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Transfusion cases Dr Claire Barrett Division Clinical Haematology
Transfusion cases
Dr Claire BarrettDivision Clinical Haematology
Learning objectives:
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)
Case 2: Ordering and administration of blood products:
FOCUS:The right specimen from the right patient.The right blood product for the right patient.
Case 2:
Picture the scene: It’s your first call at this hospital.
YOUare HERE
THE DEEP RURAL HOSPITAL
250 km from ANYWHERE
The patient:
The patient:
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.
The decision:
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+
The solution... Almost.
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?
The villain!
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 patientwithout your knowledge.
The problem:
What do you think will happen now?
12123
Identify the AHTR:
Diagnosis of AHTR:
Fever Sweating Chills/ or rigors Hypotension Tachycardia/ bradycardia Pain (chest/ flank/ back) Dyspnoea Agitation Haemoglobinuria (pink urine) Oliguria Bleeding
Management of AHTR:
Management:
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
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.
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)
Refer ICU:
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.
RECORD KEEPING and REPORTING:
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.
Risk reduction:
Review hospital policy for administration of blood products.
Train clinical staff members. If patient has alloantibodies, give a
written card specifying the identified antibodies.
Haemolytic transfusion reactions:
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.
Case 3:
Case 3:
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%)
What do you think?
What is the diagnosis? Which blood product would you
would not use? Which blood products would you
use? Why?
The progress, 3 days later:
Mr ABC is doing really well. Platelets increased to 70. Fragmentation is now 5%. Renal function is improving.
But then, 5 days later:
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?
X-Ray:
Admission: 3 days later:
What is TRALI: 1 in 5000- 10000 TxFatality 5 – 10%
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.
Implicated blood products:
Whole blood Red cell concentrate FFP Platelet concentrates Cryoprecipitate IVIG Granulocytes.
Definition and diagnosis:
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.
Differential dx:
Congestive cardiac failure/ acute left ventricular failure.
TACO (Difficult to differentiate) TACO causes raised BP.
Pulmonary embolism Rapidly progressing pneumonia
Especially viral/ fungal ARDS.
Management of TRALI:
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.
Investigation of TRALI:
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.
You should now be able to:
Order and administer blood safely. Identify and manage an acute
haemolytic transfusion reaction Identify and manage TRALI.
Any questions?
