Adverse Reactions and Events in Transfusion Flashcards
What is Haemovigilance?
The systemic surveillance of adverse transfusion reactions and events. And collecting data on these to improve safety throughout the transfusion chain from donor to patient.
What types of incidents are reported to SHOT?
All incidents, near misses, reactions and events.
What does ‘SHOT’ stand for?
Serious Hazards Of Transfusion
What is the purpose of the SHOT group?
To make recommendations to improve patient safety.
What does MHRA stand for?
Medicines and Healthcare products Regulatory Agency
What is the purpose of MHRA?
They have the power to impose the ‘case and desist’ order.
What does SABRE stand for?
Serious Adverse Blood Reactions and Events
What is SABRE?
A merged database of MHRA and SHOT
What data is reported t MHRA?
SARs (Serious adverse reactions)
SAEs (Serious adverse events).
Define a serious adverse reaction.
An unintended response to a donor in a patient that is associated with the collection, or transfusion of blood or blood components that is fatal, life-threatening, disabling or incapacitating, or which results in or prolongs hospitalisation or morbidity.
Where are notifications of SAR submitted?
On SABRE
What are the clinical symptoms of an allergic anaphylactic shock?
Severe hypotension associated with wheezing.
Stridor from laryngeal oedema.
Swelling of the face, limbs or mucous membranes.
Flushing and urticaria.
What is Stridor?
Loud breathing sounds
What is Angiodema?
Swelling of the deeper layers of the skin caused by build up of fluid.
How are less severe allergic reactions treated?
With anti-histamines
In what patients is anaphylaxis common?
In patients with a known allergy where the donor has consumed the allergen.
What type of transfusions commonly cause anaphylaxis?
Plasma rich components such as platelets of fresh frozen plasma.
What investigation usually occurs after a anaphylactic reaction due to transfusion?
Investigated by clinical immunologists for IgA deficiency.
What are the clinical symptoms of febrile reaction?
Fever (often with shivering), muscle pain and nausea
What is the main cause of febrile reaction?
Antibodies directed against donor Leukocytes and human leukocyte antigens.
What mediates febrile reaction?
Pre-formed cytokines in the donor plasma as a consequence of leukocyte breakdown.
How quickly do febrile reactions occur after transfusion?
Up to 2 hours after completion of the transfusion
In what type of patients is febrile reaction most common?
In multi-transfused patients receiving red cells.
What is the treatment for febrile reaction?
Paracetamol and slow rate of transfusion.
What transfusion advancement lowered the levels of febrile reaction?
Use of Leukodepleted blood component.
What does Ta GvHD stand for?
Transfusion associated graft versus host disease.
How does Transfusion associated graft versus host disease occur?
Engrafted T lymphocytes from the transfused blood recognise the recipient as foreign and attack the host tissues.
What tissues is Ta GvHD most likely to affect?
Skin, liver, bowel
How often is transfusion associated graft versus host disease fatal?
90% of the time
How is transfusion associated graft versus host disease prevented?
By irradiating cellular components.
What does TACO stand for?
Transfusion Associated Circulatory Overload
What is the most common cause of TACO?
Rapid transfusion of a large volume of blood.
What is the most commonly reported cause of transfusion-related death in the UK?
Transfusion associated circulatory overload (TACO)
What patients are at risk of TACO?
Patients age 60+ or the young. With cardiac or pulmonary failure With renal impairment With hypoalbuminemia Anaemia
What is hypoalbuminemia?
Deficit of albumin in the blood
What is the purpose of albumin in the blood?
Helps keep fluid in the blood and prevents it leaking to other tissues.
What does TRALI stand for?
Transfusion related acute lung injury
What are the symptoms of TRALI?
Severe breathlessness, cough, coughing up frothy pink sputum.
What is sputum?
A mixture of saliva and mucus coughed up from the respiratory tract.
Why is TRALI often confused with acute heart failure?
Both cause circulatory overload
What are the 2 possible causes of TRALI?
White cell antibody mediated TRALI.
Cytokine mediated TRALI.
Outline white-cell mediated TRALI.
The recipient expressed HLA or neutrophil receptors to which the implicated donor has formed antibodies. These antibodies react with neutrophils in the pulmonary microvasculate. Activated Neutrophils damage the endothelium which leads to vascular leakage into the alveolar space and pulmonary oedema.
How is TRALI prevented?
Transfusion of plasma components is only fro male donors and screened female aphaeresis donors.
In what type of people has TRALI been very common in the past?
Females who have previously been pregnant.
How does Cytokine mediated TRALI occur?
Neutrophils accumulate and are primed in the patient’s pulmonary microvasculature as a result of pre-exisiting systemic inflammation.
A soluble lipid substance accumulates during the storage of components. These lipids can activate Neutrophils to induce the release of cytokines which contributes to endothelial damage in susceptible patients, leading to vascular leaks and pulmonary oedema.
What type of TRALI occurs mostly in males?
Cytokine mediated TRALI
Which blood components implicate TRALI?
Plasma or platelets
Which blood components implicate TACO?
Any
How long do TRALI and TACO take to onset after transfusion?
Up to 6 hours
How does blood pressure change in patients with TRALI?
Usually lowers
How does blood pressure change in patients with TACO?
Usually high
How does oxygen saturation of the blood change in TACO and TRALI patients?
It reduces
How does venous pressure change in TRALI patients?
Normal or low
How does venous pressure change in patients with TACO?
Elevated
How does temperature change in patients with TRALI?
Often raised
How will the chest X-ray of TRALI patients appear?
Bilateral peri-hilar and nodular shadowing or white out. Normal heart size.
How will the cheat X-ray of TACO patients appear?
Enlarged heart and characteristics of pulmonary oedema.
How does the pressure of the pulmonary artery change in TACO patients?
Elevated
How does blood count change in TRALI patients?
Fall in neutrophils and monocytes followed by neutrophil leucocytosis.
What does TAD stand for?
Transfusion associated Dyspnoea
What are the symptoms of TAD?
Respiratory distress within 24 hours of transfusion that does not meet the criteria for TRALI, TACO or an allergic reaction.
What does PTP stand for?
Post transfusion purpura
What is PTP?
Unexpected thrombocytopenia occurring 5-12 days post transfusion.
What is thrombocytopenia ?
Drop in platelets
Who does PTP affect?
Usually middle aged or elderly women who have been alloimmunised against HPA-1a during earlier pregnancy or previously transfused men.
What are the clinical features of PTP?
Platelet count to drop below 10x10^9.
Haemorrhage.
Widespread purport and bruising.
What is treatment for PTP?
High does IV of IgG
What is Purpura?
Discolouration of the skin or mucous membranes due to haemorrhage from small blood vessels.
What does TTI stand for?
Transfusion Transmitted Infections
How is bacterial contamination during transfusions reduced?
Improved cleaning of donor arm
What is the most common type of TTI I the UK ?
Hepatitis B
What does SAE stand for?
Serious Adverse Reactions
What is the definition for serious adverse reactions in terms of transfusion?
Any untoward occurrence associated with the collection, testing, processing, storage and distribution of blood or blood components that might lead to death or life threatening disabling or incapacitating conditions for patients or which result in, or prolongs hospitalisation or morbidity.
What are the different causes of serious adverse reactions?
- ADU (advisable, delayed or under/over transfused).
- WCT (wrong component transfused).
- SRNM (special requirement not met)
- HSE (handling and storage errors)
- RBRP (Right blood, right patient)
- Near miss
What is ADU? (Avoidable / delayed / over or under transfusion).
When a transfusion of blood was clinically indicated but was not undertaken or non-avaibility of blood components led to a delay with impact on patient care.
Give some examples of special requirements in terms of blood transfusions.
Irradiation
HLA-matched platelets
What may occur if red cells are stored in low temperatures?
Haemolysis
What may occur if platelets are stored in low temperatures?
Activation
What may occur if red cells or platelets are stored at high temperatures?
Microbial proliferation
What may storing plasma components at low temperatures do?
Lead to the precipitation of coagulation factors and thus will not pass though the blood.
What may happen to coagulation factors in the blood if they are stored at temperatures that are too high?
Denaturation
What is ‘Near Miss’ in terms of transfusion?
Any error which if undetected could result in determination of a wrong blood group or transfusion of an incorrect component, but was recognised before the transfusion took place.
At what stages of transfusion are samples investigated for any issues?
Pre transfusion
Post transfusion
The remnants of any un-transfused units.
How are sample bags initially checked if there is a suspected error?
Check all the paperwork on the suspected bag, including crossmatch labels and report if available. Ensure that the correct crossmatch label is on the bag.
Check the samples for visible signs of haemolysis.
What is carried out in terms of pre-transfusional error checks on a sample with suspected issues ?
Manually perform direct anti-globulin test and full group antibody screen.
Set up a cross match against each unit investigated.
What is carried out in terms of post-transfusional error checks on a sample with suspected errors?
Automated full group and antibody screen.
Direct antiglobulin test (manual).
Serological crossmatch against each investigated unit.
What tests are carried out on the remnants of a transfused unit which is suspected to contain errors?
Manual short group and direct anti globulin test for each unit investigated.
If the patient has known antibodies, ensure that all the units of blood are negative for the relevant antigens.
What must happen if a sample is suspected to have bacterial contamination?
This must be reported to NHSBT so that they can immediately initiate a product recall.
How do transfusion complications lead to pulmonary oedema?
Excess fluid builds up in the circulation and leaks into the lungs by hydrostatic pressure.
What causes the inflammation associated with TRALI?
White cell antibodies in the transfused donor component are interacting with recipient antigens.
Can chest X-rays differentiate between TACO and TRALI?
No
Can a patient have TACO and TRALI at the same time?
Yes
What treatment should a patent be given if they are having trouble breathing during a transfusion?
Oxygen
Pause in transfusion
Diuretics
Possible ventilation
Is TRALI or TACO more common?
TACO
What are the risk factors for TACO?
Old age
Low body weight
Renal dysfunction
Low albumin levels
What patients should be risk assessed for TACO before transfusion?
All
Where should all pulmonary complications be reported to?
SHOT
What are the 4 critical stages of transfusion?
- Sample receipt and registration.
- Testing
- Component selection
- Component labelling
What are ‘Never events’ in terms of transfusion?
Inadvertent transfusion of ABO incompatible blood components regardless of the outcome.
Is TRALI entirely prevented by using plasma components from male donors?
No
What is the reason that TTIs are less frequent now?
More sensitive microbiological testing of blood donations.
What is the most common error associated with ABO incompatible transfusions?
Wrong blood in tube
