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Transfusion cases

Dr Claire Barrett Division Clinical Haematology. Transfusion cases. Learning objectives:. Follow the correct process of ordering and administering blood. Identify and manage an acute haemolytic transfusion reaction Identify and manage TRALI (transfusion related acute lung injury).

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Transfusion cases

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  1. Dr Claire Barrett Division Clinical Haematology Transfusion cases

  2. Learning objectives: • Follow the correct process of ordering and administering blood. • Identify and manage an acute haemolytic transfusion reaction • Identify and manage TRALI (transfusion related acute lung injury)

  3. Case 2: Ordering and administration of blood products: FOCUS:The right specimen from the right patient. The right blood product for the right patient.

  4. Case 2: • Picture the scene: • It’s your first call at this hospital. YOU are HERE

  5. THE DEEP RURAL HOSPITAL 250 km from ANYWHERE

  6. The patient:

  7. The patient: • 22 year old man brought into casualty by ambulance with stab wounds in his abdomen. • BP 80/45mm Hg, pulse 145/minute. • Tachypnoeic and weak. • He is actively bleeding and shocked. • Ward haemoglobin is 8.

  8. The decision: • What do you do? • Due to delays in arranging an anaesthetist, your patient bleeds further, his Hb is now 5. • Patient’s blood group = O+

  9. The solution... Almost. • Order blood from your hospitals small blood bank. • No group O blood. • The blood bank has 2 units of group B+ blood that has been kept on standby for another patient’s elective theatre case... • What now?

  10. The villain! Your colleague decides that it would be better to give the patient some blood rather than none at all, and administers 1 unit of group B blood to the patient without your knowledge.

  11. The problem: • What do you think will happen now? 12123

  12. Identify the AHTR:

  13. Diagnosis of AHTR: • Fever • Sweating • Chills/ or rigors • Hypotension • Tachycardia/ bradycardia • Pain (chest/ flank/ back) • Dyspnoea • Agitation • Haemoglobinuria (pink urine) • Oliguria • Bleeding

  14. Management of AHTR:

  15. Management: • Recognise symptoms and signs. • Respond: • STOP transfusion • Remove blood giving set and bag • KEEP ivi line open and running with 0,9% saline. • Maintain urine output of 100ml/hr for 24 hours. • Furosemide/ mannitol may be neccessary to maintain output • Insert second ivi line • Oxygen by face mask • Record vital signs

  16. Recheck: • Correlate patients name, hospital number and date of birth with wrist band, unit and form accompanying blood. • Ask blood bank to recheck compatibility. • Return • Return the offending unit to the blood bank.

  17. React: • Send post reaction samples to blood bank • (1 red (clotted) tube, 1 purple (EDTA) tube and urine specimen. • Send the following tests to confirm haemolysis: • Raised unconjugatedbilis, • Urine haemoglobin and haemosiderin, • Decreased haptoglobin, • Increased LDH, • Increased AST, • Decreased Hb, or insufficient rise in Hb. • Coombs. • Send Blood cultures (to exclude infection)

  18. Refer ICU: • Management/ support of • Renal failure • Maintain intravascular volume and renal blood flow. • Monitor input and output • Consult nephrology • Cardiac failure • Inotrope support may be neccessary • Respiratory failure • Possible intubation and ventillation • DIC (consult haematology) • Monitor INR, PT, PTT • FFP, platelets, cryoprecipitate • Heparin 10u/kg/hr if thrombotic features predominate.

  19. RECORD KEEPING and REPORTING: • Date and time transfusion started and stopped. • Date and time symptoms appeared. • Exact clinical findings (detail) • Interventions and outcomes. • Report to SANBS and complete the TRANSFUSION REACTION FORM. • Report to Hospital Transfusion Committee.

  20. Risk reduction: • Review hospital policy for administration of blood products. • Train clinical staff members. • If patient has alloantibodies, give a written card specifying the identified antibodies.

  21. Haemolytic transfusion reactions: • Possibly fatal complication of a blood transfusion. • Need to be recognised early. • Prevented by ALWAYS ensuring that the right blood is administered to the right patient.

  22. Case 3:

  23. Case 3: • Mr ABC: 40 year old male patient. • Known HIV positive, CD4 530. • Presents with convulsions, fever, oliguria. • Mucosal bleeds. • FBC shows platelet count of 5 and Hb of 8. • Haematopathologist reports fragmentation haemolysis. (red cell fragments = 20%)

  24. What do you think? • What is the diagnosis? • Which blood product would you would not use? • Which blood products would you use? • Why?

  25. The progress, 3 days later: • Mr ABC is doing really well. • Platelets increased to 70. • Fragmentation is now 5%. • Renal function is improving.

  26. But then, 5 days later: • Mr ABC suddenly becomes short of breath and distressed. Saturation 76%. • The nursing staff call you. • You listen to his chest and hear bilateral crepitations. • What do you think? • What do you do?

  27. X-Ray: Admission: 3 days later:

  28. What is TRALI: 1 in 5000- 10000 TxFatality 5 – 10% • Serious, life threatening syndrome that presents with: • Acute respiratory distress • Pulmonary oedema • Hypoxaemia • Hypotension • 2- 6 hours after transfusion • Usually resolves 96 hours after transfusion.

  29. Implicated blood products: • Whole blood • Red cell concentrate • FFP • Platelet concentrates • Cryoprecipitate • IVIG • Granulocytes.

  30. Definition and diagnosis: • NEW ALI • Acute onset • Hypoxaemia • PaO2/ FiO2 < 300mmHg • SpO2 < 90% on room air • Other clinical evidence of hypoxaemia • Bilateral chest infiltrates on PA CXR. • No evidence of LA hypertension. • No pre-existing ALI before transfusion • Onset within 6 hours of transfusion • No other risk factors for ALI present.

  31. Differential dx: • Congestive cardiac failure/ acute left ventricular failure. • TACO (Difficult to differentiate) • TACO causes raised BP. • Pulmonary embolism • Rapidly progressing pneumonia • Especially viral/ fungal • ARDS.

  32. Management of TRALI: • Stop infusion • Supportive: • Maintain oxygenation(intubation and ventillationprn) • Haemodynamic monitoring • Fluid support to maintain BP • Diuretics not useful (may worsen picture) • No evidence for use of steroids. • 2 patterns of resolution: • Resolve in 96 hours (Unlike ARDS) • Some take longer (7 days) to resolve.

  33. Investigation of TRALI: • Notify SANBS immediately. • Fill in Transfusion Reaction Form. • Send blood to SANBS for • HLA I/II Ab. NeutrophilAb in the donor supports the diagnosis. • Lymphocyte cross match between donor and recipient. • HNA/ HLA Ab-Ag reaction between donor and recipient must be present.

  34. You should now be able to: • Order and administer blood safely. • Identify and manage an acute haemolytic transfusion reaction • Identify and manage TRALI. • Any questions?

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