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Y4 Cancer Care > Blood transfusions > Flashcards

Blood transfusions Flashcards

1
Q

What are the key steps to take before initiating a blood transfusion?

A
  1. Wash your hands and don appropriate PPE.
  2. Request a colleague to assist you with checking the blood transfusion
  3. Ask the patient to tell you their name and date of birth and then compare this to their bracelet, medical notes and blood compatibility report to ensure they all match exactly.
  4. Check the blood group and serial number on the blood bag matches the compatibility report.
  5. Check the expiry date and time on the unit of blood to ensure it has not expired.
  6. Inspect the blood bag for:
    Signs of tampering, leaks, discolouration and clots
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2
Q

How long can blood be out of the fridge for?

A

Blood out of fridge over 30 mins should be transfused within 4 hours or discarded

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3
Q

How should you administer a blood transfusion?

A
  1. Wash your hands and don appropriate PPE (if not done so already).
  2. Attach the giving set to the blood bag and run some blood through the tubing to expel any air.
  3. Once all air has been expelled from the tubing, attach the other end of the giving set to the cannula port.
  4. Set the time the blood should be transfused over (typically 2-3 hours in non-urgent scenarios).
  5. Dispose of the relevant equipment into a clinical waste bin (including PPE) and wash your hands.
  6. Document the time and date that the transfusion was started and both you and your colleague will need to sign to confirm all checks were carried out prior to administration.
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4
Q

What is the blood transfusion threshold and Hb target?

A

Without ACS:
threshold = 70 g/L
target = 70-90g /L

With ACS
threshold = 80 g/ L
target = 80-100 g/ L

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5
Q

How quickly should one unit of red cells be transfused?

A

emergency = STAT
non urgent = over 90-120 minutes

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6
Q

How should patients be monitored during blood transfusion?

A

The patient’s baseline obs (including blood pressure, pulse, resp rate and temperature) should be checked at 0, 15 and 30 minutes from the onset of the transfusion.

Observations can then be performed on an hourly basis and again when the transfusion has finished.

Regular observations allow early detection of transfusion reactions

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7
Q

Name the key transfusion reactions

A

Got a bad unit

G raft vs. Host disease
O verload (TACO)
T hrombocytopaenia

A lloimmunization

B lood pressure instability
A cute haemolytic reaction
D elayed haemolytic reaction

U rticaria / Anaphylaxis
N eutrophilia
I nfection
T ransfusion associated lung injury

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8
Q

Irradiated blood products are required in patients following bone marrow and stem cell transplants for what reason?

A

to prevent graft versus host disease

(depleted of T lymphocytes)

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9
Q

How is TRALI differentiated from TACO?

A

hypotension in TRALI vs hypertension in TACO

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10
Q

Which blood product is most likely to cause an iatrogenic septicaemia with a Gram-positive organism?

A

Platelets - stored at room temperature

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11
Q

The first step in management of any suspected transfusion reaction is what?

A

stop the transfusion!!!

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12
Q

Fever, abdominal pain, hypotension during a blood transfusion →

A

acute haemolytic reaction

due to RBC destruction by IgM-type antibodies

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13
Q

Hypotension, dyspnoea, wheezing, angioedema during a blood transfusion →

A

anaphylaxis

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14
Q

What is the universal donor of FFP?

A

AB RhD negative blood

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15
Q

What is involved in blood conservation technique?

A

1.Increase red blood cell mass – e.g. correct iron deficiency
2.Reduce peri-operative blood loss – e.g. op for regional not GA where possible
3.Optimising transfusion practice – allogenic transfusion/ autologous transfusion (cell salvage)

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16
Q

What are the benefits of blood transfusion for a symptomatic anaemic patient?

A

reduces sx burden e.g. makes patients less tired and SOB

reduces risks of anaemia e.g. cardiovascular risk (worsening LVF or anaemia-induced MI)

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17
Q

What is the difference between a Group and Screen and a crossmatch?

A

G&S = finding out the blood group
Cross match = assess for reaction of patients serum with the red cells you are going to give them

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18
Q

What is the risk of giving a patient the wrong blood?

A

causing an acute haemolytic reaction - activated compliment system which causes a systemic inflammatory response

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19
Q

What should you ask in the history for a cancer patient with symptomatic anaemia?

A

how long have they had symptoms for?

what treatments are they receiving for their cancer and when did they last receive them? (especially things that may cause bone marrow failure)

Any visible blood loss - rectal bleeding, haematuria, bleeding from gums, epistaxis?

What is their diet like? (still can be common things like IDA in cancer patients)

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20
Q

What investigations might you do for a patient presenting with new symptomatic anaemia?

A
  • FBC (incl. MCV)
  • reticulocyte count (production issue or destruction issue)
  • LFTs - bilirubin for haemolysis
  • LDH- burden of haematological disease and cell turnover
  • iron, ferritin, transferrin saturation - IDA
  • vitamin B12 and folate - megaloblastic anaemia

G&S and crossmatch if they require transfusion

peripheral blood film

bone marrow aspirate / biopsy

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21
Q

What is the function of haptoglobin cells?

A

haptoglobins carry destroyed haem

low free haptoglobins mean more are bound carrying destroyed red cells - suggests haemolysis

22
Q

How does haemolytic anaemia present on investigation?

A

anaemia
reticulocytosis
low haptoglobin
raised lactate dehydrogenase (LDH) and indirect bilirubin

blood film: spherocytes and reticulocytes

23
Q

How would you confirm diagnosis of an autoimmune haemolytic anaemia?

A

DCT : Direct Coombs test - looking for antibodies bound to surface of RBCs

In autoimmune haemolytic anaemia there are antibodies e.g. IgG bound to the red cells’ surface that causes them to be destroyed by the spleen

patients can be managed with an anti IgG antibody

24
Q

Outline the UHL massive haemorrhage protocol

A

Alert senior staff member that you are activating massive haemorrhage protocol

Give warmed IV crystalloid bolus

Transfuse 4 units red cells if indicated (can use O- blood if required but inform Blood Bank if emergency supplies used)

Attempt to control bleeding

Consider tranexamic acid

Reverse any anticoagulation

Arrange cell salvage where available

25
Q

Which tests make up a Haemolysis screen?

A

Increased bilirubin, LDH and reticulocytes
Decreased Haptoglobins - as mops up free Hb


Blood film:
- spherocytes in all causes of haemolysis, this is the prominent feature in AIHA
- red cell fragments (schistocytes) in microangiopathic or mechanical haemolytic anaemia
- Polychromasia (young red cells) if bone marrow able to respond to anaemia

DCT - direct coombs test
- positive in immune causes of haemolysis but negative in non- immune causes

26
Q

How may haemolytic anaemia be classified?

A

Hereditary v acquired
Immune v non-immune
Extravascular v intravascular

27
Q

Give some intravascular causes of haemolysis

A

mismatched blood transfusion
G6PD deficiency
red cell fragmentation: heart valves, TTP, DIC, HUS
cold autoimmune haemolytic anaemia

28
Q

Give some extravascular causes of haemolysis

A

haemoglobinopathies: sickle cell, thalassaemia
hereditary spherocytosis
haemolytic disease of newborn
warm autoimmune haemolytic anaemia

29
Q

What is warm autoimmune haemolytic anaemia (AIHA)?

A

the most common type of AIHA

In warm AIHA the antibody (usually IgG) causes haemolysis best at body temperature and haemolysis tends to occur in extravascular sites, for example the spleen

30
Q

What causes warm AIHA?

A

idiopathic
autoimmune disease: e.g. SLE
neoplasia
lymphoma
chronic lymphocytic leukaemia
drugs: e.g. methyldopa

31
Q

How can warm AIHA be managed?

A

treatment of any underlying disorder
steroids (+/- rituximab) are generally used first-line

32
Q

What is cold AIHA?

A

The antibody in cold AIHA is usually IgM and causes haemolysis best at 4 degrees C.

Haemolysis is mediated by complement and is more commonly intravascular

Features may include symptoms of Raynaud’s and acrocynaosis

33
Q

What causes cold AIHA?

A

neoplasia: e.g. lymphoma
infections: e.g. mycoplasma, EBV

34
Q

Give some hereditary causes of haemolysis

A

Red cell enzymopathies:
* G6PD deficiency
* Pyruvate Kinase deficiency

Abnormal Hb:
* Unstable haemoglobins
* Sickle cell disease
* Thalassaemia

35
Q

Give some acquired causes of haemolysis

A

Alloimmune:
HDFN
Incompatible transfusion

Autoimmune:
Warm AIHA (1°, 2° eg CLL, drugs, SLE)
Cold AIHA (mycoplasma, EBV)

Non-immune:
Microangiopathic HA (i.e. TTP or HUS)
Prosthetic heart valves
Sepsis/ DIC
Malaria

36
Q

If transfusion becomes necessary for AIHA what problems may be encountered?

A

active antibodies will continually break down blood products
can’t crossmatch blood as antibodies will react with everything

37
Q

How is haemolysis monitored in the acute and outpatient setting?

A

daily bloods and then weekly bloods as an outpatient
includes FBC, retics, LFTs and LDH

38
Q

Give some indications for the use of irradiated blood products

A

bone marrow transplant / peripheral blood stem cell transplant recipient

due for bone marrow harvest in next 7 days

Hodgkin’s disease (even if cured)

Currently on certain medications incl. Fludarabine

exchange transfusion in neonates and infants up to 6 months

39
Q

Who needs CMV negative blood?

A

pregnant women and neonates up to 28 days from EDD

40
Q

Give indications for red cell transfusion. What dose would you transfuse at?

A

anaemia, haemorrhage

1 unit unless MHP
consider alternatives e.g. replace haematinics first, cell salvage, EPO

41
Q

Give indications for FFP transfusion. What dose would you transfuse at?

A

coagulopathy and bleeding, prolonged APTT and PT , INR >1.5

12-15ml/kg (usually 3-4 bags for an adult)

42
Q

Give indications for cryo transfusion. What dose would you use?

A

replace fibrinogen in bleeding patient with coagulopathy

fibrinogen <1.5 or <2 in obstetrics

2 pools

43
Q

How do patients with low clotting factors versus low platelets present differently?

A

low clotting factors = bruises or bleeding into joint spaces

low platelets = petechial rash (pinprick), gum bleeding, oral blisters

44
Q

What is the threshold for platelet transfusion?

A

<10 - wait till as low as possible because patients quickly make antibodies to platelets and become refractory to tx

45
Q

What is the maintenance tx for B12 deficiency?

A

IM Hydroxocobalamin 1mg every 2-3 months

46
Q

Non-haemolytic febrile reaction is thought to be caused by antibodies reacting with white cell fragments in the blood product and cytokines that have leaked from the blood cell during storage.

How does it present?
How can it be managed?

A

Fever, chills, more common following platelet transfusion

Mx:
Slow or stop the transfusion
Paracetamol
Monitor

47
Q

Minor allergic reactions to blood products are thought to be caused by foreign plasma proteins.

How may they present?
How should they be managed?

A

Pruritus, urticaria

Mx:
Temporarily stop the transfusion
Antihistamine
Monitor

48
Q

Acute haemolytic reaction occurs when a patient is given ABO-incompatible blood e.g. secondary to human error.

How does it present?
How should it be managed?

A

Fever, abdominal pain, hypotension

Mx:
Stop transfusion
Confirm diagnosis : check the identity of patient/name on blood product, send blood for direct Coombs test, repeat typing and cross-matching
Supportive care (fluid resuscitation)

49
Q

Transfusion-associated circulatory overload (TACO) occurs due to excessive rate of transfusion or pre-existing heart failure.

How does it present?
How should it be managed?

A

Pulmonary oedema, hypertension

Slow or stop transfusion
Consider intravenous loop diuretic (e.g. furosemide) and oxygen

50
Q

What causes Transfusion-related acute lung injury (TRALI)?

A

Non-cardiogenic pulmonary oedema thought to be secondary to increased vascular permeability caused by host neutrophils that become activated by substances in donated blood

51
Q

How does TRALI present?

A

Hypoxia, pulmonary infiltrates on chest x-ray, fever, hypotension

52
Q

How should TRALI be managed?

A

Titrate oxygen, give IV fluids and consider escalation of care

Y4 Cancer Care (13 decks)

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