OSCE emergencies (Blood transfusion)

Question 1

Massive haemorrhage protocol

Answer 1

I want to activate the major haemorrhage protocol

A to E approach

• 2 wide bore cannula (send blood samples, group and save, cross-match , FBC, coagulation)
• Resuscitate with warm IV fluids (crystalloid)
• Give oxygen

>40% blood volume loss / 110 beats/min and/or systolic blood pressure less than 90 mmHg

• Give group O if blood group not known or blood not immediately available

Ask Blood bank to cross match and request:

• 4 x RBCs
• 2 x FFP
• 1 x platelets
• Tranexamic acid

Contact:

• Surgeons if bleeding ongoing

Question 2

Initial investigations for transfusion reaction

Answer 2

• STOP transfusion, check patient identity, maintain venous access
• A – E Assessment including PMH
• Oxygen saturations, O2 if required
• CXR
• ECG

Question 3

presentation of acute haemolytic reaction (ABO incompatibility)

Answer 3

• Urticaria
• Hypotension
• Fever
• Haemoglobinuria from rapid haemolysis

Blood test
- Reduced Hb
- Low serum haptoglobin
- High LDH and bilirubin in

Question 4

Management of ABO incompatibility

Answer 4

Stop transfusion, begin supportive measures
- Fluid resus
- O2

Question 5

transfusion associated circulatory overload pathophysiology

Answer 5

excessive rate of transfusion, often pre-existing heart failure or renal problems

Question 6

presentation of TACO

Answer 6

Pulmonary oedema
Hypertension

Question 7

Management of TACO

Answer 7

• Slow or STOP transfusion
• Obtain an urgent chest radiograph, and for those whose diagnosis is confirmed
• Give oxygen
• Loop diuretic e.g. furosemide (20mg)

Question 8

pathophysiology of TRALI

Answer 8

This is a form of Acute Respiratory Distress Syndrome (ARDS), a non-cardiogenic cause of pulmonary oedema.
- Secondary increased vascular permeability caused by host neutrophilia that become activated by substances in donor blood
- Due to donor plasma containing antibodies against patients leukocytes.
- Implicated donors are usually multiparous women

Question 9

Presentation of TRALI

Answer 9

• Patients are dyspnoeic (hypoxic)
• Pulmonary infiltrates on CXR
• fever
• hypotension

Question 10

Management of TRALI

Answer 10

• STOP transfusion
• High flow oxygen (15l non-rebreathe)
• Obtain an urgent chest radiograph, getting specialist and intensive care input urgently.
• Supportive care

Question 11

Anaphylaxis presentation

Answer 11

itchy rash, angioedema, shortness of breath, vomiting, lightheadedness, and hypotension.

Anaphylaxis typically develops over minutes to hours and can quickly become life-threatening.

Question 12

management of anaphylaxis

Answer 12

• Adrenaline (epinephrine) 0.5-1 mg intramuscularly (IM) and repeat every 10 minutes until improvement occurs.
• High-flow oxygen.
• IV fluids.
• Nebulised salbutamol by face mask if required.
• Steroids are second-line and antihistamines are third-line treatments.

Question 13

what to do if patient exhibits any signs or symptoms of severe transfusion reaction

Answer 13

• STOP the transfusion
• Call the doctor to see the patient urgently
• Check compatibility of unit: check the details on the component against the patient’s identification band, and with the patient themselves (if possible).
• Assess the patient
• Management (under medical direction)

Replace the administration set and preserve IV access with a suitable crystalloid to maintain systolic BP

• Assess the patient
• Check urine for signs of haemoglobinuria
• Commence appropriate treatment; maintain airway and give high flow oxygen.
• If appropriate administer **adrenaline or diuretic and resuscitate **if/as required.
• Reassess patient and treat appropriately - seek expert advice if patient’s condition continues to deteriorate.

The UK BSQRs (2005 as amended) introduced a legal requirement for the reporting of all serious adverse events and reactions to the identified competent authority, check local protocols for method of reporting.

Question 14

Reporting of transfusion incident to MHRA (legal reporting system) and SHOT (voluntary but required)

Answer 14

• Never events: ABO incompatible blood components
• Most errors are preventable
• TACO and delayed transfusion biggest cause of death

Question 15

pre-transfusion assessment

Answer 15

• Body weight (low at higher risk)
• Review medical history
  o Renal
  o Cardiac
  o Respiratory
• Review current fluid balance
• Considerate of infusion rates
• Considered the need for diuretics e.g. furosemide
• Consider one unit transfusion for all none bleeding
• Review of patient in between units
• Add to fluid balance chart

Question 16

types of blood products

Answer 16

Question 17

Alternatives to blood transfusion

Answer 17

• Iron
• Folic acid
• B12
• Tranexamic acid – key in major haemorrhage
  o Antifibrinolytic prevent clot breakdown by inhibiting the activation of plasminogen to plasmin
  o Used during maor haemorrhage
• EPO
• Cell salvage

Question 18

jehovas witnesses and transfusions

Answer 18

Will refuse:

• Red cells
• White cell
• Platelet
• Plasma

Will carry round an advance decision to refuse specialised medical treatment

• If patient lacks capacity to make a decision
• Will wear a blue wrist band
• Must sign a form to refuse blood

Question 19

emergency o neg blood

Answer 19

• Emergency O Negative and Emergency O Positive are available at all times.
• Ensure you know whether you need the Emergency O Negative or Emergency O Positive blood. If in any doubt take the Emergency O Negative.
• Speak to blood bank before you take it as it may not be suitable for everybody – consider antibodies and special requirements.
• Emergency O Negative and Emergency O Positive are available at all times.

Question 20

way to prevent wrong blood

Answer 20

double checking at each stage