3.7 Transfusion Safety and Transfusion Reactions

Question 1

What is the process of transfusion like?

Answer 1

1. request
2. sample taking
3. sample receipt
4. testing
5. component selection
6. component labelling
7. component collection
8. prescription
9. administration

Question 2

Transfusion is a process involving multiple healthcare professionals
o ______________ are important in sample taking and administration
o Critical points in the transfusion lab include _________________________
- Transfusion safety is a global issue with the WHO setting guidelines, physical standards, training and technical support top increase blood product quality, safety and availability

Answer 2

Positive patient identifiers;

grouping, antibody screening, selection and cross matching

Question 3

_________________ is a tenet of blood transfusion safety – defined as a set of surveillance procedures covering the entire blood transfusion chain from donation and processing of blood and its components to provision, transfusion and follow-up of the patient
o Includes monitoring, reporting, investigating and analysis of adverse events related to the donation, processing and transfusion of blood, taking action to prevent occurrence of errors

• Objectives of haemosurveillance – data collected about near miss incidents, infectious and non-infectious hazards associated with transfusion can be used to identify and correct procedural weaknesses and problems
  o Gather and analyse reports of all adverse events and “near misses” that occurred during the entire process of transfusion
  o Determine the morbidity of transfusion
  o Provide guidance on corrective measures to prevent recurrence
  o Improve public confidence
• A just and “sharing” culture facilitates learning, enables practice and systemic changes, mitigates ongoing harm and fosters collegial support

Answer 3

Haemovigilance

Question 4

Transfusion errors prevention strategies
- Positive patient identification is very important – most effective against administration errors
o Involve the patient by asking them to state their full name and NRIC where possible (DOB can be used as a 3rd identifier)
o Assess if patient is able to physically and mentally identify themselves
- Check identifiers and details of the patient’s wristband against _______________________
- Before administration, check component on transfusion slip matches the blood pack
in terms of number of units, blood group, components and ensure __________________________
- Blood transfusion must be an uninterrupted process at bedside with 1 staff only attending to 1 patient at any 1 time

Answer 4

labels and lab generated transfusion slip;

expiry date not reached

Question 5

Blood administration and monitoring
- Fluids – use only normal saline as fluids containing calcium such as ______________ will antagonise _____________ and may cause clot formation and hypotonic saline e.g. 5% dextrose can theoretically cause ___________________________
- Do not co-administer drugs
- Use in-line ______________ filter – filtration of fibrin clots and large red cell clumps
o Leukocytic filters can be used in certain cases
- Monitoring – monitor closely in the 1st 15 minutes for vitals, new symptoms and then
hourly thereafter
o Pre-transfusion – measure baseline _________________________
o 1st 15 minutes – many serious reactions of transfusion present early in the process
o Thereafter – hourly till transfusion ends
o Post-transfusion – measure vitas within 1 hour of completion
- Patient should be monitored for development of new symptoms such as breathlessness, ____________________, which may indicate haemolytic transfusion reaction

Answer 5

Ringer’s lactate; citrate anticoagulants;

haemolysis if sugars are metabolised by red cells;

170-260 micron;

temperature, pulse rate, respiratory rate, blood pressure and SpO2;

pain along vein used for IV or flank pain

Question 6

Transfusion reactions – in a serious reaction these steps should be done concurrently and immediately
- Immediately stop the transfusion but keep the IV plug – keep line patent with __________________ for administration of resuscitation drugs if needed
- Immediately check vitals and resuscitate if necessary
- Clerical check on the _________________ – patient name, NRIC, unit number and blood product label
o Likely at this point another patient is going to be transfused with wrong product too
- Report, collect _____________________ post-stabilisation

Answer 6

normal saline drip;

transfusion slip and wrist tag;

blood and urine samples

Question 7

Mild – febrile transfusion reaction

• Seen in 1 to 2% of transfusions due to reactions to _______________ – most common in red cell and platelet products
• Fever 1 to 2oC above pre-transfusion baseline, usually no other signs and symptoms
• More severe cases e.g. 39ºC fever with _____________________
• Although most severe febrile reactions are still caused by reactions to leukocytes, when accompanied by symptoms, the risk of serous reaction increases and should be considered and managed
• Can continue transfusion with paracetamol/slower rate/ more frequent monitoring
• Think of serious transfusion reactions if other signs and symptoms appear, think underlying condition – if ______________________ appears, transfusion should be stopped
• To prevent reoccurrence, _____________________ can be used

Answer 7

transfused leukocytes;

rigor, myalgia and nausea;

hypotension or hypoxaemia;

paracetamol/ leukoreduction (in-line bedside leukocyte filter)

Question 8

Mild – Allergic transfusion reaction

• Seen in 1 to 3% of transfusions due to reactions to _____________ – most common in platelets and plasma products
• Transient flushing, rash, urticaria with no evidence of _______________, usually no other signs and symptoms
• Can continue transfusion with antihistamines/slower rate/ more frequent monitoring – transfusion can be slowed or stopped first, antihistamine administered and transfusion resumed after antihistamine takes effect
• Think anaphylaxis if severe allergy-type signs present – _________________
• Prevent with pre-transfusion antihistamines and washed blood products (plasma removed, cells suspended in another medium – consult haematologist before use)

Answer 8

plasma proteins;

angioedema or angiospasm;

angioedema, wheezing, stridor, airway problems, hypotension

Question 9

Pulmonary complications of transfusion
Transfusion-associated circulatory overload (TACO) – most common

Transfusion-related acute lung injury (TRALI) – due to activation of patient neutrophils and monocytes by antibodies present in donor blood, subsequently targeting ________________
- Damage of pulmonary endothelium and subsequently _______________ that is non-cardiogenic in nature

Answer 9

donor HLA;

pulmonary oedema

Question 10

TACO:

• diuretics ___________
• fluids __________
• BP __________
• Temperature often normal
• _________ elevated
• blood elevated/ no change (may be elevated from stress of reaction
• Brain naiuretic peptide ____________

Answer 10

improves; 
worsens; 
often high; 
JVP; 
elevated

Question 11

TACO:

• diuretics ___________
• fluids __________
• BP __________
• Temperature often normal
• _________ elevated
• blood elevated/ no change (may be elevated from stress of reaction
• Brain naiuretic peptide ____________

Answer 11

improves; 
worsens; 
often high; 
JVP; 
elevated

Question 12

TRALI:

• diuretics ___________
• fluids __________
• BP __________
• Temperature often normal
• JVP normal
• blood elevated/ no change (may be elevated from stress of reaction
• Brain naiuretic peptide ___________

Answer 12

Worsens;
improves;
often low; normal

Question 13

Severe reactions of transfusion
If significant signs and symptoms are present, consider severe reaction even if the temperature criteria is not met
- High fever (>2ºC increase from pre-Tx , >1ºC increase from pre-Tx and absolute temperature of >39ºC)
- Nausea/vomiting, pain, rigors, drop in BP, tachycardia (pulse rate increase by _______- from pre-Tx)

Acute haemolytic transfusion reaction

• Transfusion transmitted bacterial infection
• Initially – stop transfusion, maintain line, clerical check, resuscitate

After resuscitation and stabilisation, the blood bag together with 2 ______________ used for GXM are sent to the transfusion lab for further investigations
- Frequently, if the reaction is severe and bacterial infection is considered, blood bags are sent for culture and patient started on ____________________

Answer 13

> 40;

pink top EDTA tubes;

broad spectrum antibiotics empirically