Transfusion Complication - PowerPoint Presentation

Slide1

Transfusion ComplicationRisk per UNIT Allergic3:100Febrile (Leuko-reduced Units)1:100TACO1:100TRALI1:5,000Sepsis1:5,000Acute hemolytic1:75,000HBV1:160,000HIV & HCV1:2 million

Blood product consent form checklist:Reasons for transfusionRisks of transfusion vs benefitAlternative treatments (if any)** Must give Pts opportunity to ask questions!**

-Type and Screen: Determines ABO type & Rh status and screens for non-ABO RBC antibodies. - AT UNMH, crossmatch is done when orders to transfuse are submitted in Powerchart. Blood is held by blood bank until pick up at time of transfusion.

UNMH Blood Bank 272-0992

Premedication with acetaminophen is only advised for patients already receiving anti-pyretics.Premedication with diphenhydramine is only advised for patients with REPEAT allergic reactions.

Blood Products and Indications

Packed

red blood cells (PRBCs)

For hemodynamically stable patients

without active bleeding

:

-

Hgb

<

7 g/

dL

- Generally indicated

- Hgb 7 - 8 g/

dL

- Consider in pre-op

Pts

&

Pts

w

stable cardiovascular

disease

-

Hgb

8 - 10 g/

dL

- Consider

in select Pts

only (symptomatic anemia, cardiac ischemia).

For actively bleeding patients,

transfuse as needed to maintain adequate oxygenation

Notes:

1 U PRBC ≈ 300mL, 1 U PRBC =>↑

Hb

̴ 1 g/

dL

, Large trxn→↓

Ca

,↑K, ↓ Coagulation factors

Platelets

(

plts

)

- <10,000/

μ

L Generally indicated or <20,000/

μ

L w/ infection/line placement/minor biopsy

- <50,000/

μ

L With active bleeding or prior to moderate-high risk invasive procedure

- <100,000 Neurosurgery or ocular surgery

*Threshold-based trxn not appropriate for Pts bleeding 2

°

to platelet dysfunction

Notes: 1 U Apheresis

plt

≈ 300mL ≈ “6 pack” of pooled

plts

=>↑

plt

count ̴ 25,000

/μ

L.

Refractory =

Pts

with < 5000

/μ

L

plt

↑ 15-60 min post

txn

x 2 after r/o other causes (e.g. drugs)

Plasma

(FFP)

- C

orrection of bleeding

2

°

to↓ in multiple

coag

factors (

eg

,

warfarin,

vit

K

def

, DIC, liver disease, dilution)

Consider lower risk coagulation factor complex (e.g.

Bebulin

)

- Prophylactic use in non-bleeding

Pts

prior to mod-high risk procedures when INR>2.*

*Available studies do not support the efficacy of FFP as prophylaxis for most invasive procedures in patients with a mild coagulopathy (

ie

, INR <2.0)

Notes:

1U FFP

≈ 250mL, Initial dose: 15 mL/kg ( ̴ 3 to 5 units of FFP for

average

adult).

Transfuse close to time of procedure due to short half-life of coagulation factors

Cryo

-precipitate (

Cryo

)

- Correction of significant bleeding 2° ↓fibrinogen (<160)

- Emergency

use for bleeding in

vWD

Pts

Notes: 1 U of

cryo

≈ 10-20 mL, 10U of

cryo

will ↑ fibrinogen ̴70 mg/

dL

in 70kg

Pt

Irradiated

(IRR)

To

prevent

Txn

-assoc.

GVHD

(

eg

, in

Pts

w/cellular immune-

def

, stem cell recipients, premature neonates,

heme

malignancies, and

Pts

receiving

Fludarabine

or

Cladribine

, HLA matched

plts

or directed units.) *

May cause delay in availability

Leuko-reduced

To ↓ Risk of febrile

rxns

, ↓ risk of trxn transmission of CMV.

Notes: Risk of CMV transmission w/

leukoreduction

≈ risk w/CMV

sero

-negative products

**All blood products at UNM (with the exception of granulocytes) are pre-storage

leukoreduced

**

Washed

To

↓ risk of allergic

rxns

for

Pts

with h/o prior

severe

allergic

rxn

. Rarely indicated.

NOT recommended for platelets (reduces yield ~ ½,

plts

less functional)

Acute Transfusion Reactions Febrile non-hemolyticSymptoms & Signs*: Fever (>1C°↑ and >38°) and chills Severity: Low morbidityDdx: Acute Hemolytic Rxn, Sepsis & TRALIPrevention & Tx: Prevented by using leukoreduced products.In RCTs acetaminophen not shown to ↓ incidence; premed advised only if Pt is already febrile. Allergic/AnaphylacticSymptoms & Signs*: Urticaria, pruritus Anaphylaxis =>Dyspnea, tightening of throat, ↓BPSeverity: Low morbidity (simple allergic) to life threatening (anaphylaxis)Ddx: TRALI, TACO (consider both in Pt’s with shortness of breath)Prevention & Tx: Reactions dose-dependent => STOP Trxn and wait for symptoms to resolve with treatment. For repeated rxns, consider pre-medication with diphenhydramine, famotidine and/or steroids. Rx anaphylaxis w/ Epi. Consider washed units for Pts with h/o anaphylaxis. Acute HemolyticSymptoms & Signs*: Fever, chills, hypotension, dyspnea, chest pain, flank pain, and anxietySeverity: Life threatening

Ddx: Febrile Non-Hemolytic, Sepsis, TRALIPrevention & Tx:

Proper ID of Pt and blood product. Only transfuse RBC with normal saline. Maintain urine output (IV fluids, mannitol and/or diuretics), CV support.

TACO(Transfusion –Assoc. Circulatory Overload)

Symptoms & Signs*: Dyspnea, hypertension, hypoxia, pulmonary edema, ↑BNP

Severity:

Moderate morbidity to life threateningDdx: TRALI, Acute Hemolytic Transfusion Rxn, Anaphylaxis, Non-Txn ARDSPrevention & Tx: Conservative transfusion, ID at risk Pts (eg, elderly, h/o heart disease, and pediatric Pts) and transfuse slowly over max of 4hrs . Rx with supplemental O2 and diuretics. TRALI(Transfusion-Related Acute Lung Injury)Symptoms & Signs*: SOB, fever, hypoxia, pulmonary edema, ↓ BP, within 6 hrs of transfusion. Severity: Life threateningDdx: TACO, Sepsis, Acute Hemolytic Transfusion Reaction, Anaphylaxis, non-Trxn ARDS Prevention & Tx: Conservative transfusion. Treat like ARDS.SepsisSymptoms & Signs*: Hypotension, fever, and rigorsSeverity: Life threateningDdx: Acute Hemolytic Transfusion Rxn, TRALI, Febrile Non-Hemolytic RxnPrevention & Tx: Bacterial testing of blood units. Rx w/antibiotics and supportive care.

2013 UNMH Transfusion Service (Ramos, Reyes, Crookston & Koenig)

Draw 2 purple tops and send to BB with remainder of unit for trxn rxn work-up. Send urine if s/s of hemolysis. Unless emergent, wait for results and pathology approval to transfuse another unit.

Transfusion

Reaction Suspected

STOP Transfusion

Fill out Trxn Rxn form & call Blood Bank

Trxn can resume AFTER symptoms resolve (Rx with diphenhydramine)

Itching and hives

only

All other symptoms

-

Stabilize patient

- Notify attending

- Perform Clerical Check

*

Not all signs and symptoms may be present