transfusion medicine iii complications and safety of transfusion practices

4th year medical students 2nd Feb,2008

Transfusion Medicine IIIComplications and Safety of Transfusion

Practices

Salwa Hindawi

Medical Director of Blood Transfusion ServicesKAUH

4th year medical students2nd Feb,2008

The risks associated with transfusion can be reduced by: - Effective blood donor selection.- Screening for TTI in the blood donor population. high quality blood grouping, compatibility testing. - Component separation and storage.

- Appropriate clinical use of blood and blood products. - Quality assurance

Donor Patient


Principles of Clinical Transfusion Practices

Avoid blood transfusion Transfusion is only one part of the

patient’s management. Prevention and early diagnosis and

treatment of Anemia & underlying condition

Use of alternative to transfusion.eg. IV fluids

Good anesthetic and surgical management to minimized blood loss.


– Prescribing should be based on Prescribing should be based on national guidelines on the clinical use national guidelines on the clinical use of of blood taking individual patient blood taking individual patient needs into needs into account.account.

– Hb level should not be the sole Hb level should not be the sole deciding Factor Clinical evaluation is deciding Factor Clinical evaluation is importantimportant


– Consent form to be obtained from the patient before transfusion.

– The clinician should record the reason for transfusion clearly.

– A trained person should monitor the transfused patient and if any adverse effects occur respond immediately.


Paid Directed Volunteers


Blood Donation

• WB every 8 weeks, Hct > 38%

• Plateletpheresis every 3 days or 24 times per year, Hct > 38%

• Autologous Blood– WB every 3 days (twice/week)– up to 3 days prior to surgery– Hct > 33%


Donor Selection

Is Important

To Be Sure That The Donor Is Fit To DonateThe Required Amount Of BloodBlood Donation Will Not Harm The Donor

The Donated Blood Should Be Safe And FreeFrom Transfusion Transmitted Infections TTI


Donor Selection

I. Interview

II. Questionnaires

III. Physical examination

Donor safety

Patient safety


Single Donation Testing

Different countries screen for different organisms.Each country has to set its own policies for screeningof donors.

i. Serological screeningii. Microbiological screening

HIV I & II (Ag-Ab), HBV, HCV, Syphilis

HTLV-I & IIHBcAb

Special donors for CMVMalaria screen (in some countries)


Confirmatory tests

Any reactive donation should repeat testing in duplicate. If any of the repeated tests is reactive, a sample should be send to a reference laboratory and the donation will be destroyed by autoclaving or used for batch validation or quality control purposes.


Complications of Blood Transfusion

Immediate Delayed

HTR GVHD

FNTR PTP

TRALI Iron overload

Bacterial Infectious

contamination diseases

Allergic, Anaphylaxis Alloimmunization


Acute Hemolytic Transfusion Reaction

• a clerical error (wrong specimen, wrong patient)

• 1 in 6,000 to 25,000 transfusions

• back pain, chest pain, fever, red urine, oliguria, shock, DIC, death in 1 in 4

• stop the transfusion


Work up of An AHTR

• start normal saline

• treat patient symptomatically

• send blood bag and tubing to culture

• send red top and purple top tubes

• urine specimen for hemoglobinuria

• DAT is positive


Non Hemolytic Febrile Transfusion Reaction

• NHFTR (1:100)

• Recipient has WBC antibodies to Donor WBCs contained within RBCs and Plateletpheresis products

• DAT is negative

• rise in temperature by 2F or 1C

• other causes for fever are eliminated


Allergic (Urticarial) Transfusion Reaction

• Recipient has antibodies to the Donor’s plasma proteins (1 in 1000)

• offending protein is not identified

• urticaria, itching, flushing, wheezing

• this is the only transfusion reaction where the blood that is hanging can be restarted after treatment with Benadryl

• if symptoms continue then STOP


Anaphlyactic Transfusion Reaction

• anaphylactic reaction (1 in 150,000)

• 1 in 700-900 people never made IgA

• occurs when exposed to normal blood products which contain IgA

• bronchospasm, vomiting and diarrhea and vascular collapse

• treat with Epinepherine, Solu-Medrol,


Circulatory Overload

• marginal cardiovascular status

• given blood components too rapidly

• develops acute shortness of breath, heart failure, edema (1: 10,000)

• systolic BP increases 50 mm

• infuse slowly, not to exceed 4 hours

• split the unit of RBC and give half


Transfusion Related Acute Leukocyte Lung Injury

• TRALI reaction (1:10,000)

• Donor plasma contains WBC antibodies that when transfused to the recipient cause agglutination of recipient’s WBC in the pulmonary capillary beds

• Chest X ray looks like ARDS

• Donor removed from donating blood


Transfusion - Related Acute Lung Injury (TRALI)

A potentially fatal transfusion reactionManifested usually within 6hrs after transfusionCharacterised by

Hypoxemia PaO2/ FiO2< 300mmhg O2 sat <90% on room air

Chest X-ray:Bilateral hilar infiltratesAbsence of evidence of circulatory overload

Toronto TRALI Concensus Conference 1 April 2004Transfusion,44;1774-91 Dec 2004


Diagnosis

High Index of suspicion / Timing of Transfusion

Blood Gases

Chest X-ray

hypoxia and pulmonary oedema ; most consistent findings.

Diagnosis of exclusion


TRALI Non-cardiogenic pulmonary oedema(result of increased vascular permeability)

The first sign of the reaction can be“Production of copious quantities of frothyblood-tinged fluid” from the endotracheal tubeduring intubation


Other courses of pulmonary oedema

• Volume Overload• Congestive heart failure• Myocardial infarction

Response to diuretics?

Differential Diagnosis


Other Differential Diagnosisacute reaction

• Acute haemolytic transfusion reaction

• Bacterial infection(TTI)

• Acute anaphylaxis IgA def with anti-IgA


Management

• Adequate respiratory support

100% patients need O2 support

71% required mechanical ventilation

Steroids not beneficial

Important to distinguish TRALI from volume overload

Treatment with diuretics may have a detrimental effect /reduced cardiac out put.May need fluid support.


Sepsis from Bacterial Comtamination

• Platelets:– skin contaminants most common cause– plateletpheresis 1 in 5000– pooled platelets 1 in 1000

• RBC:– Sepsis from RBC due to Yersinia,

Enterics or Gram Positive 1 in 3,000,000


Transfusion Transmitted Disease (TTD)• HBV 1 in 63,000

• HCV 1 in 103,000

• HTLV-I 1 in 641,000

• HTLV-II 1 in 641,000

• HIV-1 1 in 587,000

• HIV-2 < 1 in 1,000,000


Adverse Effects of TransfusionDelayed Effects Immunological Etiology

* *Delayed HaemolysisDelayed Haemolysis

* *Graft Vs Host Graft Vs Host diseasedisease

* *Post-Transfusion Post-Transfusion PurpuraPurpura

* * AlloimmunizationAlloimmunization

RBCs Antibody ReactionRBCs Antibody Reaction

Engraftment of Engraftment of Functional Transfused Functional Transfused LymphocytesLymphocytes

Anti platelet Anti platelet AbsAbs

Exposure to Antigens of Exposure to Antigens of Donor OriginsDonor Origins


Adverse Effects of TransfusionsDelayed EffectsNon-Immunological Etiology

Iron OverloadIron Overload

HepatitisHepatitis

AIDSAIDS

Protozoa Protozoa InfectionInfection

Multiple TransfusionMultiple Transfusion

HVB, HCV, and Non-A, HVB, HCV, and Non-A, Non-B, and Non-CNon-B, and Non-C

HIV -I / HIV-2HIV -I / HIV-2

Malaria, Babesia Malaria, Babesia TrypanosomesTrypanosomes

transfusion medicine iii complications and safety of transfusion practices

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