clinical condition associated with transfusion

64
Clinical Condition Associated with Transfusion 章章章 章章 章章章章章章 章章章章章章章

Upload: olaf

Post on 27-Jan-2016

49 views

Category:

Documents


3 download

DESCRIPTION

Clinical Condition Associated with Transfusion. 章人欽 醫師 高雄捐血中心 台灣血液基金會. Adverse effects of transfusion. Immediate Management of a Suspected Transfusion Reaction Investigation Requirements Immediate Adverse Effects of Transfusion Delayed and Long Term Adverse Effects of Transfusion - PowerPoint PPT Presentation

TRANSCRIPT

Page 1: Clinical Condition Associated with Transfusion

Clinical Condition Associated with Transfusion

章人欽 醫師高雄捐血中心

台灣血液基金會

Page 2: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Management of a Suspected Immediate Management of a Suspected Transfusion Reaction Transfusion Reaction Investigation Requirements Investigation Requirements Immediate Adverse Effects of Transfusion Immediate Adverse Effects of Transfusion Delayed and Long Term Adverse Effects of Delayed and Long Term Adverse Effects of Transfusion Transfusion Transfusion Reaction Report FormTransfusion Reaction Report Form

Page 3: Clinical Condition Associated with Transfusion

Should be Should be reported toreported to the patient's the patient's treating treating doctordoctor and to the and to the hospital blood hospital blood bankbank as soon as possible as soon as possible

SpeedSpeed is essential because of the possible is essential because of the possible life-threatening naturelife-threatening nature of acute of acute transfusion reactionstransfusion reactions

Immediate nursing managementImmediate nursing management• stopping the transfusionstopping the transfusion• reperforming the pretransfusion checklistreperforming the pretransfusion checklist• documenting observationsdocumenting observations• providing immediate patient careproviding immediate patient care• contacting the treating medical officercontacting the treating medical officer

Adverse effects of transfusionAdverse effects of transfusion

Page 4: Clinical Condition Associated with Transfusion

Immediate ManagementImmediate Management

If the transfusion is to be discontinued and thIf the transfusion is to be discontinued and the reaction investigated:e reaction investigated:

1.1. DisconnectDisconnect pack from patient pack from patient

2.2. Complete Transfusion Reaction Complete Transfusion Reaction Report FormReport Form

3.3. Obtain Obtain blood/urine samplesblood/urine samples as directed as directed

4.4. Send pack, Transfusion Reaction Report Form Send pack, Transfusion Reaction Report Form and samples to hospital Blood Bankand samples to hospital Blood Bank

Adverse effects of transfusionAdverse effects of transfusion

Page 5: Clinical Condition Associated with Transfusion

Investigation RequirementsInvestigation Requirements1.1. Blood pack Blood pack

2.2. Post reaction blood sample (EDTA) Post reaction blood sample (EDTA)

3.3. Post reaction urine sample (do not Post reaction urine sample (do not delay investigation while waiting for a delay investigation while waiting for a urine sample)urine sample)

4.4. Forward above to the hospital blood Forward above to the hospital blood bankbank

5.5. Completed Transfusion Reaction Report Completed Transfusion Reaction Report Form Form

Adverse effects of transfusionAdverse effects of transfusion

Page 6: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusionImmediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion Febrile Reactions Febrile Reactions Urticarial (Allergic) Reactions Urticarial (Allergic) Reactions Severe Allergic (Anaphylactic) Reactions Severe Allergic (Anaphylactic) Reactions Acute Hemolytic Reactions Acute Hemolytic Reactions Bacterial Contamination Bacterial Contamination Transfusion-Related Acute Lung Injury Transfusion-Related Acute Lung Injury Volume Overload Volume Overload Hypothermia Hypothermia Citrate Toxicity Citrate Toxicity Potassium Effects Potassium Effects

Page 7: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Febrile ReactionsFebrile Reactions - - 11 to be caused by to be caused by

• recipient antibodiesrecipient antibodies reacting with reacting with white white cell antigenscell antigens or white cell fragments in or white cell fragments in the blood productthe blood product

• or due to or due to cytokinescytokines which accumulate in which accumulate in the blood product during storagethe blood product during storage

fever occurs more commonly with fever occurs more commonly with platelet transfusion (10-30%)platelet transfusion (10-30%) than red than red cell transfusion (1-2%)cell transfusion (1-2%)

Page 8: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Febrile ReactionsFebrile Reactions - - 22 It is important to distinguish from fever It is important to distinguish from fever

due to the patient's due to the patient's underlying diseaseunderlying disease or infection (check pretransfusion or infection (check pretransfusion temperature). temperature).

Fever may be the initial symptom in a Fever may be the initial symptom in a more serious reactionmore serious reaction such as bacterial such as bacterial contamination or hemolytic reaction and contamination or hemolytic reaction and should be taken seriouslyshould be taken seriously

Page 9: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Febrile ReactionsFebrile Reactions - - 33 If the fever is accompanied by significant If the fever is accompanied by significant

changes in changes in blood pressureblood pressure or other signs or other signs and symptoms, the transfusion should be and symptoms, the transfusion should be ceased and investigatedceased and investigated

Check for Check for HLA antibodiesHLA antibodies in patients having in patients having repeated febrile reactionsrepeated febrile reactions

ManagementManagement:: • Symptomatic, paracetamolSymptomatic, paracetamol• Many are prevented by Many are prevented by leucocyte filtrationleucocyte filtration

Page 10: Clinical Condition Associated with Transfusion

粉 厲 害 吧 !!

Page 11: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Urticarial (Allergic) Reactions - Urticarial (Allergic) Reactions - 11 approximately approximately 1%1% of recipients of recipients caused by caused by foreign plasma proteinsforeign plasma proteins On rare occasions they may be associated On rare occasions they may be associated

with with laryngeal oedema and bronchospasmlaryngeal oedema and bronchospasm If urticaria occurs in isolation (without fever If urticaria occurs in isolation (without fever

and other signs), slow the rate or and other signs), slow the rate or temporarily stop transfusiontemporarily stop transfusion

Page 12: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Urticarial (Allergic) Reactions - Urticarial (Allergic) Reactions - 22 If symptoms are bothersome, consider If symptoms are bothersome, consider

administering an administering an antihistamineantihistamine before before restarting the transfusionrestarting the transfusion

If If associated with other symptomsassociated with other symptoms, cease , cease the transfusion and proceed with the transfusion and proceed with investigationinvestigation

mild urticarialmild urticarial reactions with no other signs reactions with no other signs or symptoms, it is not necessary to submit or symptoms, it is not necessary to submit blood specimens for investigationblood specimens for investigation

Page 13: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Severe Anaphylactic Reactions Severe Anaphylactic Reactions - 1- 1Cardiovascular instabilityCardiovascular instability

• HypotensionHypotension• TachycardiaTachycardia• cardiac arrhythmiacardiac arrhythmia• loss of consciousnessloss of consciousness• shock and cardiac arrestshock and cardiac arrest

Respiratory involvementRespiratory involvement • dyspnoeadyspnoea• stridorstridor

Page 14: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Severe Anaphylactic Reactions Severe Anaphylactic Reactions - 2- 2 Immediately Immediately stopstop transfusion transfusion Supportive care includingSupportive care including

• airwayairway management may be required management may be required• AdrenalineAdrenaline may be indicated. Usually given as may be indicated. Usually given as

1:1000 solution, 0.01mg/kg s.c./i.m. or slow i.v.1:1000 solution, 0.01mg/kg s.c./i.m. or slow i.v. Check Check IgA levelsIgA levels and anti-IgA antibodies and anti-IgA antibodies Patients with anti-IgA antibodies require Patients with anti-IgA antibodies require

special blood products such as washed red special blood products such as washed red blood cells and plasma products prepared blood cells and plasma products prepared from IgA deficient donorsfrom IgA deficient donors

Page 15: Clinical Condition Associated with Transfusion
Page 16: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Acute Haemolytic ReactionsAcute Haemolytic Reactions - 1- 1 The majority are caused by transfusion of The majority are caused by transfusion of

ABO incompatible bloodABO incompatible blood, eg. group A, B or , eg. group A, B or AB red cells to a group O patientAB red cells to a group O patient

Most are the result of Most are the result of human errorhuman error such as such as the transfusion of properly labelled blood to the transfusion of properly labelled blood to the wrong patient, or improper identification the wrong patient, or improper identification of pretransfusion blood samplesof pretransfusion blood samples

Non-immune haemolysis in the blood Non-immune haemolysis in the blood container or during administration can occur container or during administration can occur due to due to physical disruptionphysical disruption (temperature (temperature changes, mechanical forces, non-isotonic changes, mechanical forces, non-isotonic fluid)fluid)

Page 17: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Acute Haemolytic ReactionsAcute Haemolytic Reactions - 2- 2 SymptomsSymptoms

• Chills, feverChills, fever• pain (along IV line, back, chest)pain (along IV line, back, chest)• HypotensionHypotension• dark urinedark urine• uncontrolled bleeding due to DICuncontrolled bleeding due to DIC

Page 18: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Acute Haemolytic ReactionsAcute Haemolytic Reactions - 3- 3 ManagementManagement

• Immediately stop transfusionImmediately stop transfusion

• Notify hospital blood bank urgently Notify hospital blood bank urgently ((another patientanother patient may also have been may also have been given the wrong blood!)given the wrong blood!)

• ICU support and therapy includesICU support and therapy includes vigorous treatment of hypotensionvigorous treatment of hypotension maintenance of renal blood flowmaintenance of renal blood flow

Page 19: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Acute Haemolytic ReactionsAcute Haemolytic Reactions - 4- 4 PreventionPrevention

• Proper identification of the patient Proper identification of the patient sample collectionsample collection proper labelling of samples and productsproper labelling of samples and products blood administrationblood administration

• Prevention of non-immune hemolysis Prevention of non-immune hemolysis adherence to proper handling, storage and adherence to proper handling, storage and

administration of blood productsadministration of blood products

Page 20: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Bacterial ContaminationBacterial Contamination - 1 - 1 Bacteria may be introduced into the pack at Bacteria may be introduced into the pack at

the time of blood collection from sources the time of blood collection from sources such as donor skin, donor bacteraemia or such as donor skin, donor bacteraemia or equipment used during blood collection or equipment used during blood collection or processing. processing.

Bacteria may multiply during storage.Bacteria may multiply during storage. Gram positive and Gram negative organisms Gram positive and Gram negative organisms

have been implicated.have been implicated. PlateletsPlatelets are more frequently implicated are more frequently implicated

than red cellsthan red cells

Page 21: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Bacterial ContaminationBacterial Contamination - 2 - 2 SymptomsSymptoms

• Very high feverVery high fever• RigorsRigors• profound hypotensionprofound hypotension• nausea and/or diarrheanausea and/or diarrhea

Page 22: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Bacterial ContaminationBacterial Contamination - 3 - 3 ManagementManagement

• Immediately Immediately stopstop the transfusion the transfusion

• Notify the hospital blood bankNotify the hospital blood bank

• After initial supportive care, After initial supportive care, blood blood culturescultures should be taken and broad- should be taken and broad-spectrum antimicrobials commencedspectrum antimicrobials commenced

• Laboratory investigation will include Laboratory investigation will include culture of the blood packculture of the blood pack

Page 23: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Bacterial ContaminationBacterial Contamination - 4 - 4 PreventionPrevention

• Inspect blood productsInspect blood products prior to transfusion prior to transfusion• Some but not all bacterially contaminated Some but not all bacterially contaminated

products can be recognised (products can be recognised (clots, clumps, clots, clumps, or abnormal colouror abnormal colour))

• Maintaining appropriate Maintaining appropriate cold storagecold storage of red of red cells in a monitored blood bank refrigerator cells in a monitored blood bank refrigerator is importantis important

• Transfusions should not proceed beyond Transfusions should not proceed beyond the recommended the recommended infusion time (4 hours)infusion time (4 hours)

Page 24: Clinical Condition Associated with Transfusion

就是要海尼根 ...

Page 25: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Transfusion-Related Acute Lung Injury Transfusion-Related Acute Lung Injury - 1- 1 a clinical diagnosis of exclusion a clinical diagnosis of exclusion

characterised by characterised by acute respiratory distress and bilaterally acute respiratory distress and bilaterally

symmetrical pulmonary edema with symmetrical pulmonary edema with hypoxemia developing during or within hypoxemia developing during or within 6 6 hours afterhours after a transfusion a transfusion

A CXR shows interstitial or alveolar A CXR shows interstitial or alveolar infiltrates when no cardiogenic or other infiltrates when no cardiogenic or other cause of pulmonary edema existscause of pulmonary edema exists

Page 26: Clinical Condition Associated with Transfusion

TRALI - Radiographic findingsTRALI - Radiographic findings Chest radiograph, before and after Chest radiograph, before and after

blood transfusion, of a patient with blood transfusion, of a patient with transfusion-related acute lung injury transfusion-related acute lung injury (TRALI)(TRALI)

Bilateral pulmonary infiltratesBilateral pulmonary infiltrates consistent with consistent with pulmonary edemapulmonary edema are are an essential criterion for the clinical an essential criterion for the clinical diagnosis of TRALI. diagnosis of TRALI.

Radiographs may be Radiographs may be patchypatchy in the in the first hoursfirst hours following transfusion, with following transfusion, with progression of the alveolar and progression of the alveolar and interstitial infiltrates such that there interstitial infiltrates such that there can be a can be a ‘‘whiteout’whiteout’ of the entire lung of the entire lung

Radiological findings tend to be Radiological findings tend to be more more remarkable than physical findingsremarkable than physical findings

Blood Reviews (2006) 20, 139–159Vox Sanguinis (2005) 89, 1–10

Page 27: Clinical Condition Associated with Transfusion
Page 28: Clinical Condition Associated with Transfusion

Criteria for the clinical diagnosis of TRALICriteria for the clinical diagnosis of TRALI

British Journal of Haematology (2007) 136, 788–799

Page 29: Clinical Condition Associated with Transfusion

Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion Transfusion-Related Acute Lung Injury Transfusion-Related Acute Lung Injury – 2– 2

• IncidenceIncidence• In North America In North America

Quebec Quebec 1/100,000-1/10,0001/100,000-1/10,000 transfusions transfusions United States United States 1/5,000-1/1,3231/5,000-1/1,323 transfusions transfusions

• In Europe (rarer) In Europe (rarer) 1.3/1,000,000-1/7,9001.3/1,000,000-1/7,900 transfusions transfusions

• to date the definition of TRALI appears to be differto date the definition of TRALI appears to be different depending upon the local, the true incidence of ent depending upon the local, the true incidence of TRALI remains unknownTRALI remains unknown

Blood Reviews (2006) 20, 139–159

Adverse effects of transfusionAdverse effects of transfusion

Page 30: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Transfusion-Related Acute Lung Injury Transfusion-Related Acute Lung Injury - 3- 3 CauseCause

Pulmonary vascular effectsPulmonary vascular effects are thought are thought to occur secondary to to occur secondary to cytokinescytokines in the in the transfused product or transfused product or

from interaction between from interaction between patient white patient white cell antigens and donor antibodiescell antigens and donor antibodies (or (or vice versa)vice versa)

Page 31: Clinical Condition Associated with Transfusion

Anti Neutrophil antibodies: **

3% during pregnancy

7.7% female donors

78% of granulocyte recipients

Anti Neutrophil antibodies: **

3% during pregnancy

7.7% female donors

78% of granulocyte recipients

TRALI Mechanisms: Maternal Sensitization to Fetal AntigensTRALI Mechanisms: Maternal Sensitization to Fetal Antigens

Anti – HLA antibodies*

1st pregnancy : 7.8%

2nd pregnancy: 14.6%

3rd pregnancy: 28.3%

Anti – HLA antibodies*

1st pregnancy : 7.8%

2nd pregnancy: 14.6%

3rd pregnancy: 28.3%

* Densmore et al. Transfusion 1999;39:103-6

** Stroncek et al. Transfusion 1996;36: 1009-15

Page 32: Clinical Condition Associated with Transfusion

TRALI - PathogenesisTRALI - Pathogenesis

Blood Reviews (2006) 20, 139–159

The two-event model of TRALI

Page 33: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Transfusion-Related Acute Lung Injury Transfusion-Related Acute Lung Injury - 4- 4 ManagementManagement

Symptomatic supportSymptomatic support oxygen administrationoxygen administration may require intubation and may require intubation and

mechanical ventilationmechanical ventilationSymptoms generally resolve over 24-48 Symptoms generally resolve over 24-48

hourshours

Page 34: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

HypothermiaHypothermia Rapid infusion of Rapid infusion of large volumeslarge volumes of stored of stored

bloodblood InfantsInfants are particularly at risk during are particularly at risk during

exchange or massive transfusionexchange or massive transfusion ManagementManagement

• Appropriately maintained Appropriately maintained blood warmersblood warmers during massive or exchange transfusionduring massive or exchange transfusion

• warming of other intravenous fluidswarming of other intravenous fluids• the use of devices to maintain patient body the use of devices to maintain patient body

temperaturetemperature

Page 35: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Volume OverloadVolume Overload Patients with cardiopulmonary disease and Patients with cardiopulmonary disease and

infants are at risk of volume overload infants are at risk of volume overload especially during rapid transfusion.especially during rapid transfusion.

ManagementManagement• Stop the transfusionStop the transfusion• administer administer oxygen and diureticsoxygen and diuretics as required as required

PreventionPrevention• Avoid unnecessary fluidsAvoid unnecessary fluids• use appropriate infusion ratesuse appropriate infusion rates

Page 36: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Citrate toxicityCitrate toxicity - 1- 1 Citrate is the anticoagulant used in blood Citrate is the anticoagulant used in blood

productsproducts usually rapidly metabolised by the liverusually rapidly metabolised by the liver may cause may cause hypocalcaemia and hypocalcaemia and

hypomagnesaemiahypomagnesaemia when citrate binds when citrate binds calcium and magnesiumcalcium and magnesium

can result in myocardial depression or can result in myocardial depression or coagulopathycoagulopathy

Page 37: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Citrate toxicityCitrate toxicity - 2- 2 Patients most at risk are those with liver Patients most at risk are those with liver

dysfunction or neonates with immature liver dysfunction or neonates with immature liver function having rapid large volume function having rapid large volume transfusiontransfusion

ManagementManagement• Slowing or temporarily stoppingSlowing or temporarily stopping the the

transfusion allows citrate to be metabolisedtransfusion allows citrate to be metabolised• Replacement therapyReplacement therapy may be required for may be required for

symptomatic hypocalcaemia or symptomatic hypocalcaemia or hypomagnesaemiahypomagnesaemia

Page 38: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Potassium Effects Potassium Effects - 1- 1 Stored red cellsStored red cells leak potassium leak potassium

proportionately throughout their storage proportionately throughout their storage lifelife

IrradiationIrradiation of red cells increases the rate of of red cells increases the rate of potassium leakagepotassium leakage

Clinically significant Clinically significant hyperkalaemiahyperkalaemia can can occur during rapid, large volume occur during rapid, large volume transfusion of older red cell units in small transfusion of older red cell units in small infants and childreninfants and children

Page 39: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Immediate Adverse Effects of TransfusionImmediate Adverse Effects of Transfusion

Potassium Effects Potassium Effects - 2- 2 PreventionPrevention

• Red cells are irradiated just prior to issueRed cells are irradiated just prior to issue

• Blood Blood less than 7 daysless than 7 days old is generally old is generally used for rapid large volume transfusion used for rapid large volume transfusion in small infants (eg cardiac surgery, in small infants (eg cardiac surgery, ECMO, exchange transfusion)ECMO, exchange transfusion)

Page 40: Clinical Condition Associated with Transfusion
Page 41: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusionDelayed and Long Term Adverse EffectsDelayed and Long Term Adverse Effects Delayed Haemolysis Delayed Haemolysis Alloimmunisation Alloimmunisation Transfusion associated Graft Versus Host Transfusion associated Graft Versus Host

Disease Disease Immunomodulatory effects Immunomodulatory effects Iron accumulation Iron accumulation Infectious Disease transmission Infectious Disease transmission

Page 42: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Delayed and Long Term Averse EffectsDelayed and Long Term Averse Effects

Delayed Hemolysis Delayed Hemolysis - 1- 1 Patients may develop Patients may develop antibodiesantibodies to red cell to red cell

antigens. Antibodies can occur naturally, or antigens. Antibodies can occur naturally, or may arise as a consequence of previous may arise as a consequence of previous transfusion or pregnancytransfusion or pregnancy

The antibody may cause shortened red cell The antibody may cause shortened red cell survival, survival, with clinical features of fever, with clinical features of fever, jaundice and lower than expected jaundice and lower than expected hemoglobin following transfusionhemoglobin following transfusion

Most delayed haemolytic reactions produce Most delayed haemolytic reactions produce few symptoms and may go unrecognisedfew symptoms and may go unrecognised, , however there are reports of serious however there are reports of serious consequences in critically ill patients consequences in critically ill patients

Page 43: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Delayed and Long Term Averse EffectsDelayed and Long Term Averse Effects

Delayed Hemolysis Delayed Hemolysis - 2- 2 PreventionPrevention

• An An antibody screenantibody screen is performed as part is performed as part of pre-transfusion testingof pre-transfusion testing

• When an antibody is detected, it is When an antibody is detected, it is identified and appropriate antigen identified and appropriate antigen negative blood is providednegative blood is provided

• Sometimes antibodies fall below Sometimes antibodies fall below detectable limits and may not be detected detectable limits and may not be detected by pretransfusion testing by pretransfusion testing

Page 44: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Delayed and Long Term Averse EffectsDelayed and Long Term Averse Effects

Alloimmunisation (RBC)Alloimmunisation (RBC) - 1- 1 Patients experiencing Patients experiencing alloantibodyalloantibody

formation are asymptomaticformation are asymptomatic The alloantibody is discovered at the The alloantibody is discovered at the

time of pretransfusion testingtime of pretransfusion testing Appropriate antigen negative blood will Appropriate antigen negative blood will

be suppliedbe supplied

Page 45: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Delayed and Long Term Averse EffectsDelayed and Long Term Averse Effects

Alloimmunisation (RBC)Alloimmunisation (RBC) - 2- 2PreventionPrevention

• Alloimmunisation to the D and K (Kell) Alloimmunisation to the D and K (Kell) antigens is prevented by the provision of antigens is prevented by the provision of Rh(D) negative and Kell negative blood Rh(D) negative and Kell negative blood

• This is important for This is important for females with child-females with child-bearing potentialbearing potential as these antibodies can as these antibodies can cause severe hemolytic disease of the cause severe hemolytic disease of the newborn during pregnancynewborn during pregnancy

Page 46: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Delayed and Long Term Averse EffectsDelayed and Long Term Averse Effects

Alloimmunisation (RBC)Alloimmunisation (RBC) - 3- 3At risk groupsAt risk groups

• Patients with sickle cell disease or major Patients with sickle cell disease or major haemoglobinopathy syndromes who are haemoglobinopathy syndromes who are chronically transfusedchronically transfused are at greatest are at greatest risk of alloantibody formationrisk of alloantibody formation

• Prior to commencing transfusion, patients Prior to commencing transfusion, patients with these condition should have extended with these condition should have extended red cell phenotypingred cell phenotyping performed (EDTA performed (EDTA sample)sample)

• Blood matchedBlood matched for for the patient's Rhesus the patient's Rhesus and Kell antigens is usually supplied for and Kell antigens is usually supplied for transfusion transfusion

Page 47: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Delayed and Long Term Averse EffectsDelayed and Long Term Averse Effects

Alloimmunisation (Platelets)Alloimmunisation (Platelets) - 1- 1 When When thrombocytopenic patientsthrombocytopenic patients do not do not

achieve the expected post-transfusion achieve the expected post-transfusion platelet count increment they are said to platelet count increment they are said to be refractorybe refractory

This usually occurs in patients receiving This usually occurs in patients receiving frequent platelet transfusionsfrequent platelet transfusions

There are clinical and immunological There are clinical and immunological causes of platelet refractorinesscauses of platelet refractoriness

Page 48: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Delayed and Long Term Averse EffectsDelayed and Long Term Averse Effects

Alloimmunisation (Platelets)Alloimmunisation (Platelets) - 2- 2CauseCause

• Clinical causesClinical causes include; sepsis, DIC, include; sepsis, DIC, bleeding, fever, some drugs, and bleeding, fever, some drugs, and enlarged spleen.enlarged spleen.

• Immunological causesImmunological causes include the include the development of antibodies to human development of antibodies to human leucocyte antigens (HLA) or human leucocyte antigens (HLA) or human platelet antigens (HPA) platelet antigens (HPA)

Page 49: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Delayed and Long Term Averse EffectsDelayed and Long Term Averse Effects

Alloimmunisation (Platelets)Alloimmunisation (Platelets) - 3- 3 ManagementManagement

• Immunological refractoriness can be Immunological refractoriness can be managed by the provision of managed by the provision of HLA or HPA HLA or HPA matched plateletsmatched platelets

PreventionPrevention• Leucocyte reductionLeucocyte reduction of blood products to of blood products to

levels less than 10levels less than 1066/unit reduces the /unit reduces the likelihood of alloimmunisationlikelihood of alloimmunisation

• This can be achieved through the use of This can be achieved through the use of prestorage or bedside leucocyte reducedprestorage or bedside leucocyte reduced blood products blood products

Page 50: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Delayed and Long Term Averse EffectsDelayed and Long Term Averse Effects

Transfusion associated Graft Versus-Transfusion associated Graft Versus-Host Disease (Ta-GVHD) Host Disease (Ta-GVHD) - 1- 1

Ta-GVHD occurs when Ta-GVHD occurs when donor lymphocytesdonor lymphocytes in cellular blood products engraft in a in cellular blood products engraft in a susceptible transfusion recipientsusceptible transfusion recipient

These donor lymphocytes proliferate and These donor lymphocytes proliferate and damage target organsdamage target organs especially bone especially bone marrow, skin, liver and gastrointestinal marrow, skin, liver and gastrointestinal tracttract

Page 51: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Delayed and Long Term Averse EffectsDelayed and Long Term Averse Effects

Transfusion associated Graft Versus-Transfusion associated Graft Versus-Host Disease (Ta-GVHD) Host Disease (Ta-GVHD) - 2- 2

Clinical syndrome comprisesClinical syndrome comprises

• fever, skin rash, pancytopeniafever, skin rash, pancytopenia

• abnormal liver function and diarrhoeaabnormal liver function and diarrhoea

• fatal in over fatal in over 80%80% of cases of cases The usual onset is The usual onset is 8-10 days post8-10 days post

transfusiontransfusion, with a longer interval between , with a longer interval between transfusion and onset of symptoms in transfusion and onset of symptoms in infants infants

Page 52: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Delayed and Long Term Averse EffectsDelayed and Long Term Averse Effects

Transfusion associated Graft Versus-Transfusion associated Graft Versus-Host Disease (Ta-GVHD) Host Disease (Ta-GVHD) - 3- 3

The most commonly reported setting for Ta-The most commonly reported setting for Ta-GVHD is GVHD is immunocompetent recipientsimmunocompetent recipients of of blood from biologically related (directed) or blood from biologically related (directed) or HLA identical donors. The disease is also HLA identical donors. The disease is also reported in reported in immunologically compromisedimmunologically compromised patientspatients

PreventionPrevention:: Gamma Gamma irradiationirradiation of cellular of cellular blood products (whole blood, red blood cells, blood products (whole blood, red blood cells, platelets, granulocytes) for at risk patients platelets, granulocytes) for at risk patients

Page 53: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Delayed and Long Term Averse EffectsDelayed and Long Term Averse Effects

Transfusion associated Graft Versus-Host Transfusion associated Graft Versus-Host Disease (Ta-GVHD) Disease (Ta-GVHD) - 4- 4At risk groups:At risk groups: Recipients of blood from biologically related (directed) Recipients of blood from biologically related (directed)

or HLA matched donors' or HLA matched donors' Intrauterine and all subsequent transfusion and Intrauterine and all subsequent transfusion and

exchange transfusion recipients exchange transfusion recipients Patients with congenital cellular immunodeficiency Patients with congenital cellular immunodeficiency Patients receiving granulocyte transfusions Patients receiving granulocyte transfusions Patients with Hodgkin's Disease Patients with Hodgkin's Disease Allogeneic and autologous Peripheral Blood Stem Cell Allogeneic and autologous Peripheral Blood Stem Cell

(PBSC) and bone marrow transplant recipients (PBSC) and bone marrow transplant recipients Patients with Aplastic Anaemia receiving Patients with Aplastic Anaemia receiving

immunosuppression immunosuppression Patients treated with purine analogue drugsPatients treated with purine analogue drugs

Page 54: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Delayed and Long Term Averse EffectsDelayed and Long Term Averse Effects

Immunomodulatory effectsImmunomodulatory effects Some studies suggest a link between Some studies suggest a link between

blood transfusion and increased risk of blood transfusion and increased risk of infectioninfection and and cancer recurrencecancer recurrence

Cause:Cause:•Unknown, possibly mediated by donor Unknown, possibly mediated by donor

white cells or plasma.white cells or plasma.Management and Prevention:Management and Prevention:

•Not known, possibly leucocyte Not known, possibly leucocyte depletion of blood products depletion of blood products

Page 55: Clinical Condition Associated with Transfusion

Allogeneic Blood ProductsAllogeneic Blood Products

Large amounts of foreign antigenLarge amounts of foreign antigens (alloantigens) in both soluble ans (alloantigens) in both soluble and cell-associated forms.d cell-associated forms.

Alloimmunization Alloimmunization The The down-regulationdown-regulation of immune r of immune r

esponses (Transfusion-Associateesponses (Transfusion-Associated Immunomodulation, TRIM)d Immunomodulation, TRIM)

Transfusion-Associated Immunomodulation

Page 56: Clinical Condition Associated with Transfusion

TRIM has been associated with alterations TRIM has been associated with alterations in immune function in allogeneic transfusin immune function in allogeneic transfusion recipients, includingion recipients, including decreased helper-to-suppressor T-decreased helper-to-suppressor T-

lymphocyte ratiolymphocyte ratio decreased natural killer cell function decreased natural killer cell function defective antigen presentationdefective antigen presentation reduction in cell-mediated immunityreduction in cell-mediated immunity

Transfusion-Associated Immunomodulation

Page 57: Clinical Condition Associated with Transfusion

Given an intraoperative or postoperative blood transfusion, or not ??(193 patients with rectal cancer)

Page 58: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Delayed and Long Term Averse EffectsDelayed and Long Term Averse Effects

Iron accumulationIron accumulation Organ toxicity begins when Organ toxicity begins when

reticuloendothelial sites of iron storage reticuloendothelial sites of iron storage become saturatedbecome saturated

Liver and endocrine dysfunction creates Liver and endocrine dysfunction creates significant morbidity and the most serious significant morbidity and the most serious complication is complication is cardiotoxicitycardiotoxicity which which causes arrhythmias, and congestive heart causes arrhythmias, and congestive heart failurefailure

Management and PreventionManagement and Prevention• Iron chelation therapyIron chelation therapy is usually is usually

commenced early in the course of commenced early in the course of chronic transfusion therapychronic transfusion therapy

Page 59: Clinical Condition Associated with Transfusion

Adverse effects of transfusionAdverse effects of transfusion Delayed and Long Term Averse EffectsDelayed and Long Term Averse Effects

Infectious Disease transmission Infectious Disease transmission - 1- 1 Definitive evidence Definitive evidence

• demonstration of demonstration of seroconversion or new seroconversion or new infectioninfection in the recipient and in the recipient and

• isolation of an agent with isolation of an agent with genomic identitygenomic identity from both the recipient and the implicated from both the recipient and the implicated donordonor

Strong presumptive evidenceStrong presumptive evidence• recipient seroconversion within an appropriate recipient seroconversion within an appropriate

interval after transfusioninterval after transfusion• the recognition of appropriate infectious the recognition of appropriate infectious

markers in an implicated donor on follow-up markers in an implicated donor on follow-up investigation, or bothinvestigation, or both

Page 60: Clinical Condition Associated with Transfusion

Estimated risk of transfusion transmitted infectionEstimated risk of transfusion transmitted infection Virus and testing

standardWindow Period

(Days)Point estimate of residual risk

'per unit'

HIV 1 and 2 antibody only 22 1 in 2,404,000

HIV antibody + NAT 9 1 in 7,299,000

HCV antibody only 66 1 in 330,000

HCV antibody + NAT 7 1 in 3,663,000

HBV 45 1 in 1,339,000

HTLV I & II 51 Considerably less than 1 in 1,000,000

vCJD   Possible. Not yet reported in Australia

Page 61: Clinical Condition Associated with Transfusion

Transfusion risk in the U.S.Transfusion risk in the U.S.

1:2,000Bacteria in platelets

Page 62: Clinical Condition Associated with Transfusion

Some Risk of Blood Transfusion

risk factorrisk factor estimated risk estimated risk per unitper unit

No. of deaths No. of deaths per million unitper million unit

InfectionInfectionViralViral

Hepatitis BHepatitis B 1/5,000~1/170,0001/5,000~1/170,000 0~0.140~0.14

Hepatitis CHepatitis C <1/2,000,000<1/2,000,000 <0.5<0.5

HIVHIV <1/2,000,000<1/2,000,000 <0.5<0.5

HTLVHTLV 1/19,000 to <1/80,0001/19,000 to <1/80,000 00

Bacterial ContaminationBacterial Contamination

RBCRBC 1/500,0001/500,000 0.1~0.250.1~0.25

PlateletPlatelet 1/2,0001/2,000 2121

ImmuneImmuneAcute Hemolytic ReactionAcute Hemolytic Reaction 1/250,000~1/1,000,0001/250,000~1/1,000,000 0.670.67

Delayed Hemolytic ReactionDelayed Hemolytic Reaction 1/1,0001/1,000 0.40.4

Page 63: Clinical Condition Associated with Transfusion
Page 64: Clinical Condition Associated with Transfusion

謝謝聆聽 !!

捐血快樂 用血安全