TRACS Flashcards
List 11 transfusion reactions from most the least common
- febrile non-hemolytic transfusion reaction
- Respiratory Reaction
- Allergic reactions
- Hemolytic Reactions
- Delayed serologic transfusion reactions
- Infections
- Hypocalcemia/Citrate Toxicity
- Hyperammonemia
- Hypotensive transfusion reaction
- Post-transfusion purpura
- Transfusion associated graftversus host disease
How is febrile non-hemolytic transfusion reaction defined
- acute either non-immunologic or immunologic
- temp >102.5 and increaed by at least 1.8 since pre-transfusion
- during or within 4 hours of end of transfusion
- ruled out: external warming/underlying infection, AHTR, TRALI, transfusion associated infection (either transmission or contamination)
What are the 2 causes for febrile non-hemolytic transfusion reactions?
- donor white blood cell or platelet antigen-antibody reactions (70% in people)
- proinflammatory mediators in stored blood products
Which blood products have shown to cause FNHTR more commonly in people?
PLT products
non-leukoreduced RBC products
How dangerous are FNHTR?
not life-threatening but uncomfortable
What are the 3 types of Respiratory Transfusion reactions?
- Transfusion associated Dyspnea
- Transfusion associated circulatory
- Transfusion-related acute lung injury
How is transfusion associated dyspnea defined?
- acute respiratory distress during or within 24 hours of end of transfusion
- r/o TACO, TRALI, allergic reaction, underlying pulmonary disease
How is TACO defined?
- increased blood volume from transfusion
- acute respiratory distress and hydrostatic pulmonary edema
- during or within 6 hours of transfusion
- clinical, echocardiographic, laboratory evidence of LA hypertension or volume overload
- typically respond positive to diuretics
What is needed to make the definitive diagnosis of TACO
no other explanation for circulatory overload AND
- clinical signs
- echo
- radiographs
- BNP
Who is more at risk for TACO, a patient with acute or chronic anemia?
chronic
What are differential diagnoses for TACO?
- TRALI
- anaphylaxis
- bacterial contamination
- PTE
- hemolytic reaction
How is TRALI defined?
- acute onset immunologic reaction - antigen-antibody interactions in the lungs
- during or within 6 hours of transfusion
- acute hypoxemia and non-cardiogenic pulmonary edema on rads
- r/p prior lung injury, LA hypertension, alternative risk factors for ARDS
What is typically elevated in a donor blood unit that causes ARDS?
anti-HLA type I or HNA antibodies - elevated in plasma from multiparous women
What are the two types of TRALI defined in people?
TRALI type I - patient without known risk factors for ARDS and:
* acute onset
* hypoxemia (PF < 300 or SPO2 <90 on room air)
* bilateral pulmonary edema on imaging
* no evidence of LA hypertension
* within 6 hours of transfusion
* no temporal relationship to alternative ARDS risk factors
TRALI type II - patients with other risk factor for ARDS or existing mild ARDS but stable resp status before transfusion - stable for 12 hours before transfusion
What blood products are most likely to cause TRALI?
plasma
platelets
How are allergic transfusion reactions defined?
- type I hypersensitivity
- during or within 4 hours of transfusion reaction
- dogs: urticaria, eryhtema, pruritus, GI, hemoabdomen, collapse
- cats: respiratory, GI, pruritus
What timing and response to therapy defines an allergic transfusion reaction as definitive versus probably
definitive:
* within 1 hour of starting the transfusion
* responds rapidly to cessation of transfusion and supportive care
probable
* after 1 hour but during transfusion
* does not respond rapidly to cessation and supportive care
List potential causes for non-immunologic hemolytic transfusion reactions
- chemical damage
- thermal damage
- osmotic damage
- mechanical damage
immunologic would be blood type incompatibility
What type of sensitivity is a immunologic acute hemolytic transfusion reaction?
type II
What are the criteria to diagnose an acute hemolytic transfusion reaction
- within 24 hours of transfusion
- hyperbilirubinemia, hemoglobinemia, hemoglobinuria, spherocytosis (dogs), or ghost cells
- inadequate increase in PCV
What type of antibodies are the naturally occuring anti-A antibodies in type B cats?
IgM
hemolyzing and hemo-agglutinating
What is the time frame for delayed hemolytic transfusion reactions?
24 hours to 28 days after blood product administration
What is the mean half life of dog RBC in cats? (xenotransfusion)
3.6 days
what is the mean half life of type B RBCs in type A cats?
2.1 days
which DEA type antibody has shown delayed hemolytic transfusion reactions in dogs?
DEA 7
How is a delayed serologic transfusion reaction defined?
- antibodies against the transfused product without evidence of hemolysis
- within 24-28 days
How can definitve delayed serologic transfusion reactions be diagnosed?
unexplained drop in Hct/Hb withint 24 hours to 28 days after transfusion
AND
positive Coombs test
What type of blood product is most commonly associated with bacterial contamination and why?
fresh platelet transfusion - stored at room temp
How is citrate toxicity defined and diagnosed in SA?
- patient received massive transfusion and has impaired hepatic function
- CS of hypocalcemia
- hypocalcemia, iCa <0.7
probably 0.71-0.8
possible 0.81-0.9
Which blood products contain most citrate?
FFP
What are complications from citrate toxicity other than hypocalcemia?
- metabolic alkalosis
- hypernatremia (if sodium citrate used)
- decreased iMg
Who is at risk for transfusion associated hyperammonemia?
- patients receiving outdated blood products
- patients with decreased liver function (e.g., PSS)
- neonates with immature liver function
- patients with hypoperfusion due to shock
What is the time frame for diagnosing hypotensive transfusion reactions
within 15 min of starting and 1 hour of stopping the transfusion
What type of transfusion is most implicated in causing hypotensive transfusion reactions?
red cell transfusions
what is the suspected cause of hypertensive transfusion reactions?
- activation of contact pathway (FXII) - conversion of high-molecular-weight kininogen to bradykinin => vasodilation + increased vascular permeability
not reported in veterinary patients
Define Posttransfusion purpura
alloimmunization against platelet antigens (including destruction of own)
5-12 days following transfusion
Define transfusion associated graft versus host disease
donor lymphocytes engraft on and eventually attack host tissues
48 hours to 6 weeks after transfusion
high mortality rate in people (>90%)
Is a closed transfusion collection system preferred over semi-closed or open systems in cats?
suggest any can be used - not enough evidence to make strong recommendations
What is the recommendation for leukoreduced versus non-leukoreduced blood?
insufficient evidence for recommendations
suggest to consider it - decreases rate of FNHTR in humans (PLT and pRBC)
When should frehser RBC transfusions be considered in dogs?
- in septic or hemolytic cases (suggestion)
- in dogs with liver dysfunction requiring massive transfusions (suggestion)
no recommendatiosn on cats
When do RBCs expire?
After 42 days
How should pRBC units be assessed for hemolysis
- recommend checking units for hemolysis prior to administration
- if >1% hemolysis - don’t use
- collect from main bag, not RBC segments
measure free hemoglobin, then calculate:
Hemolysis % = (100-Hct) x (plasma free Hb g/dL) / totalHb d/dL)
What is the current recommendation on typing and cross-matching transfusion-naive dogs before blood transfusions
- strongly recommend giving DEA neg to DEA neg dogs (to prevent further immunization against DEA)
- can administer either DEA neg or pos to DEA pos dog - however suggest matching pos to optimize inventory
- suggest major cross match may not be necessary
What is the recommendation for cross-matching before subsequent blood transfusions?
strongly recommend cross match in any dog that received a previous transfusion more than 4 days prior
What is the recommendation for typing or cross matching dogs before plasma transfusions?
insufficient evidence to make recommendations on DEA1 testing or minor cross matches
What is the current recommendation on typing and cross matching cats before blood transfusions
- strongly recommend typing
- suggest cross match before first transfusion
- strongly recommend cross match before any subsequent transfusion if previous transfusion more than 2 days prior
What is the current recommendation on typing and cross-matching cats before plasma transfusions?
- recommend AB typing prior to plasma transfusion
- insufficient evidence for minor cross matching but recommend it if AB typing not available
What is the recommendation for transfusion methods of RBC in cats and dogs?
Cats: suggest syringe pump and 18-micron microaggregate filter
Dogs: suggest standard 170-260 micron in-line blood administration set with gravity flow pr with a piston pump, avoid peristaltic or rotary infusion pumps
What is the recommendation on ionized Ca monitoring in cats and dogs receiving transfusions
suggest to monitor iCa regularly if massive transfusion administered
What is the recommendation for the treatment of allergic transfusion reactions?
non-anaphylactic
* suggest antihistamine therapy
* suggest avoiding corticosteroid therapy
* insufficient evidence on whether to slow the transfusion rate
anaphylaxis
* recommend immediate epinephrine use
Should transfusions rates be slowed after a FNHTR occurs?
insufficient evidence
neither recommend for or against
What is the recommended response to vomiting in a patient receiving a transfusion
- stop the transfusion temporarily
- asses for serious reactions
- restart at slower rate if patient stable and reaction mild
- if cardiovascular or respiratory instability - discontinue –> assess unit for bacterial contamination and assess patient and unit for hemolysis
What is the recommended treatment for Post-transfusion purpura?
corticosteroids or IVIG suggested
What is the recommendation for treating dogs with hypocalcemia from citrate toxicity
recommend Ca supplementation if iCa <0.9, or at higher values if clinically indicated
suggest considering empirical supplementation during massive transfusion
