Approach to a patient with suspected blood transfusion reaction...Acute Transfusion Reaction • Acute transfusion reactions range clinically benign to life-threatening reactions •

Approach to a patient with

suspected blood transfusion

reaction

Raju Vaddepally, MD

Goals

• Detection of Acute Transfusion Reactions (ATR)

• Clinical and Laboratory Evaluation of ATR

• Management of individual ATR

Q&A

• Which one of the following ATRs is most common reactions based on their frequency

a) Urticaria

b) Febrile non-hemolytic transfusion reaction (FNHTR)

c) Transfusion-associated circulatory overload (TACO)

d) Transfusion-related acute lung injury (TRALI)

e) Anaphylaxis

f) Acute Hemolytic Transfusion Reaction

g) Sepsis

Q&A

• In which ATRs you should not continue transfusion of the original blood product a) Urticaria b) Febrile non-hemolytic transfusion reaction

(FNHTR) c) Transfusion-associated circulatory overload (TACO) d) Transfusion-related acute lung injury (TRALI) e) Anaphylaxis f) Acute Hemolytic Transfusion Reaction g) Sepsis

Acute Transfusion Reaction

• Acute transfusion reactions range clinically benign to life-threatening reactions

• Clinical nonspecific symptoms range from- fever or chills to ARDs, Anaphylaxis and DIC

• Prompt evaluation is necessary

• Different Types of ATRs Urticaria Febrile non-hemolytic transfusion reaction (FNHTR) Transfusion-associated circulatory overload (TACO) Transfusion-related acute lung injury (TRALI) Anaphylaxis Acute Hemolytic Transfusion Reaction Sepsis

Urticarial transfusion reaction (UTR)

• Urticarial reactions are associated with hives but no other allergic findings (ie, no wheezing, angioedema, hypotension)

• Most common cause is an antigen-antibody interaction ▫ commonly implicated antigens include a number of donor serum

proteins.

• UTR is not a contraindication to continuing the transfusion as long as it is clear there are no other allergic symptoms

• Antihistamines can be given, but are not indicated prophylactically

Febrile non-hemolytic transfusion

reaction (FNHTR)

• Fever, usually accompanied by chills, in the absence of other systemic symptoms

• FNHTR is a diagnosis of exclusion ▫ the possibility of other febrile transfusion reactions must be eliminated,

including AHTR, sepsis, and TRALI

• Most common cause, is release of cytokines from WBCs in a product that has not been leukoreduced

• Management is symptomatic

• High quality evidence to support the prophylactic use of premedication with acetaminophen or antihistamines is lacking

Transfusion-associated circulatory

overload (TACO)

• TACO is a form of pulmonary edema due to volume excess or circulatory overload

▫ large volume of a transfused product over a short period of time

▫ or in those with underlying cardiovascular disease or elderly

• Management includes

▫ diuresis and supplementary oxygen

▫ ventilatory support may rarely be required

Transfusion-related acute lung injury

(TRALI)

• TRALI is a life-threatening form of acute lung injury

• It occurs when recipient neutrophils are activated by the transfused product in pulmonary vasculature

• Presenting findings include fever, chills, and respiratory distress

• Therapy is largely supportive ▫ may include intubation and mechanical ventilation

• A subsequent evaluation is directed at identifying an implicated donor so

that individual does not continue to donate

• The patient can receive blood products from other donors without restrictions

Anaphylactic transfusion reaction

• This includes angioedema, wheezing, and/or hypotension

• It occurs in IgA-deficient individuals who produce anti-IgA antibodies that react with IgA in the transfused product ▫ or patients who have allergies to another constituent in the

transfused product

• Management may include ▫ epinephrine (0.2 to 0.5 mL of a 1:1000 solution) SC or IM,

antihistamines, and vasopressors depending on the degree of allergic symptoms

Acute hemolytic transfusion reaction

(AHTR)

• Caused by acute intravascular hemolysis of transfused red blood cells (RBCs)

• often caused by a clerical error that results in transfusion of a product not intended for the recipient.

• Symptoms include fever, chills, flank pain, and oozing from intravenous sites

• Immediate communication with the transfusion service is critical to allow for appropriate record checking ▫ which may prevent administration of a wrongly labeled unit to another

patient

• Treatment involves aggressive hydration and diuresis

Transfusion-associated sepsis

• Caused by transfusion of a product that contains a microorganism

• Initial findings may include fever, chills, and hypotension.

• Unlike sepsis from an underlying localized infection, transfusion-associated sepsis may involve a large intravenous inoculum

• Treatment includes broad-spectrum antibiotics and hemodynamic support

WHEN TO SUSPECT AN ATR • Adverse signs and symptoms during or within 24 hours after completion of a

transfusion ▫ Many of the most severe reactions occur within the first 15 minutes of transfusion

• Fever (a 1°C rise in temperature above baseline), chills, pruritus, and urticaria ▫ Often these resolve promptly without specific treatment or complications

• Other findings that may be an indication of a more severe, potentially fatal reaction include

respiratory distress ▫ Hemoglobinuria ▫ loss of consciousness ▫ Hypertension ▫ hypotension ▫ flank or back pain, jaundice ▫ abnormal bleeding, ▫ oliguria/anuria ▫ Disseminated bleeding or oozing from intravenous sites ▫ mental status changes, including feelings of anxiety and/or dread

IMMEDIATE ACTIONS (ALL PATIENTS)

• Immediately stop the transfusion ▫ save the remaining bag and tubing for potential analysis

• Maintain a patent intravenous line with normal saline

• Confirm the correct product was transfused to the intended

patient based on product labeling and patient identification

• Assess the patient ▫ s/s ▫ measure VS ▫ perform a limited PE

• Contact the transfusion service to discuss the appropriate

evaluation and initial management

What do you do with remaining

sample?

• Additional transfusion of the remaining product or another product is usually deferred until ▫ preliminary evaluation has been conducted

▫ If the symptoms subside and the correct product is confirmed

decision deferred to treating physician and transfusion service

• Reactions in which transfusion of the same product may be possible include

▫ urticaria without other allergic symptoms ▫ fever due to an underlying illness rather than the transfusion ▫ TACO that has resolved with diuresis or other measures

• Transfusion of the original product should NOT be continued in cases of

▫ suspected AHTR ▫ Anaphylaxis ▫ Sepsis ▫ TRALI

Do you really need lab testing in all

ATRs?

• Patients with following symptoms may not require additional evaluation

▫ urticaria alone

▫ increase in temperature of <1°C

▫ fever related to the patient's underlying illness

▫ TACO may not require laboratory evaluation

• In contrast, patients with the following symptoms will require laboratory or other testing

▫ suspected AHTR

▫ anaphylaxis, sepsis

▫ TRALI

Blood bank or laboratory will do the

following • A clerical check of the component container, label,

paperwork, and initial patient sample used for typing and crossmatching

• Repeat ABO testing on the post-transfusion patient sample

• A visual check of both pre-and post-transfusion patient samples for evidence of hemolysis

• A direct antiglobulin (Coombs) test (DAT) on the post-transfusion patient sample

ADDITIONAL TESTING AND

MANAGEMENT • The aggressiveness of interventions depends on the

severity of the reaction and the suspected diagnosis ▫ Monitoring urine for pink color and/or urine analysis

for blood ▫ Serial hemoglobin levels, Hemolytic labs to detect

intravascular hemolysis ▫ Coagulation testing for DIC ▫ Quantitative IgA levels, as well as the presence of

antibodies (anti-IgA) ▫ CBC, WBC, Blood cultures ▫ CXR, BNP

Stable patient, mild reaction

• Examples: ▫ Isolated fever less than 1 degree celsius without chills ▫ Isolated hives/itching without other allergic sx ▫ Hypothermia from refrigerated blood product

• It is important to monitor the patient until the reaction

has subsided

• Symptomatic Rx could be enough without other additional testing

• Blood transfusion can be resumed after a 15 to 30minute pause

General INFO One(1) unit of blood = 500 ml NSS = The Only fluid compatible with Blood Tranfusion Gauge = 19, 18, 17, 16 ( 18 - 19 most commonly use) Administer within 30 minutes to decrease bacterial growth Four(4) hours = maximum time of infusion Two(2) nurses = check compatibility of blood Warm the blood = wrap it in a dry towel Mixing blood = tilt side to side Twenty(20) gtts/min for the first 20 mins or 15 minutes KVO = 10 TO 15gtts Consent = needed for Blood Transfusion. Now you can offer video on TV to bypass paper consent

If there is reaction

Stop infusion ↓ Open the NSS line ↓ Notify the physician ↓ Bring blood at the Blood Bank

- Austrian biologist and physician.

- He is noted for having first distinguished the main blood groups in 1900, having developed the modern system of classification of blood groups from his identification of the presence of agglutinins in the blood