Case 46 - transfusion reaction Flashcards
1
Q
what is the most severe immediate transfusion reaction?
A
- acute hemolytic transfusion reaction
- due to ABO blood type incompatability
2
Q
what are some immediate and delayed reactions after blood transfusion?
A
Immediate transfusion rxn
- acute intravascular hemolytic transfusion rxn
- acute extravascular hemolytic trasnfusion rxn
- allergic transfusion rxn
- febrile nonhemolytic transfusion rxn
- TRALI - transfusion related acute lung injury
- TACO - transfusion assoc circ overload
Delayed rxn
- occur after 24 hrs
- GVHD
- infecious (viral, bacterial)
3
Q
Can all bood products cause transfusion reaction?
A
- yes; however type of transfusion rxn depends on blood product administered
- only incomptatbile RBC transfuion cause intravasc or extravasc hemolytic tranfuion
4
Q
what is acute intravascular hemolytic transfusion reaction?
A
- AIHTR most common cause is ABO incompatability
- can alo see with antibodies towards RH, Duffy, Kell, etc…
- anti-bodies in recipient’s blood destroy donor red blood cells
- destruction of cells 2/2 complement activation –> produces cell lysis –> free hemoglobin released into bloodstream
s/sx
- complement activation leads to degranulation of mast cells, histmaine release, release of proinflammatory cytokines
- hypotension and leaky capilllaries
- reflex tachycardia
- renal dysfunction
- resp dysfunction
- TNF-alpha released –> leads to endothelial release of tissue factor
- TF release –> binds to factor VII and initiations extrinisic pathway coagulation cascade
- could lead to DIC
5
Q
Acute extravascualar hemolytic transfusion reaction
A
- non-ABO antigen groups
- most commonly asosciated with Rh group incompatibility
- no intravascular destruction
- anti-bodies bind to RBC and are brought to spleen or liver for destruction
6
Q
febrle nonhemolytic transfusion reaction
A
- Most common type of transfusion reaction
-
2/2 presence of donor leukocytes in transfused blood products (typically RBC and PLT)
- recipient alloantibodies attack donor leuko
- results in release of cytokines
- can occur immedietely or several hours after transfusion
- resolves within 48 hrs
- leukoreduction –> decreases incidence
s/sx
- chills, subjective feeling of cold, rigors, low-grade fever
- these symptoms also seen with AIHTR, acute extravasc hemo trans rxn, anaphylactic reaction
7
Q
Allergic transfusion reaction
A
- most commonly seen in IgA-deficient individuals
- release of histamine when donor plasma protein attach to preformed antibodies on mast cells in sensistized indiviauls
-
mild reaction
- urticaria, pruritus, swelling, rash
-
anaphylactic reaction
- most commonly seen in IgA-deficient individuals
- sensitizied by exposure to “foreign” IgA proteins from previous transfusion or pregancy
- bronchospasm, hypotension, tachycardia, urticaria, possible laryngeal edema
- chest pain, n/v, dyspnea
8
Q
bacteria contaminated or septic transfusion
A
- higher incidence of transmitted bacterial infection from PLT
- stored at room temp (allows for bacterial growth)
blood product contamination
- asymptomatic donors who later devleop infection
- transmission of donor skin flora into collection system
Sepsis
- transfused baceria or endotoxins
- release of proinflam cytokines, IL’s, complement activation
- hypotension, reflex tachy, resp distress, DIC, circulatory collapse.
- Absence of free hemoglobin in blood or urine distinguishes this rxn from AIHTR
9
Q
TRALI
A
- leading cause of transfusion moridity
- higher incidence in PLT and FFP transfusion
mechanism
- two-step proess
- initial incite of pro-inflammatory event such as trauma, recent surgery, infections
- leds to sequester of neutrophils along pulm vessels
- second step = transufed blood activates cytotoxic substances –> cauess leaky capillaries –> interstitial and alveolar edema
S/sx
- noncardiogenic pulmonary edema (occurs w/i 6 hrs of transfusion)
- chills, hypoexmia, fever, b/l pulm infilitrates on CXR, ARDS like picture
- most pts require intubation and mech ventilation
10
Q
TACO
A
- rapid admin of blood products results in TACO
- cardiac diseaes and renal insuffiency most at risk
S/Sx
- CHF –> dyspnea, hypoxemia, circ overload, JVD, increase CVP
11
Q
Hyperkalemia and citrate toxicity associated with blood transfusion reaction
A
Hyperkalemia
- as stored blood ages, potassium concentration within that unit will increase linear fashion
- increaes in K+ is transient, often normal several hours after transfusion
Citrate toxicity
- associated with massive transfusions, reduced liver perfusion (liver tx), and hypothermia
- normally metabolized in liver
- citrate binds to calcium (also magnesium) and leads to hypocalcemia and hypomagnesemia –> impairs cardiac function and produce coagulopathy
*
12
Q
What viruses do blood banks scren for during blood donor collection?
A
- Hep B
- Hep C
- HIV
- HTLV (Human t-lymphotrophic virus)
- CMV
13
Q
what s/sx would you notice in a patient that is having an immediate transfusion reaction?
A
Awake patients:
- chills, fever, rigots, h/a, flank pain, chest pain, itching, dyspnea
Anesthestized:
- hypotension, shock, decrease SaO2, bronchospasm, urticaria, coagulopathy, venipuncture oozing, red/pink urine (hemoglobinuria)
14
Q
You are in the OR and you start to a notice an acute decrease in SaO2 and hypotension. This occured 10 min after you began transfusing blood. You suspect an acute transfusion reaction. What are your intial steps to stabilize the patient?
A
management = removing the cause and assessing ABCs
- stop transfusion, remove unit of blood
Airway
- establish airway, maintain oxygenation and ventilation (supplemental oxygen vs intubation)
- if oxygen desaturation or shock state develop, tracheal intubation and mech vent with PEEP to maintain oxygenation
- titrate FiO2 and PEEP to maintain SaO2
Circulation
- place invasivie monitors (a line, central line)
- pressore support and inotopes as needed
- vasopressin or methyelene blue infusions for refractory hypotension.
*
15
Q
Patient is stablized after suspecting acute transfusion reaction. What labs would you order?
A
- first, confirm unit identification info against patients name band to rule out clerical erros
- send patient blood sample and suspected unit of donor blood to Lab for compatability testing as well as direct antibody test (direct coombs test)
- obtain CBC, coag profile (INR/PTT), free hemoglobin levels, haptoglobin conc, urine hemoglobin level, CMP (electrolytes), BUN/Cr
- ABG to assess acid/base as well as PaO2
- obtain blood cultures (if sepsis 2/2 bacterial contamination is suspected)
