Transfusion Medicine III Complications and Safety of Transfusion Practices

1. Transfusion Medicine IIIComplications and Safety of Transfusion Practices Salwa Hindawi Medical Director of Blood Transfusion Services KAUH 4th year medical students 2nd Feb,2008

2. Donor Patient 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 4th year medical students 2nd Feb,2008

3. 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. 4th year medical students 2nd Feb,2008

4. Prescribing should be based on national guidelines on the clinical use of blood taking individual patient needs into account. • Hb level should not be the sole deciding Factor Clinical evaluation is important 4th year medical students 2nd Feb,2008

5. 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. 4th year medical students 2nd Feb,2008

6. Blood Donors Homologous Paid Directed Volunteers Autologous 4th year medical students 2nd Feb,2008

7. 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% 4th year medical students 2nd Feb,2008

8. Donor Selection Is Important To Be Sure That The Donor Is Fit To Donate The Required Amount Of Blood Blood Donation Will Not Harm The Donor The Donated Blood Should Be Safe And Free From Transfusion Transmitted Infections TTI 4th year medical students 2nd Feb,2008

9. Donor Selection I. Interview Donor safety II. Questionnaires Patient safety III. Physical examination 4th year medical students 2nd Feb,2008

10. Single Donation Testing Different countries screen for different organisms. Each country has to set its own policies for screening of donors. i. Serological screening ii. Microbiological screening HIV I & II (Ag-Ab), HBV, HCV, Syphilis HTLV-I & II HBcAb Special donors for CMV Malaria screen (in some countries) 4th year medical students 2nd Feb,2008

11. 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. 4th year medical students 2nd Feb,2008

12. Complications of Blood Transfusion Immediate Delayed HTR GVHD FNTR PTP TRALI Iron overload Bacterial Infectious contamination diseases Allergic, Anaphylaxis Alloimmunization 4th year medical students 2nd Feb,2008

13. 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 4th year medical students 2nd Feb,2008

14. 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 4th year medical students 2nd Feb,2008

15. 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 4th year medical students 2nd Feb,2008

16. 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 4th year medical students 2nd Feb,2008

17. 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, 4th year medical students 2nd Feb,2008

18. 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 4th year medical students 2nd Feb,2008

19. 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 4th year medical students 2nd Feb,2008

20. Transfusion - Related Acute Lung Injury (TRALI) A potentially fatal transfusion reaction Manifested usually within 6hrs after transfusion Characterised by Hypoxemia PaO2/ FiO2< 300mmhg O2 sat <90% on room air Chest X-ray:Bilateral hilar infiltrates Absence of evidence of circulatory overload Toronto TRALI Concensus Conference 1 April 2004 Transfusion,44;1774-91 Dec 2004 4th year medical students 2nd Feb,2008

21. Diagnosis High Index of suspicion / Timing of Transfusion Blood Gases Chest X-ray hypoxia and pulmonary oedema ; most consistent findings. Diagnosis of exclusion 4th year medical students 2nd Feb,2008

22. TRALI Non-cardiogenic pulmonary oedema (result of increased vascular permeability) The first sign of the reaction can be “Production of copious quantities of frothy blood-tinged fluid” from the endotracheal tube during intubation 4th year medical students 2nd Feb,2008

23. Differential Diagnosis • Other courses of pulmonary oedema • Volume Overload • Congestive heart failure • Myocardial infarction • Response to diuretics? 4th year medical students 2nd Feb,2008

24. Other Differential Diagnosis • acute reaction • Acute haemolytic transfusion reaction • Bacterial infection(TTI) • Acute anaphylaxis IgA def with anti-IgA 4th year medical students 2nd Feb,2008

25. 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. 4th year medical students 2nd Feb,2008

26. 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 4th year medical students 2nd Feb,2008

27. 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 4th year medical students 2nd Feb,2008

28. * Delayed Haemolysis * Graft Vs Host disease * Post-Transfusion Purpura * Alloimmunization RBCs Antibody Reaction Engraftment of Functional Transfused Lymphocytes Anti platelet Abs Exposure to Antigens of Donor Origins Adverse Effects of TransfusionDelayed EffectsImmunological Etiology 4th year medical students 2nd Feb,2008

29. Iron Overload Hepatitis AIDS Protozoa Infection Multiple Transfusion HVB, HCV, and Non-A, Non-B, and Non-C HIV -I / HIV-2 Malaria, Babesia Trypanosomes Adverse Effects of TransfusionsDelayed EffectsNon-Immunological Etiology 4th year medical students 2nd Feb,2008

30. Thanks 4th year medical students 2nd Feb,2008