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

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

4th year medical students 2nd Feb,2008 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 – 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 –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 PaidDirected Volunteers

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

4th year medical students 2nd Feb,2008 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 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 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 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 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 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 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 Anaphlyactic Transfusion Reaction anaphylactic reaction (1 in 150,000) 1 in 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 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 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 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; Dec 2004

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

4th year medical students 2nd Feb,2008 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 Management Adequate respiratory support 100% patients need O 2 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 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 Transfusion Transmitted Disease (TTD) HBV1 in 63,000 HCV1 in 103,000 HTLV-I1 in 641,000 HTLV-II1 in 641,000 HIV-11 in 587,000 HIV-2< 1 in 1,000,000

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

4th year medical students 2nd Feb,2008 Adverse Effects of Transfusions Delayed Effects Non-Immunological Etiology Iron Overload HepatitisAIDS Protozoa Infection Multiple Transfusion HVB, HCV, and Non-A, Non-B, and Non-C HIV -I / HIV-2 Malaria, Babesia Trypanosomes

4th year medical students 2nd Feb,2008