BLOOD TRANSFUSION BRI BUDLOVSKY R3 JANUARY 2015

OVERVIEW The process Blood components Testing Consent Transfusion reactions

DONATION

TESTSPECIFIC AGENTSTESTS Group ABO,Rh Alloantibodies ABO and Rh antigen testing Virus HIV Hep B Hep C HTLV West Nile Antibodies, nucleic acid testing Bacteria Syphilis Bacterial contamination Serology Bacterial Culture (plt only) Parasites Chagas in at risk donors antibody

BLOOD COMPONENTS

CONSENT: HISTORY

CONSENT Time to think of alternatives Describe the product Describe benefits & risks Describe alternatives Answer questions/confirm understanding Complete consent form Document in chart

RISKS Hep B: 1/ 153,000 Hep C: 1/ 2.3 million HIV: 1/ 7.8 million Minor urticaria: 1/100 Febrile non-hemolytic: 1/300 ABO incomp/serious immune: 1/ 40,000 Sepsis: 1/ 10,000 plts, 1/ 500,000 pRBCs

TESTING TEST TIMIN G (min) Group5Patient tested for ABO and Rh antigen Screen45 Patient tested for alloantibodies from prior transfusion/pregnancy Xmatch45 Incubate patient’s blood with donor blood, checks for immune reaction due to alloantibodies Computer Xmatch 2 Computer picks appropriate unit based on patient and donor testing. Blood is not actually mixed. DAT 45 RBCs from patient are washed, and then mixed with Coombs Reagent. If they stick together, it means they have antibodies on their surface (+ for immune transfusion reaction)

TRANSFUSION REACTIONS

56F – POD#3 L hemi-colectomy for diverticulitis Transfusion for low Hb You are called for FEVER

DDX: FEVER Usual post-op fever causes Transfusion specific: Febrile non-hemolytic Hemolytic Septic

FEBRILE TRANSFUSION REACTION During or within 4 hours of transfusion: >38°C Increase by 1°C

MANAGEMENT STOP THE TRANSFUSION Maintain IV access Check patient ID and blood product Notify the blood bank

RED FLAGS T>39°C Hypotension/shock Tachycardia Dyspnea Back/chest pain Oliguria/Hematuria Nausea/vomiting Bleeding from IV sites

NON-HEMOLYTIC

HEMOLYTIC BACTERIAL CONTAMINATION

From: Donor skin/blood Poor handling 10% of transfusion mortality

BACTERIAL CONTAMINATION Cultures Two patient sites Bag/line  lab Antibiotics Pip-tazo Vanco

HEMOLYTIC REACTION ABO incompatibility ½ from proper labeling  wrong patient Others from improper labeling, testing error etc. Non-ABO incompatibility From pregnancy/previous transfusion >50%: No morbidity <10%: Fatal

MANAGEMENT Check labels Call blood bank UA for Hb DAT Fluids Supportive

60F – VAGINAL BLEEDING Transfused 2U pRBC You are called for: SOB  SaO2

DDX: DYSPNEA Usual post-op SOB causes Transfusion specific: TACO TRALI Anaphylaxis

TACO Fluid overload Impaired cardiac function +/- Fast rate of transfusion 1/700 transfusions Management Stop transfusion Oxygen Diurese

TACO Prevention is key Identify at risk patients Diuretics between/after units Slow speed (4 hours/U) Divide products into smaller aliquotes Reduce speed without waste

TRALI Acute onset: Hypoxemia Bilateral lung infiltrates on CXR No cardiac cause No ALI before transfusion, and now ALI present DURING or WITHIN 6 hours of transfusion No other risk factors for ALI ALI

TRALI Etiology Passive transfer of antibodies Neutrophil reaction to biologically active compounds in blood Most common cause of transfusion related death (up to 10% of TRALI) Usually 1-2 hours post (up to 6)

TRALI - MANAGEMENT Supportive care No evidence for steroids or diuretics Reducing risk: No plasma/plasma products from multip females Platelets from males or nullip females Pool platelets in male plasma Testing of & deferral of donors with TRALI hx  2/3 reduction

ANAPHYLAXIS Mechanism unclear Transfusing IgA / IgE Antibodies to serum proteins Transfusion an allergen consumed by donor Rare 1/40,000 3% of transfusion fatalities

URTICARIA 1/100 transfusions Management: Interrupt transfusion Benadryl 25-50mg IV Resume if: Urticaria improving/mild No associated symptoms

72M – DIALYSIS PATIENT Transfused 2U pRBC for chronic support Complaining of palpitations

HYPERKALEMIA Prolonged storage & irradiation  K leakage

62F – LGIB 6U pRBC for massive LGIB in ER C/O: Anxiety Foot and hand “cramping” Peri-oral tingling

CITRATE TOXICITY Rare! Massive transfusion or plex only Replace PO or IV More common: Metabolic alkalosis

SUMMARY Know the risks Know the benefits Know the alternatives Document Have a high suspicion Stop the transfusion and investigate

TO STOP OR NOT? Sick or severe TRALI Hemolysis Lab/clerical error Sepsis Anaphylaxis Urticaria Febrile non-hemolytic TACO

Fever NHTR Sepsis HTR Dyspnea TRALI TACO Anaphylaxis Allergic Urticaria Anaphylaxis Hypotension Sepsis Anaphylaxis HTR

REFERENCES Bloody Easy Rosen’s Up-to-date CMPA TRALI: A clinical review. The Lancet. Sept Vlaar et al.

EXTRA SLIDES

STORAGE