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Transfusion Science > Chapter 11 Adverse Complications of Transfusions > Flashcards

Chapter 11 Adverse Complications of Transfusions Flashcards

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1
Q

What is an adverse transfusion reaction?

A

An undesirable response or effect in a patient during or after the administration of blood components or human-derived plasma products.

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2
Q

What does the hemovigilance model do?

A

The hemovigilance model tracks, analyze, and improve transfusion outcomes.

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3
Q

Who administers red cell units? Other requirements.

A
  1. Done by nurses with training.
  2. Have to have patient consent.
  3. Patient can refuse blood product.
  4. Administered through IV set with filter.
  5. Double ID of patient and double check unit and paperwork (2 Nurses).
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4
Q

What is the most common cause of ABO incompatibility?

A

Patient misidentification is the most common cause of ABO incompatibilty.

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5
Q

How long does a red cell unit take to transfuse? And must not exceed?

A

Typically takes 2 hours to infuse, and must not exceed 4 hours.

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6
Q

What vital signs need to measured before and during the transfusion? When and how often?

A

Blood pressure, temperature, pulse and respiration rate are measured before the transfusion and every 15 mins during transfusion and for one hour following the transfusion.

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7
Q

During the first 15 mins of the transfusion what is done?

A
  1. Sit with the patient for the first 15 mins. If there is an ABO incompatibility it will be evident within that time.
  2. Advise patient to report if experiencing any side effects –> shortness of breath, rash, urticaria (hives), hemoglobinuria, pain (chest or lower back), fever or chills.
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8
Q

What are some of the many symptoms of a transfusion reaction?

A

Fever (>=1C temp change)
Chills or rigors
Hypotension/shock
Tachycardia
Respiratory distress
Urticaria, Skin rash
Flushing
Edema
Anxiety
Nausea/vomiting
Back or chest pain
Hemoglobinuria
Abnormal bleeding
Jaundice

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9
Q

What happens if the patient exhibits signs and symptoms of a transfusion reaction?

A
  1. Stop the transfusion immediately but keep IV line open with 0.9% saline.
  2. Inform Dr. ASAP to decide if to continue or not.
  3. Check vital signs every 15 mins until stable.
  4. Check all labels, tags, treatment order, forms, patient ID band to see if there is a clerical error.
  5. Notify the Transfusion Science Lab.
  6. Complete the Transfusion Reaction Investigation Form.
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10
Q

Where are transfusion reactions reported to?

A

All transfusion reactions, mild to life-threatening, and transfusion-related errors must be reported to the hospital’s transfusion service (Blood Bank).

They will investigate, assess, and report the event to the Transfusion Transmitted Injuries Surveillance System (TTISS) at the Public Health Agency of Canada.

Reactions relating to the quality of the product must be reported directly to CBS.

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11
Q

What are minor symptoms of a transfusion reaction considered to be?

A
  1. Hives or rash on less than 25% of body and exhibits no other symptoms. (Dr. may prescribe diphenhydramine and continue transfusion with careful observation).
  2. Febrile reaction of 1 deg above baseline after 15 mins into transfusion and no other symptoms. (Dr. may prescribe acetaminophen and continue transfusion with careful observation).
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12
Q

What are major symptoms of a transfusion reaction?

A

One or more of the following:
- Hypotension/shock
- Rigors
- Anxiety
- Back or chest pain
- Dyspnea/SOB
- Nausea/vomiting
- Hemoglobinuria
- Generalized flushing
- Hives are rash on more than 25% of the body
- Bleeding or pain at the site of IV
- Temp. increase of 1 deg or more over baseline
- Tachycardia/arrhythmias.

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13
Q

What happens if a one or more major symptom is exhibited by the patient of transfusion reaction?

A

Transfusion must be stopped and blood samples are collected and sent to the lab along with the blood component set. An investigation is started.

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14
Q

What are two categories of acute (<24 hours) transfusion reactions?

A
  1. Immune Mediated
  2. Non-immune Mediated
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15
Q

What are some types of acute immune mediated TRs?

A

Hemolytic Transfusion Reaction
Febrile, non-hemolytic
Allergic
Anaphylactic
TRALI

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16
Q

What are some types of acute non-immune mediated TRs?

A

Sepsis
TACO (Transfusion -associated circulatory overload)
Pseudohemolytic

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17
Q

What are the types of delayed immune mediated TRs?

A

Hemolytic Transfusion Reaction.
Graft vs. Host (TA-GVHD)
Post-Transfusion Purpura

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18
Q

What are the types of delayed non-immune mediated TR?

A

Hemosiderosis
Citrate toxicity
Disease Transmission

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19
Q

What happens in an acute hemolytic transfusion reaction (AHTRS)?

A

Rapid destruction of RBCs within 24 hours of transfusion. Usually shows signs within a few minutes.

Most severe is due to ABO incompatibility (clerical or patient error).

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20
Q

What are signs of an Acute Hemolytic Transfusion Reaction (AHTRS)?

A

Fever to death: Fever/chills, pain at infusion site, back/flank pain, nausea/vomiting, hemoglobinemia, hemoglobinuria, feeling of doom, hypotension, renal failure, shock, bleeding, DIC (disseminated intravascular coagulation).

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21
Q

What is the most common reason for an incidence of AHTR?

A

Half of all errors are due to administering properly labelled blood to the wrong patient!

Other errors are the result of improper labelling of samples or testing.

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22
Q

What does the risk of death due to an AHTR correlate with?

A

Correlates with the amount of incompatible blood transfused.

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23
Q

What causes an AHTR from RBC alloantibodies?

A

Compatible blood was missed because of low titre (Ab not detected in screen), clerical error in screen, lab error (no IAT crossmatch).

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24
Q

What follow-up testing is done after an AHTR?

A
  1. Check of clerical error (ID on unit, patient)
  2. Hemolysis in post-transfusion reaction sample (not difficult draw).
  3. DAT (may be neg if all donor cells have been lyzed).
  4. Verify original sample ABO/D type and Ab screen.
  5. Post sample ABO/D type and Ab screen.
  6. Crossmatch on pre and post samples.
  7. Hgb levels in blood and urine.
  8. LDH (increases)
  9. Total and direct bilirubin (increases)
  10. Haptoglobin (decrease as it binds to free hemoglobin).
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25
Q

What is a delayed hemolytic reaction?

A

Symptoms usually appear after 24 hours from time of transfusion.
Less severe than acute hemolytic reactions.
Extravascular hemolysis.
Usually IgG Abs (from prev transf or pregnancy).

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26
Q

What are common antibodies implicated in a delayed hemolytic reactions?

A

Common antibodies: anti-E, anti-Jk_a, anti-C, anti-Fy_a, anti-K.

1 in 6715 units of RBCs.

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27
Q

What are signs and symptoms of a delayed hemolytic reaction?

A

3 to 14 days after transfusion
Fever with or without chills
Unexplained decrease in hemoglobin and hematocrit
Presence of spherocytes
Jaundice and hemoglobinuria.

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28
Q

What are the test results for a delayed hemolytic reaction?

A
  1. DAT: positive
  2. Post transfusion Ab screen positive.
  3. Hemoglobin decreased; 4. Haptoglobin decreased
  4. Bilirubin increased.
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29
Q

What is a nonimmune or pseudo-hemolytic anemia?

A

RBC destruction when antibodies are not implicated:
1. Exposure of RBCs to extrmeme temperature.
2. Improper deglycerolization.
3. Mechanical destruction of RBCs (use warmer, small bore IV needle, stored on ice, stored too close to a heater).
4. Incompatible solutions: use only physiologic saline.
5. Bacterially contaminated blood products.
6. Intrinsic RBC defects (e.g. sickle cell).

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30
Q

What is a febrile, nonhemolytic reaction?

A

Temperature rises >= 1C during or within 4 hours after transfusion.

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31
Q

What are the symptoms of a febrile, nonhemolytic reaction? DAT result?

A

May have chills, rigors, headache - but no severe symptoms.

Non-threatening to patient (but uncomfortable).

DAT is negative; no sample hemolysis.

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32
Q

What causes a febrile, nonhemolytic reactions?

A

Cytokines from unit (a few WBCs present). May be due to HLA antibodies (recipient Abs to donor’s WBCs).

1 in 300 RBC transfusions; 1 in 20 pooled platelets.

33
Q

What helps to reduce the possibility of a febrile, nonhemolytic reaction?

A

Leukoreduction helps with this, but does not eliminate all WBCs.

34
Q

How does one treat a febrile nonhemolytic reaction?

A

Can administer acetaminophen and continue transfusion monitoring carefully if only 1 degree rise in temperature with no other symptoms.

35
Q

If someone develops only localized or diffuse urticaria (hives) or redness in the first 15 to 20 mins of a transfusion reactions what type of a reaction do they have and what causes it?

A

Mild allergic reaction.

IgE mediated hypersensitivity to donor’s plasma proteins (not a lot of plasma in packed RBC unit).

Can administer diphenhydramine (antihistamine) and continue transfusion cautiously.

1 in 100 (most common).

36
Q

What is an extra measure that can be done to prevent a mild allergic reaction?

A

Can wash cells prior to administering.

37
Q

How fast does an anaphylactic allergic reaction occur?

A

Symptoms very early in transfusion (within seconds to minutes).

Signs and symptoms include: Urticaria, itching, wide-spread rash, edema (lips, tongue), erythema and edema around the eyes, respiratory distress, hypotension, tachycardia.

38
Q

What are possible causes for an anaphylactic allergic reaction?

A

Most are unexplained but some of the following reasons have been implicated:
- IgA deficient recipients have formed Anti-IgA.
- Abs to polymorphic forms of serum proteins (IgG, albumin, Haptoglobin, alpha-1-antitrypsin, transferrin, C3 or C4)
- Allergen present in donor (penicillin).

Note: Haptoglobin deficiency is not uncommon in Asian patients (1 in 1000) has been associated with this rxn.

39
Q

How frequent are anaphylactic allergic reactions?

A

Rarely occurs but can be deadly (3% of transfusion fatalities).

Transfusion terminated and patient administering epinephrine and oxygen.

40
Q

What is a transfusion -related acute lung injury (TRALI)?

A

Has acute onset, during or within 6 hours of transfusion (often in the first one to two hours) of plasma or platelets (less often with rbc units)

41
Q

What patients do transfusion-related acute lung injury (TRALI) occurs?

A

Occurs in patients that have had no evidence of acute lung injury before.

Thought to be underdiagnosed and underreported.

1 in 1200 to 1 in 5000 (2017 statistics – numbers are reducing by over 50% due to TRALI reduction measures)

42
Q

What are the symptoms of a transfusion-related acute lung injury (TRALI)?

A

Can be fatal.
Fever, hypoxemia (low O2 in blood), dyspnea, and bilateral lung infiltration on chest x-ray with no evidence of circulatory overload.

43
Q

What are the two postulated mechanisms of transfusion-related acute lung injury (TRALI)?

A
  1. Antibody-mediated: passive transfer of HLA or granulocyte antibodies in donor to recipient or less commonly HLA or granulocyte antibodies in the recipient toward donor. Abs are most common in multiparous female donors.
  2. Neutrophil priming hypothesis: Biologic response modifiers such as active lipids in the transfused component may induce TRALI in a susceptible patient
44
Q

What prevention measures are taken against TRALI (in particular for antibody mediated postulated cause)?

A

Prevention measures include:
1. Plasma collected predominantly from males to help prevent this
2. Platelet pools are suspended in plasma from males
3. Plateletpheresis collected from male donors or females that have never been pregnant

45
Q

What is transfusion associated graft versus host disease?

A

Immunocompromised recipient does not recognize donor lymphocytes as non-self but fully immunocompetent donor T lymphocytes attack recipient. Mounts an immune response against recipient.

46
Q

What is the prognosis of someone who gets graft-versus-host disease?

A

Not good. TA-GVHD is a rare but a highly lethal complication of transfusion. It has a 90% mortality rate associated with it

47
Q

What increases the risk of TA-GVHD?

A

It happens more often if the donor is a close HLA match - haploidentical (recipient’s immune system too weak to notice or fight off)
Can confirm by HLA typing

48
Q

What is the onset timeframe and symptoms of TA-GVHD?

A

Onset 3 to 30 days post-transfusion.
Fever, rash, abnormal liver function, diarrhea, pancytopenia

49
Q

What is the treatment for TA-GVHD?

A

There is no treatment.

50
Q

How can TA-GVHD be prevented?

A

Gamma irradiation of blood products before transfusions to high-risk recipients.

See slide 29 for those types of patients indicated for gamma irradiation blood products.

51
Q

What are sources for bacterial sepsis or contamination in blood products?

A

Major sources include:
1. Transient asymptomatic bacteremia in the donor
2. Improper cleansing of the donor’s skin during collection
3. Manufacturing defect in collection set

52
Q

What are symptoms for receiving bacterial contaminated blood products?

A

Fever, rigors, tachycardia, hypotension, nausea, vomiting, dyspnea, DIC

Accounts for 10% of transfusion-associated fatalities

53
Q

What makes platelets susceptible to bacterial contamination?

A

Platelets are stored at room temp 20-24C.

Common culprits are:
Gram positive
1. Staphylococcus aureus
2. Staphylococcus epidermidis
3. Bacillus cereus

54
Q

What organisms are common culprits to contaminate RBC units stored at 4degC?

A

Gram negative:
Yersinia enterocolitica
Klebsiella pneumonia
Serratia marcescens
Pseudomonas species
Esherichia coli

and … Listeria monocytogenes

55
Q

What is done in case of bacterial sepsis or contamination?

A
  1. Blood cultures are drawn post-transfusion
  2. Identify bacteria in donor bag and from recipient
  3. Give patient broad spectrum antibiotics (don’t wait for microbiology results)

Note: Incidence of bacterial contamination: pooled platelets 1 in 1000, packed RBCs 1 in 50,000 – may be reduced since culturing occurs now on all platelets.

56
Q

What prevention measures are taken against bacterial sepsis or contamination?

A

Prevention:
1. Closed sterile system for collection
2. Donor screening
3. Proper skin cleansing for collection
4. First 40 mL diverted to pouch (removal of skin plug and commensal orgs)
5. Apheresis and buffy coat platelets are cultured prior to issue to hospitals
6. Keep red cells at proper temperature before transfusing (limited to 60 minutes outside of fridge)
7. Pooled platelets and platelet apheresis now cultured prior to issue to hospitals.

57
Q

What is a transfusion-associated circulatory overload (TACO)?

A

Circulatory overload results from:
1. Impaired cardiac function and/or
2. Excessively rapid rate of transfusion

58
Q

What patients are susceptible to TACO upon a transfusion?

A

Common in the elderly (>70 yrs) and infants, and in patients with severe euvolemic anemia (Hgb<50g/L)

59
Q

When do symptoms appear of TACO and what are they?

A

Symptoms within 6 hours after transfusion:
- Signs of congestive heart failure
- Dyspnea, severe headache, peripheral edema, cyanosis, hypertension, tachycardia, can lead to death

60
Q

How is transfusion-associated circulatory overload (TACO) treated?

A

Treated with oxygen and diuretics.

Incidence: 1 in 700 transfusions (most common cause of death from transfusion)

61
Q

How can someone susceptible to TACO be given a transfusion?

A

Candidates susceptible to circulatory overload should receive RBC units over a slower time.

  1. Maximum 4 hours
  2. Can split component into smaller aliquots to reduce the speed of infusion
  3. Pre-emptive diuretics
62
Q

What is transfusion hemosiderosis?

A
  1. Accumulation of excess iron in macrophages within tissues (liver, spleen, heart and kidney)
  2. Usually occurs in patients undergoing long-term transfusions (e.g., thalassemia and sickle cell disease)
  3. Iron intake exceeds daily iron excretion
63
Q

What organs does transfusion hemosiderosis affect?

A

Affects function of liver, heart and endocrine glands

64
Q

What can be done to prevent transfusion hemosiderosis?

A

Prevention involves iron chelation:
Deferiprone
Deferoxamine

65
Q

What is used to detect hemosiderosis in pathology?

A

Perl’s Prussian Blue Stain

66
Q

What is citrate toxicity? Who does it effect?

A

Occurs when large quantities of citrated blood are transfused

May have adverse effects in:
1. Those receiving large volumes of blood (massive transfusion)
2. Patients with impaired liver function
3. Preterm infants with hepatic or renal insufficiency

67
Q

What are the symptoms of citrate toxicity?

A

Symptoms: chills, iron taste in mouth, scalp “on too tight”

68
Q

How can citrate toxicity be prevented in a transfusion patient?

A

Prevention:
1. Remove plasma that may contain citrate
2. Inject calcium chloride or calcium gluconate

69
Q

What is a massive transfusion?

A

Massive transfusion: > 10 units or entire blood volume in a 24 hour period.

70
Q

What are the problems that can result from a massive transfusion?

A
  1. Citrate Toxicity: Binds calcium and magnesium
  2. Hypothermia: Rapid infusion of blood at 1-6° C
  3. Diluted Coagulopathy: Low coagulation factors and platelets
    Should receive plasma and platelets as well (monitor coagulation and platelet results)
  4. Metabolic acidosis: Rare; acid pH of blood products
  5. Hyperkalemia: Potassium released slowly from cells upon storage
71
Q

What happens in women that are negative for high incidence platelet antigen HPA-1a?

A

Post-transfusion Purpura (PTP).

Women produce anti-HPA-1a.

Develop a rash of purple spots on the skin caused by internal bleeding from small vessels.

72
Q

What are the symptoms of Post-transfusion Purpura?

A

Fever, chills, rigors, and bronchospasm.

Platelet count decreases 5 to 12 days after transfusion.

Purpura (rash of purple spots on skin caused by internal bleeding from small vessels) and bleeding which can be fatal (e.g. intracranial hemorrhage).

73
Q

What is the treatment of Post-transfusion Purpura (PTP)?

A

Treatment: Plasmapheresis, exchange transfusion, and intravenous IgG

74
Q

What type of diseases can be accidently transmitted through transfusion products?

A

Viruses, prions, and parasitic infections from donor products

75
Q

What screening is done to prevent transfusion of diseases?

A
  1. All donated blood is tested for HIV, Hepatitis B, Hepatitis C, West Nile Virus (seasonally), Human T-cell lymphotropic virus, and Syphilis
  2. Some products are checked for Chagas disease, Cytomegalovirus and bacterial contamination.
  3. Questions on donor forms try to prevent malaria, Leishmaniasis, babesiosis, Creutzfeldt-Jakob Disease
76
Q

Despite all the checks can someone still get a disease transmission through a transfusion?

A

May get disease for something that is not tested or donated blood was in the “window period” – the interval between the time of infection and detection.

77
Q

What are the procedures for an adverse reaction?

A
  1. Stop the transfusion.
  2. Keep IV open with saline.
  3. Perform clerical check for ID errors.
  4. Contact treating physician.
  5. Monitor/record vital signs.
  6. Contact transfusion service.
  7. Collect post-sample and return with blood bag and attached IV fluids to the lab.
78
Q

What is involved in a post-reaction workup?

A
  1. Clerical check: ID errors?
  2. Visual check: Hemolysis or icteric?
  3. Direct antiglobulin test (DAT).

See slide 43 for additional testing in a Transfusion Reaction Investigation.

Transfusion Science (17 decks)

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