REACTIONS TO BLOOD TRANSFUSION
Dr. Akram Al-Hilali 2009
08/03/14
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INTRODUCTION Transfusion Hazards Blood, as a biological product, carries many hazards. Main Hazard is transmission of infection: viral, bacterial and parasitic. Immune modulation is another hazard. Iron overload is a hazard. One of the hazards is the possible immunological reactions to the blood components transfused. 08/03/14
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BLOOD TRANSFUSION REACTIONS Hemolytic Reactions (HTR), directed against transfused red cells. – Immediate – Delayed
Non-hemolytic Reactions (NHTR) – Febrile non-hemolytic transfusion reactions (FNHTR) – Allergic reactions
Transfusion-related acute lung injury
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HEMOLYTIC REACTIONS a- Immediate Patient gets the reaction during transfusion, usually in the first minutes. Very serious. Caused by ABO incompatibility Basically caused by clerical, rather than technical error nowadays. Bacterial contamination of the blood can give similar picture clinically. 08/03/14
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IMMEDIATE REACTIONS Symptoms Pain in the back Pain in the chest Pain along the arm receiving blood Apprehension
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IMMEDIATE REACTION Signs Pallor & sweating Fever, starting within a short time Shivering Rapid pulse Drop in BP Reddish urine within hours Rise in bilirubin the following day 08/03/14
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ACTION BY NURSE 1. Stop transfusion. 2. Call doctor. 3. Continue monitoring patient. 4. If doctor agrees that there is a possible reaction send to BB – BTR investigation form-properly filled. – Blood bag with remaining contents. – EDTA (CBC) blood specimen. – Clotted blood specimen. – Urine specimen, if available. 08/03/14
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DELAYED HEMOLYTIC REACTIONS Caused by weak antibodies to red cells. No immediate signs and symptoms at transfusion, usually. Failure to maintain the Hb level in the days following transfusion. Rise in bilirubin within days. No hemoglobinuria If suspected, investigation is carried out as for the immediate type (bag may not be available) 08/03/14
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FEBRILE TRANSFUSION REACTION Caused by leukocyte antibodies, produced from past pregnancies or blood transfusions. SIGNS & SYMPTOMS – Rise of 1oC temp is significant. – Can be associated with rigors.
ACTION BY NURSE – – – –
Stop transfusion. Call doctor May need investigation. Leukocyte depletion of blood by special filter will usually prevent this reaction.
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ALLERGIC TRANSFUSION REACTION A. Allergy to transfused plasma proteins B. Allergy transferred passively from donor through allergens in his plasma (transient). C. Anaphylactic shock resulting from antibodies to IgA in patient’s plasma. This occurs in patient who lack IgA (inherited defect). 08/03/14
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TRANSFUSION-RELATED ACUTE LUNG INJURY (TRALI)
A life-threatening complication of blood transfusion, leading to massive damage in capillaries and alveolar walls of the lungs, thought to be caused by leukocyte agglutinins in transfused plasma against leukocytes of the patient. 08/03/14
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TRALI First described by Brittingham in 1957. Fatal cases reported since 1985. This drew attention to this under-diagnosed or widely unknown condition. Until October 2001 45 fatal cases had been reported in USA. This represented 13% of transfusionrelated deaths. Incidence is 1 in 1000-2000 transfusions of all types of products. 08/03/14
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TRALI-Etiology Traditionally attributed to antibodies against leukocytes (anti-granulocyte, antiHLA Class I and rarely Class II). These antibodies are present in donors (usually multiparous women). There is no direct evidence that the antibodies cause the problem and only in 89% there are such antibodies, not necessarily specific. Recent Canadian study suggests some other predisposing factors in recipients and donor blood. 08/03/14
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TRALI- Etiology, Contd. Predisposing factors in patient include hematologic malignancies, cardiac disease, higher lipids and higher interleukin-6. Predisposing factors in donors (other than antibodies), include older product, presence of lipemia and higher interleukin-6. 08/03/14
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TRALI- Clinical Picture Presentation is almost identical to ARDS. Signs and symptoms of dyspnea and hypoxia. X-ray picture of pulmonary edema, without cardiac function abnormality. Picture starts 1-6 hours after transfusion and progresses insidiously. 08/03/14
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TRANSFUSION REACTION INVESTIGATION FORM BLOOD TRANSFUSION REACTION INVESTIGATION FORM Patient’s Name: Hospital Number: Location: Date: Time reported: Type of Blood Product: Unit Number: DESCRIPTION OF SUSPECTED REACTION ? Fever ? Rigor ? Itching ? Urticaria ? Others Temp before transfusion: Temperature after transfusion: BP at reaction time: Pulse rate at reaction time: Volume of the product transfused when reaction noticed: ACTION TO BE TAKEN BY NURSE ? Transfusion discontinued ? Doctor called ? Patient and unit identity checked DOCTOR’S IMPRESSION & ACTION ? Suspected reaction confirmed ? Reaction compromised patient’s health: YES NO ? Investigation order entered in the system. FORM FILLED AND SENT WITH THE FOLLOWING ? BAG ? EDTA BLOOD SAMPLE ? CLOTTED BLOOD SAMPLE ? URINE SPECIMEN
INVESTIGATION IN BLOOD BANK a- Check of pre-transfusion sample ABO GROUP Rh TYPE ANTIBODY SCREEN
CROSS MATCH
b- Check of post-transfusion sample ABO GROUP Rh TYPE ANTIBODY SCREEN
CROSS MATCH
c- Rechecking blood group and Rh type of unit [ ] d- Check urine sample - If reddish, check for free hemoglobin [ ] - If normal color, check for urobilinogen [ Normal Excess] e- Check serum bilirubin and compare to pre-transfusion figure [ f- Culture of residual blood product in bag, in case of febrile reaction [ COMMENTS BY SENIOR BLOOD BANK TECHNOLOGIST
] ]
COMMENTS BY HEMATOPATHOLOGIST
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Signed:……………… Date:…………………
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NOTES Blood Bank does not check for leukocyte antibodies nor for allergy, as part of the crossmatching procedure. Allergic donors are excluded, if known.
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Investigation of suspected transfusion reaction involves only exclusion of hemolytic reactions and culture for bacteria. 17
How to avoid hazards of blood transfusion? Avoiding transfusion, whenever possible. AUTOTRANSFUSION Use of leukocyte-depleted blood Use of blood substitutes 08/03/14
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Avoiding or limiting blood transfusion Sticking to new criteria for indications and cut off values. Type-and-screen instead of crossmatching Using medicinal means for anemia correction, whenever possible. Using medicinal means to minimize hemorrhage Early diagnosis of treatable causes of anemia to avoid arriving at a stage when transfusion becomes unavoidable Education of patient and family on hazards of blood transfusion 08/03/14
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PATIENTS MAY REACT TO BLOOD AND COMPONENTS Watch transfusion to detect the reaction Report to BB BB responds BB investigates They should take corrective actions if reaction is proven. Watching and reporting suspected reactions is one good practice point. 08/03/14
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WE HAVE TO RISE ABOVE THE FOG TO SEE THE HIGH POINTS
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