Transfusion Challenges - Transfusion Reactions - Do they need - - PowerPoint PPT Presentation
Transfusion Challenges - Transfusion Reactions - Do they need platelets? Dr. Eoghan Molloy Haem SpR 2016 Guidance on Transfusion Hospital transfusion guidelines and procedures Irish Blood Transfusion Service (IBTS) www.giveblood.ie
Hospital transfusion guidelines and procedures Irish Blood Transfusion Service (IBTS)
www.giveblood.ie
E-Learning & Accreditation
www.learnbloodtransfusion.org.uk
British Committee for Standards in Haematology
www.bcshguidelines.com
Immune mediated:
Acute Haemolysis Febrile Non-Haemolytic Allergic (Urticarial, Anaphylactic) TRALI Delayed Haemolysis TA-GVHD Post Transfusion Purpura
Non-immune mediated:
TACO Transfusion transmitted infection Coagulopathy (massive transfusion) Transfusion haemosiderosis Electrolyte abnormalities
76 year old lady
PMHx: CCF, CKD, T2DM
Left flank pain, vomiting, MSU: ++bacteria Hb 7.0, WCC 19, PLT 343, Creatinine 300, CRP 240 Plan: IV Abx, IV fluids, 2 units RCC 1 hour after commencing 1st RCC:
Temp 38.5, HR 90, SpO2 98%, BP 125/79, RR 18 Complains of headache
Clerical/ID/Component checks done, transfusion held, cannula
kept patent
MIOC attends to assess patient O/E: slightly anxious, vitals stable, no skin rash, left renal angle tender Pre-transfusion: Temp 37.5, HR 95 What do you do?
66 year old man, elective admission for craniotomy PMHx; Anaemia, Thrombocytopaenia, B12 deficiency Hb 10.1, WCC 4.0, Platelets 90 Commences 1 unit of platelets the night before surgery 15 minutes later: erythema over face, neck and back, itchy Intern on call comes to assess
Clerical/ID/Component checks done, transfusion held, cannula
kept patent
Temp 37.1, BP 115/75, HR 80, RR 16, SpO2 98% O/E: Appears well, not dyspnoeic, chest clear, raised erythematous
rash
What do you do?
Restart transfusion, paracetamol if febrile, anti-
Careful observation
Stop transfusion, disconnect giving set, administer IV NaCl 0.9% Check ABC High flow O2 if dyspnoeic If wheeze: salbutamol nebuliser If hypotensive; lie flat and elevate legs Consider the diagnosis and treat accordingly
26 year old man post splenectomy, RTA Hb 7.3 postoperatively. Prescribed 2 units RCC 5 minutes into 1st unit RCC: BP 80/40, HR 100, SpO2 85%, RR 24, Temp 36.5 O/E: critically unwell, wheeze, stridor, generalised rash
ABC IM Adrenaline 0.5 ml of 1:1000 (repeated if necessary) Rapid fluid resusitation (crystalloid) IV Chlorpheniramine 10 mg IV Hydrocortisone 200 mg Inhaled/IV Salbutamol
77 year old lady admitted with #NOF Hb 7.1 1 hour into 2nd unit RCC, becomes unwell, short of breath BP 124/80, HR 95, RR 28, SpO2 80%, Temp 36.9 O/E: no signs of anaphylaxis, crackles throughout both lung fields,
JVP elevated
What is your differential diagnosis?
Differential Diagnosis:
TACO (Transfusion associated circulatory overload) TRALI (Transfusion associated acute lung injury)
Management:
Discontinue transfusion, high flow O2, urgent Chest X-Ray TACO: Diuresis TRALI: Ventilatory support
55 year old lady day 2 post right hemicolectomy for CRC Hb 7.1, prescribed 2 units RCC by SROC 1st unit transfused uneventfully 2nd unit commenced: After 5 minutes; complains of new flank pain, fever Call to SIOC: “Temp is 39.1, should we stop the transfusion? Do you
want to take blood cultures?”
SIOC attends immediately Patient acutely distressed, diaphoretic, bleeding from surgical
wound and IVC site, urine reddish brown
BP 90/50, HR 109, Temp 39.1, SpO2 96%, RR 18 What do you do? What is the differential diagnosis?
Differential Diagnosis:
Acute Haemolysis (ABO incompatibility) Bacterial contamination (sepsis)
Management:
Discontinue transfusion and manage as per all severe reactions If ABO incompatible, contact lab immediately If bacterial contamination suspected; take blood cultures and start
Piperacillin/Tazobactam and Gentamicin
“pool” of platelets:
a preparation of platelets derived from 4 units of whole blood,
Apheresis platelets:
single donor platelets, collected specifically from a platelet donor at the IBTS
One unit of platelets (pooled or apheresis) is sufficient for one Adult
Therapeutic Dose (ATD)
One ATD should increase the platelet count by 20-40 x 109/L Platelet shelf life: 5 days, at room temp (22 degrees), on an agitator
Platelets are always in very high demand; be sensible All platelets must come from IBTS in Dublin. NONE stored in Cork Cost of one pool of platelets: € 826 If platelets are ordered and subsequently they are not actually
required/clinical scenario changes:
Contact the blood bank immediately as these platelets could be
used for transfusion to a different patient
Prophylactic
1.
Prevent spontaneous bleeding
2.
Prior to an invasive procedure
Therapeutic; in active bleeding
Indication Target Platelet Count Stable patient 10 x 109/L Febrile patient 20 x 109/L Prior to invasive procedure 50 x 109/L Prior to invasive procedure at a critical site 100 x 109/L
Patients taking antiplatelet medications who require urgent invasive procedures?
Procedure Target Platelet Count Non-critical site:
50 x 109/L Critical site:
100 x 109/L
Indications for platelets when bleeding: Active major bleeding e.g. haematemesis
Platelets <50 x 109/L
Active CNS bleeding
Platelets <100 x 109/L
Patients requiring massive blood transfusion: follow massive transfusion
protocol
Active major bleeding on antiplatelet treatment
Idiopathic Thrombocytopaenic Purpura (ITP)
Platelet transfusion rarely required, even in severe thrombocytopaenia Usually only require platelet transfusion in an emergency setting
TTP, HUS, HIT, DIC
Complex haematological disorders All associated with thrombocytopaenia, bleeding AND thrombosis Require specialist assessment prior to platelet transfusion Transfusion can be life-saving in major haemorrhage