1. Dr Claire Barrett Division Clinical Haematology

2.  Follow the correct process of ordering and administering blood.  Identify and manage an acute haemolytic transfusion reaction  Identify and manage TRALI (transfusion related acute lung injury)

3. FOCUS: The right specimen from the right patient. The right blood product for the right patient.

5.  Picture the scene:  It’s your first call at this hospital. YOU are HERE

6. THE DEEP RURAL HOSPITAL 250 km from ANYWHERE

7. The patient:

8.  22 year old man brought into casualty by ambulance with stab wounds in his abdomen.  BP 80/45mm Hg, pulse 145/minute.  Tachypnoeic and weak.  He is actively bleeding and shocked.  Ward haemoglobin is 8.

9.  What do you do?  Due to delays in arranging an anaesthetist, your patient bleeds further, his Hb is now 5.  Patient’s blood group = O+

10.  Order blood from your hospitals small blood bank.  No group O blood.  The blood bank has 2 units of group B+ blood that has been kept on standby for another patient’s elective theatre case...  What now?

11. Your colleague decides that it would be better to give the patient some blood rather than none at all, and administers 1 unit of group B blood to the patient without your knowledge.

12.  What do you think will happen now? 12123

14.  Fever  Sweating  Chills/ or rigors  Hypotension  Tachycardia/ bradycardia  Pain (chest/ flank/ back)  Dyspnoea  Agitation  Haemoglobinuria (pink urine)  Oliguria  Bleeding

16.  Recognise symptoms and signs.  Respond:  STOP transfusion  Remove blood giving set and bag  KEEP ivi line open and running with 0,9% saline. ▪ Maintain urine output of 100ml/hr for 24 hours. ▪ Furosemide/ mannitol may be neccessary to maintain output  Insert second ivi line  Oxygen by face mask  Record vital signs

17.  Recheck:  Correlate patients name, hospital number and date of birth with wrist band, unit and form accompanying blood.  Ask blood bank to recheck compatibility.  Return  Return the offending unit to the blood bank.

18.  React:  Send post reaction samples to blood bank ▪ (1 red (clotted) tube, 1 purple (EDTA) tube and urine specimen.  Send the following tests to confirm haemolysis: ▪ Raised unconjugated bilis, ▪ Urine haemoglobin and haemosiderin, ▪ Decreased haptoglobin, ▪ Increased LDH, ▪ Increased AST, ▪ Decreased Hb, or insufficient rise in Hb. ▪ Coombs.  Send Blood cultures (to exclude infection)

19.  Management/ support of  Renal failure ▪ Maintain intravascular volume and renal blood flow. ▪ Monitor input and output ▪ Consult nephrology  Cardiac failure ▪ Inotrope support may be neccessary  Respiratory failure ▪ Possible intubation and ventillation  DIC (consult haematology) ▪ Monitor INR, PT, PTT ▪ FFP, platelets, cryoprecipitate ▪ Heparin 10u/kg/hr if thrombotic features predominate.

20.  Date and time transfusion started and stopped.  Date and time symptoms appeared.  Exact clinical findings (detail)  Interventions and outcomes.  Report to SANBS and complete the TRANSFUSION REACTION FORM.  Report to Hospital Transfusion Committee.

21.  Review hospital policy for administration of blood products.  Train clinical staff members.  If patient has alloantibodies, give a written card specifying the identified antibodies.

22.  Possibly fatal complication of a blood transfusion.  Need to be recognised early.  Prevented by ALWAYS ensuring that the right blood is administered to the right patient.

24.  Mr ABC: 40 year old male patient.  Known HIV positive, CD4 530.  Presents with convulsions, fever, oliguria.  Mucosal bleeds.  FBC shows platelet count of 5 and Hb of 8.  Haematopathologist reports fragmentation haemolysis. (red cell fragments = 20%)

25.  What is the diagnosis?  Which blood product would you would not use?  Which blood products would you use?  Why?

26.  Mr ABC is doing really well.  Platelets increased to 70.  Fragmentation is now 5%.  Renal function is improving.

27.  Mr ABC suddenly becomes short of breath and distressed. Saturation 76%.  The nursing staff call you.  You listen to his chest and hear bilateral crepitations.  What do you think?  What do you do?

28. Admission: 3 days later:

29.  Serious, life threatening syndrome that presents with:  Acute respiratory distress  Pulmonary oedema  Hypoxaemia  Hypotension  2- 6 hours after transfusion  Usually resolves 96 hours after transfusion.

30.  Whole blood  Red cell concentrate  FFP  Platelet concentrates  Cryoprecipitate  IVIG  Granulocytes.

31.  NEW ALI  Acute onset  Hypoxaemia ▪ PaO2/ FiO2 < 300mmHg ▪ SpO2 < 90% on room air ▪ Other clinical evidence of hypoxaemia  Bilateral chest infiltrates on PA CXR.  No evidence of LA hypertension.  No pre-existing ALI before transfusion  Onset within 6 hours of transfusion  No other risk factors for ALI present.

32.  Congestive cardiac failure/ acute left ventricular failure.  TACO (Difficult to differentiate)  TACO causes raised BP.  Pulmonary embolism  Rapidly progressing pneumonia  Especially viral/ fungal  ARDS.

33.  Stop infusion  Supportive:  Maintain oxygenation (intubation and ventillation prn)  Haemodynamic monitoring  Fluid support to maintain BP  Diuretics not useful (may worsen picture)  No evidence for use of steroids.  2 patterns of resolution:  Resolve in 96 hours (Unlike ARDS)  Some take longer (7 days) to resolve.

34.  Notify SANBS immediately.  Fill in Transfusion Reaction Form.  Send blood to SANBS for  HLA I/II Ab. Neutrophil Ab in the donor supports the diagnosis. ▪ Lymphocyte cross match between donor and recipient. ▪ HNA/ HLA Ab-Ag reaction between donor and recipient must be present.

35.  Order and administer blood safely.  Identify and manage an acute haemolytic transfusion reaction  Identify and manage TRALI.  Any questions?