The Postgraduate Medical Education Service Ms. Brd Doyle, MSc., - - PowerPoint PPT Presentation

Recognition & Investigation

• f

Transfusion Reactions

The Postgraduate Medical Education Service Intern Presentation @ Cork University Hospital Date: 2016

• Ms. Bríd Doyle, MSc., FAMLS.

A/Haemovigilance Officer, C.U.H.

• Ms. Emma O’Riordan.

A/CNM2 (Haemovigilance) C.U.H.

EU Blood Directive 98/EC/2002

Article 10: Personnel ---“…personnel directly involved in collecting, testing, processing, storage and distribution of human blood and blood components shall be qualified to perform those tasks and be provided with timely, relevant and regularly updated training’ Article 15: Notification of Serious Adverse Reactions and Events – “..mandatory notification of serious adverse reactions and events”

• Based on NHO handbook, which lists reportable types of

adverse events and reactions

• All transfusion reactions reviewed by consultant

haematologist and hospital transfusion committee

Serious Adverse Reaction

Unintended response associated with the transfusion of blood/components that is fatal, life threatening, disabling, incapacitation, or which results in or prolongs hospitalisation or morbidity

Serious Adverse Event

Any untoward occurrence associated with the distribution or transfusion of blood/components that is fatal, life threatening, disabling, incapacitation, or which results in or prolongs hospitalisation or morbidity

Near Miss Event

which undetected could have resulted in the determination of a wrong blood group or the issue/administration of incorrect/unsuitable/inappropriate component, but which was recognised before transfusion.

PPG-CUH-CUH-30

‘Policy and Procedure on recognizing, investigating and managing a Suspected Transfusion Reaction’

Refers to suspected adverse reaction to a blood component transfusion occurring

• During the transfusion
• Within 24 hours of transfusion

Prior to Transfusion

Nurses/midwives/doctors must advise patients

• Of the possible signs & symptoms of a transfusion reaction
• The patient should immediately inform the nurse if

experiencing any of those signs/symptoms

Form No.15 (Paediatric or Maternity)

Form 15 A (Adults Only)

Infusion Rates

Product

Start Infusion Rate Transfuse within Red Cells

Within 30 min 2-4mls/kg/hr

4 hours (usually 2-3 hours)

Plts

Immediately

30 – 60 mins For immediate transfusion (If not to be transfused immediately, leave in Blood bank for agitator storage)

OCTAPLAS

Immediately

30 – 60 mins For maximum benefit, transfuse immediately. Recommended be used within 4 hours of thawing

Transfusions

• Patients should be transfused in clinical area

where they can be readily observed

• Staff trained
• in administration of blood components
• in emergency treatment of anaphylaxis
• In as far as possible, it is recommended that

transfusion are only undertaken during the routine day. Only emergency transfusions should take place at night.

Documented on the final page of the prescription & transfusion record (form 15/15a) Complete form FULLLY!! Circle sign or symptom detected Advice on how to deal with suspected reaction is outlined here

Suspected Transfusion Reaction

Investigations

Blood Transfusion

• Complete the blood

transfusion request form

• indicating a suspected

transfusion reaction.

• Draw 1 x 6ml EDTA

(pink) & 2 x clotted (red) specimens

• Send the specimens plus

the implicated unit immediately to the blood transfusion laboratory Other Investigations recommended

• Full Blood Count
• Coagulation Screen
• Urea & Electrolytes,

LFTs, LDH

• Ward Urinalysis/

haemoglobinurea

• Fluid balance
• Aerobic and Anaerobic

Blood Cultures on patient for febrile reactions

Blood Bank Investigations

The Blood Bank will Quarantine any un-transfused units ?Rapid Alert to IBTS? On PRE & POST samples

• Perform Clerical checks
• Repeat ABO & Rh groups
• Repeat antibody screens
• Repeat crossmatches for that unit and

any as yet un-transfused units

• Direct Coombs Tests

Blood Cultures on Unit (aerobic/anaerobic) on pack

Haemovigilance Review

• Event
• Clinical status
• Chest X-Ray, Fluid Balance
• LFTs, LDH, Haptoglobin
• Perform extra testing as required

Consultant Haematologist Review

• Future Transfusion Policy
• Report to Clinician
• Report to NHO, if required

Observing/Monitoring Patients

Severe transfusion reactions

• most likely to occur < first 15mins/50mls
• patients require close monitoring during this

period

On-going visual observation

• essential to detect signs/symptoms of a suspected

transfusion reaction / adverse event

Unconscious, unresponsive, paediatric patients will require closer monitoring

Observations

What

• Temperature
• Pulse
• Respirations
• Blood pressure
• O2 Sat

When

• Baseline before Commencement
• After commencement
• At 15 minutes
• At 30 minutes
• At 60 minutes intervals until

completion

• On Completion of the transfusion

Additional

• bservations

are discretionary

• depending on

the patient’s clinical condition

• If there are

signs of a suspected transfusion reaction

Signs & Symptoms

Fever

• Related symptoms chills, flushing, rigors,

Generally feeling ‘unwell’

• Nausea, diarrhea, vomiting, headache,

collapse Cutaneous symptoms

• Urticaria, rashes, pruritis

Respiratory symptoms

• Dyspnoea, stridor, wheeze, hypoxia, coughing

Anxiety

• Confusion, restlessness, 'impending doom’

A mild reaction may be the early stages of a severe reaction DON’T IGNORE IT! Pain

• Loin, chest,

abdominal, infusion site, muscle, bone Angiodema Tachycardia, Hypotension, Hypertension Bleeding

• Haematuria
• Wounds etc

Suspected Transfusion Reaction

Nurse/midwife must immediately

• Temporarily stop the transfusion
• Maximum permitted cessation time: 15 Minutes
• Outside 15 minutes, transfusion MUST NOT be recommenced
• Contact a doctor to review the patient as a matter of urgency
• Check patient’s observations and oxygen saturation levels
• Check the Identification Details on the Unit and of the Patient
• Verify ABO and Rh group compatibility of the Patient and the Unit
• IMMEDIATELY contact Blood Bank if discrepancy
• Leave cannula in situ
• Document suspected reaction, fluid balance etc.
• Take laboratory tests as directed.
• Seal unit, place in re-sealable plastic bag for return to Blood Bank
• Inform Blood Transfusion Laboratory & Haemovigilance

Acute Intravascular Haemolysis

• Often noticed during first 15 minutes or first few mls
• Transfusion of wrong blood
• ABO incompatible transfusions ~

1:50,000 to 1:80,0000 units

• Death from mis-transfusion 1:2.6 million (due to DIC and

acute renal failure) ABO incompatibility

• Sample mis-labelling
• Patient mis-identification
• Failure of bedside checking procedure

Delayed Haemolytic Transfusion Reaction

• Signs and Symptoms:
• Unexplained fall in HB
• Rising LFTs
• Jaundice
• Dark urine
• 5-10 days or longer after the transfusion
• Development of an irregular antibody (e.g. Anti

Kell, Anti Duffy)

• Importance of full transfusion history

• Isolated fever >1.5 degrees
• May also have chills/rigors
• Platelets now taken from male-
• nly donors
• Leuco-depletion of red cell

units

• Frequency 0.05% of

transfusions

• Rash
• Possible itch
• More common with

Platelets

• Up to 1-3%

transfusions

• Can occur 2-3hours

post Transfusion

Febrile Non-Haemolytic Transfusion Reaction

Urticaria

Non- Severe Allergic Reactions

 May include rash, pruritus & urticaria  Along with any of the following

 Localised angioedema  Oedema of lips, tongue & uvula  Peri-orbital pruritus, erythema and oedema

 Responds to symptomatic treatment (steroid and

antihistamine)

Severe Allergic Reactions/Anaphylaxis

 Involve respiratory and cardiovascular systems  Usually occurs during the transfusion or very soon after  Cause not completely understood  May be associated with patients who have IgA deficiency

with anti-IgA antibodies

 Very rare

(approx 1:50,000)

 Life threatening

TACO

(Transfusion Associated Circulatory Overload)

Development of acute pulmonary oedema secondary to CCF as a result of transfusion. Characterized by any four of the following:

• Acute Respiratory distress (dyspnoea, cyanosis)
• Tachycardia
• Increased Blood Pressure
• Acute or worsening pulmonary oedema chest x-ray
• Evidence of positive fluid balance
• Occurring within 6 hours of completion of transfusion.
• Acute left ventricular failure
• Caused by: Too much fluid or too rapid transfusion
• Risk: Infants, Elderly, low weight, Diminished Cardiac Reserve or/& Chronic

Anaemia

• Preventable in at risk patients by close monitoring and transfusing smaller

volumes at a slower rate

• May affect up to 1% transfusions in elderly: may be underdiagnosed
• Take chest X-rays

TRALI

(Transfusion Related Acute Lung Injury)

Acute lung injury unrelated to circulatory overload occurring within six hours of transfusion. Clinical Signs and Symptoms:

• Acute respiratory distress, hypoxia (SpO2 ˂90%), fever, chills,

hypotension, bilateral pulmonary oedema

• Bilateral pulmonary infiltrates on chest X-Ray
• No evidence of circulatory overload
• No pre-existing acute lung injury
• May be life-threatening
• Donor WBC antibodies interact with recipient’s WBCs, leading WBC

sequestration in lungs

• 1:5000, but possibly under-diagnosed?
• Rapid alert to IBTS

Bacterial contamination

• Signs and Symptoms:

Rigors, Fever, Tachycardia, Circulatory collapse

• Occurs within first 100ml
• Life threatening; associated

with high mortality

• Most frequently occurs with

platelets

• Incidence 1:80,000 to

1:100,000 platelet transfusion

• Incidence 1:3-5million red

cells (rare) Residual transmission risk very low

• Transfusion transmitted viral infection

(IBTS 2014) e.g.

• HBV ( ~1:1.29 million units donated)
• HCV ( ~ 1: 8.5 million units donated)
• HIV-1/2(~1:20 million units donated)
• Transfusion transmitted parasite

infection (e.g.)

• Malaria
• Transfusion transmitted prion infection

e.g vCJD

Post Transfusion Infection

Transfusion-associated GvH Disease

• Signs and Symptoms: fever, rash, liver dysfunction, diarrhoea,
• pancytopenia. Occurs 1-6 weeks following transfusion with no other

apparent cause.

• Transfused donor T-cells engraft and initiate GvH disease in

immuno-compromised recipient

• BMT, IUT, Hodgkins, Solid Organ Transplants, some chemotherapy

(e.g. fludarabine), etc

• Prevention: Irradiation of blood units for susceptible recipients
• Incidence reduced since universal leucodepletion of red cells
• Very rare complication, but fatal 80-90% time

Special Blood Requirements

3 SAE’s ~ irradiation requirement not indicated in 2014 2 SAE’s ~ irradiation requirement not indicated in 2015

Haemovigilance is everyone’s responsibility

Any Questions?

Any Questions?