أكاديمية الدراسات العليا - طرابلس

1. أكاديمية الدراسات العليا - طرابلس BLOOD TRANSFUSION REACTION Non immunological complication:ByYousef Ali KhalefaSaleh إشراف الدكتور: داود سعيد داود التخصص : طب حيوي رقم لقيد: 17554

2. Blood transfusion reaction

3. Introduction 1

4. ●Human blood is made up of fluid called plasmathat contains red blood cells, white blood cellsand platelets. Each part of the blood has a special purpose. A person may be given blood or only the parts of the blood needed, called blood products (1). BLOOD:- 2

5. ●Components (1). Blood Composition 3

6. A transfusion is the process of giving blood products through an intravenous (IV) catheter. TRANSFUSION:- 4

7. TRANSFUSION COMPLICATION ●complications can be classified into two categories: ♦Immune Complications ♦Non-immune Complications (1). 5

8. ●Hemolytic (acute and delayed) ●Non-Hemolytic (includes febrile, urticarial, anaphylactic, purpura, etc.) (1). IMMUNE COMPLICATION :- 6

9. BLOOD CONTAMINATION DURING STORAGE 7

10. Non immunological transfusion reaction 1- Bacterial contamination reactions. 2- Circulatory overload. 3- Transfusion haemosiderosis. 4- Complications of massive transfusion. 5- Non immune hemolytic reaction (1). 8

11. 1. Bacterial contamination reaction. ● Although uncommon, but this type of specific reaction can have a rapid onset and high mortality in recipients. ● The presence of bacteria in transfused blood may lead either to febrile reactions in the recipient ( due to pyroxenes ) or serious manifestations of septic or end toxic shock. ● Commonly caused by end toxinproduced by bacteria capable of growing in cold temperatures such as Pseudomonas species, E. coli, Yesinia enterocolitica. (2). 9

12. Source of infection. ● Infection of stored blood is extremely rare. ●Skin contaminantsare not infrequently present in freshly donated blood but these organisms ( predominantly staphylococci ) do not survive storage at 4 º C although they will grow profusely in platelet concentrates stored at 22 º C. ● Healthy donor who are bacteremic at the time of donation. The majority are due to Yersinia enterocolitica, which grows well in red cell components due to its dependence on citrate and Iron. ● Gram negative, endotoxin – producing contaminants found in dirt, soil and faeces may rarely grow in the storage condition of blood. (2). 10

13. ● According to CDC , most are caused by blood components contaminated by Yersinia enterocolitica. 11

14. Clinical manifestation ● Usually appear rapidly during transfusion or within about 30 minutes after transfusion with dryness, flushing of skin. ● Fever, Hypotension, Chills, Muscle pain, vomiting, Abdominal cramps, Bloody diarrhoea, Hemoglobinuria, Shock, Renal failure, DIC. 12

15. Management. ● Rapid recognition is essential ● Immediately stop the transfusion. ● Therapy of shock, steroids, vassopressors, fluid support, respiratory ventilation and maintenance of renal function. ● Broad spectrum IV antibiotics ● The blood component unit and any associated fluids and transfusion equipment should be sent immediately to blood bank for investigation ie: gram stain and culture. ● Blood C & S from the recepient. (2) 13

16. Prevention ● Strict adherence to policies & procedures regarding blood component collection, storage, handling,and preparation is essential to reduce the risk. ● Visual Inspection of components before release from the transfusion service include any discolouration, visible clots, or hemolysis. ● Ensure the blood components are infused within standard time limits ( 4 hours ). (2). 14

17. Prevention ● Blood packs should never be opened for sampling, if any open method of preparation has been used, the unit should be transfused within 24 hours. ● Blood should always be kept in accurately controlled refrigerators (with alarms), maintained strictly at 2 – 6 º C, the blood should never be removed and taken to the ward or OT until it is required. (3) 15

18. 2. Circulatory overload ● All patient will experience a temporary rise in blood volume and venous pressure following the transfusion of blood or plasma except for those who are actively bleeding. However, young people with normal cardiovascular function will tolerate this changes provided it is not excessive. ● Pregnant women, patient with severe anaemia, elderly with compromised cardiovascular function will not tolerate the increase in plasma volume and acute pulmonary oedema may develop. (3) 16

19. Clinical manifestation ● Frequently due to transfusion of a unit at too fast rate. ● Signs of cardiac failure – raised JVP, basal crepitations in both lungs, dry cough, breathlessness. (3). 17

20. Management ● Stop the transfusion immediately. ● Prop up the patient ● Oxygen therapy ● Intravenous diuretics should be used appropriately. ● If more rapid volume reduction is needed, therapeutic phlebotomy can be used. (4). 18

21. Prevention ● Packed cell should be used instead of whole blood. ● Packed cells should be given slowly over 4 hours.The usual rate of transfusion is about 200 ml per hour. In patient at risk rate of 100 ml per hour or less are appropriate. ● Diuretics should be given at the start of the transfusion and only one or two units of concentrated red cells should be transfused in any 24 hour period. ● Blood transfusion should be given during the daytime, Overnight transfusion should be avoided wherever possible. (4). 19

22. 3. Transfusion haemosiderosis ● A complication of repeated long term blood transfusion. ● Most commonly seen in thalassaemic patient. ● Each unit of blood has about 200 mg of iron, while the daily excretion rate is about 1 mg. The body has no way of excreting the excess unless the patient is bleeding. ● Assessment of storage iron levels such as ferritin levels should be done. (4). 20

23. The use of Iron chelating agent, Desferrioxamine does not completely overcome the Iron load, but has delayedthe onset of problems due to haemosiderosis. Transfusion of neocytes or young red cells is the other alternative. However, it is expensive, time consuming, and the result are not as favorable as expected (4). 21

24. 4. Complication of massive transfusion ● Massive transfusion is defined as the replacement of total blood volume within a 24 hour period. ● This will inevitably lead to : 1- Dilution of platelets. Blood effectively has no functional platelets after 48 hours storage, after 8 to 10 units of blood transfusion, thrombocytopenia will usually seen. Bleeding due to a slightly low platelet is uncommon, therefore routine administration of platelet after certain amount of blood transfusion is unnecessary. Regular monitoring of platelet count is more important. Platelet transfusion may be recquired if platelet count <100 x 10 9 /L with continous bleeding or surgical intervention (4). 22

25. 2. Dilution of coagulation factors. • Stored Whole blood < 14 days has adequate levels of • most coagulation factors for homeostasis. • If stored blood of more than 14 days, or plasma reduced • blood or red cells in optimal additive solution is used, • replacement of coagulation factors with FFP is necessary. • 3- Hypothermia • ( defined as core body temperature less than 35 c ) is associated with large volumes of cold • fluid transfusion. This may results in cardiac irregularities . • Therefore the use of blood warmer is important • (4). 23

26. 4- Excess citrate can act on the patient’s plasma free ionized calsium and results in hypocalcaemia ( transient ). Citrate toxicity occur with extremely rapid transfusion ( one unit every 5 minute ), in premature infant having ET with blood stored in citrate for longer than 5 days. 5. Hyperkalemia Can be caused by intracellular loss of potassium from RBC during storage or infusion of intracellular potassium depleted RBC blood components such as washed RBC or frozen washed RBC (5). 24

27. The most important consideration in massive blood transfusion is to replace blood loss quickly and adequately. Too little blood , too late has more serious consequences than massive blood transfusion itself (5). 25

28. 5.Non immune hemolytic reaction ● Mechanical – heat damage from blood warmer, cold, small gauge needle. ● Environment – hypotonic or hypertonic solution. 26

29. Investigation of transfusion reactions. 27

30. Investigations of transfusion reaction are necessary for : 1- Diagnosis 2- Selection of appropriate therapy 3- Transfusion management 4- Prevention of future transfusion reaction. Investigations should include correlations of clinical data with laboratory result (5). 28

31. Important clinical data : • 1- Diagnosis • 2- Medical history of pregnancies, transplant, and previous transfusion. • 3- Current medication • 4- Clinical signs and symptoms of the reaction • (5). 29

32. Laboratory investigation outline of transfusion reaction. 1- Immediate procedures ● Clerical checks. ● Visual inspection of serum and plasma for free . . ●hemoglobin ( pre and post transfusion ) ● Direct anti – globulin test. ( post transfusion EDTA sample ) (5). 30

33. 2. As required procedures • ● ABO grouping and RH typing, pre and post transfusion • ● Major compatibility testing , pre and post transfusion • ● Antibody screening test , pre and post transfusion • ● Alloantibody identification • ● Antigen typing • ● Free hemoglobin in first voided urine post transfusion • Unconjugated bilirubin 5 – 7 hours post transfusion • (5). • 2 1 31

34. References: Goodnough, L. (2007).Transfusion medicine. In: Goldman L, Austell D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier;:chap 3 pp 183. 2. Manta ,W. Y.and Snyder. S. E. (2008).Transfusion reactions. In: Hoffman R, Benz EJ Jr., Chattel SJ, et al, eds. Hoffman Hematology: Basic Principles and Practice. 5th ed. Philadelphia, Pa: Churchill Livingstone Elsevier;:chap 4 pp 153. 3- Denise, M. and Hardening (2008). Modern blood banking and transfusion practice chap 4 pp: 95-144 32

35. 4- Holt, I. , Spitealinic ,S.L.andMcMican, A. E. (2005). A technitium -99m red cells survival technique for in vivo compatibility testing transfusion 23: 148-151. 5- chpujani,R.L. I and Rajesh B. (2002). Third edition Medical paracytology chap 2 pp 324. 33

36. THE END Thank you for your attention.