Fibrinogen)

Blood culture in special blood culture bottles

Blood unit

Specimen of patient’s first urine following reaction u/a - bilirubin

RISK FACTORS

1. Individual patient characteritics

2. Blood Component

3. Equi[ment

4. Concomitant Medications

5. Procedures

PREVENTION

PREVENTION

1. Correct identification patient and blood products

2. Following protocol

3. ?use of prophylactic drugs

4. Identification of risk groups

5. Treatment of blood products

PATIENTS FOR WHOM GAMMA IRRADIATED BLOOD PRODUCTS SHOULD BE CONSIDERED 1. Patients with known or suspected congenital

immunodeficiency syndromes

2. Patients with hematologic malignancies (leukemia, lymphoma)

3. Patients with solid tumors receiving chemotherapy

4. Patients after bone marrow transplant

5. Patients receiving human leukocyte antigen-matched donations or directed blood prodcuts from first-degree relatives

PATIENTS FOR WHOM LEUKOREDUCED BLOOD PRODUCTS SHOULD BE CONSIDERED1. Patients who are non-hepatic solid organ transplant candidates

2. Patients who have had 1 or more documented FNHTR

3. Patients requiring long-term platelet support (eg, aplastic anemia, ITP)

4. Patients at risk for clinically significant CMV infection (eg, bone marrow transplant recipients, etc.)

5. Abbreviations: CMV, cytomegalovirus; FNHTR, febrile nonhemolytic reaction; ITP, idiopathic thrombocytopenic purpura

CASE REPORT

68yo lady b/g CML px ED with Respiratory Distress and febrile

?Diagnosis

?Management Plan

SUMMARY…

1. Risk Factors for Transfusion Reaction

2. Early Identification

3. Early Notification

4. Supportive Management

5. Prevention Transfusion Reaction

REFERENCES

1. Toy P, Popovsky MA, Abraham E, et al. Transfusion-related acute lung injury: definition and review. Crit Care Med. 2005;33(4):721-726. (Review)

2. Kleinman S, Caulfield T, Chan P, et al. Toward an understanding of transfusion-related acute lung injury: statement of a consensus panel. Transfusion. 2004;44(12):1774-1789.

3. 2014 Australian Red Cross Blood Service. http://www.transfusion.com.au/adverse_events/management_steps

4. Rosa Sanchez, MD, Peter Bacchetti, PhD, Pearl Toy, MDTransfusion-Related Acute Lung Injury: A Case-Control Pilot Study of Risk Factors American Journal of Clinical Pathology. Am J Clin Pathol. 2007;128(4):128-134. v

5. Reprinted from Transfusion Medicine Reviews, Vol 6/ issue 2, Jeanne V. Linden, Patricia T. Pisciotta. Transfusion-associated graft-versushost disease and blood irradiation, pages 116-123. Copyright 1992. Elevesier.

6. Ratko TA, Cummings JP, Oberman HA, et al.Evidencebased recommendations for the use of WBC-reduced cellular blood components. Transfusion. 2001;41(10):1310-1319

7. Cadogan m. http://www.lifeinthefastlane.com/education/symptoms/transfusion-reaction/ Dec 2011

THANK YOU! ??????

QUESTIONS?????