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  E-Learning & Accreditation  www.learnbloodtransfusion.org.uk  British Committee for Standards in Haematology  www.bcshguidelines.com

 What kinds of transfusion reactions do you know?  What transfusion reactions are common?  What transfusion reactions are life threatening?  Can transfusion reactions be avoided?

Types of Transfusion Reactions  Immune mediated:  Acute Haemolysis  Febrile Non-Haemolytic  Allergic (Urticarial, Anaphylactic)  TRALI  Delayed Haemolysis  TA-GVHD  Post Transfusion Purpura

Types of Transfusion Reactions  Non-immune mediated:  TACO  Transfusion transmitted infection  Coagulopathy (massive transfusion)  Transfusion haemosiderosis  Electrolyte abnormalities

Scenario 1  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 1 st RCC:  Temp 38.5, HR 90, SpO2 98%, BP 125/79, RR 18  Complains of headache

Scenario 1  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?

Scenario 2  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

Scenario 2  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?

Mild Transfusion Reaction  Fever > 38 ⁰ C and rise 1-2 ⁰ from baseline and/or pruritis or rash but with no other features  Management:  Restart transfusion, paracetamol if febrile, anti- histamine for rash, slow rate of transfusion  Careful observation

Severe Transfusion Reaction  What is the differential diagnosis?  Acute Haemolytic Transfusion Reaction  Anaphylaxis  TACO  TRALI  Bacterial contamination

Management of severe reaction  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

Scenario 3  26 year old man post splenectomy, RTA  Hb 7.3 postoperatively. Prescribed 2 units RCC  5 minutes into 1 st unit RCC:  BP 80/40, HR 100, SpO2 85%, RR 24, Temp 36.5  O/E: critically unwell, wheeze, stridor, generalised rash

Shock/Hypotension with evidence of Anaphylaxis:  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

Scenario 4  77 year old lady admitted with #NOF Hb 7.1  1 hour into 2 nd 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?

Severe dyspnoea without shock  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

Scenario 5  55 year old lady day 2 post right hemicolectomy for CRC  Hb 7.1, prescribed 2 units RCC by SROC  1 st unit transfused uneventfully  2 nd 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?”

Scenario 5  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?

Shock/Hypotension with no evidence of overload or anaphylaxis  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

A quick word on platelets…

What is a bag of platelets  “pool” of platelets: a preparation of platelets derived from 4 units of whole blood, ie. 4 donors  Apheresis platelets: single donor platelets, collected specifically from a platelet donor at the IBTS

Platelet practicalities  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 10 9 /L  Platelet shelf life: 5 days, at room temp (22 degrees), on an agitator

Platelet practicalities  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

Indications for platelet transfusion  Prophylactic Prevent spontaneous bleeding 1. Prior to an invasive procedure 2.  Therapeutic; in active bleeding

Prophylactic Transfusion Indication Target Platelet Count Stable patient 10 x 10 9 /L Febrile patient 20 x 10 9 /L Prior to invasive procedure 50 x 10 9 /L Prior to invasive procedure at a critical 100 x 10 9 /L site Patients taking antiplatelet medications who require urgent invasive procedures? • Platelet transfusion has an undetermined role in this setting • Each case should be considered individually

Invasive Procedures Procedure Target Platelet Count Non-critical site: 50 x 10 9 /L Lumbar Puncture • OGD & Biopsy • Liver Biopsy • Transbronchial Biopsy • Epidural Anaesthesia • Laparotomy • Critical site: 100 x 10 9 /L Intracranial • Ophthalmic • Spine •

Therapeutic Transfusion  Indications for platelets when bleeding:  Active major bleeding e.g. haematemesis Platelets <50 x 10 9 /L  Active CNS bleeding Platelets <100 x 10 9 /L  Patients requiring massive blood transfusion: follow massive transfusion protocol  Active major bleeding on antiplatelet treatment

Specific scenarios  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

Questions, comments, concerns? Please get in touch: Haemovigilance Blood Bank Haematology Team