Transfusion CC Flashcards
70 yo pt admitted with lower GI bleed, HgB of 5.0 and given 2 units blood; 2 hours in she has fever, chills, increased HR, slight anxiety, significant change in BP no dysnpea and back pain: what are our concerning symptoms and what should we do?
Stop transfusion
fever/ chills/ change in BP/ no worsening dysnpea all important to note
Which of following arent related to fever in transfusion rxn? A. FNHTR = Febrile Nonhemolytic Transfusion Reaction B. Hemolytic Transfusion Reaction C. TACO = Transfusion Associated Circulatory Overload D. TRALI = Transfusion Related Acute Lung Injury
C!!
All the other are related to fever!
List of DDx in fever after transfusion
Differential Diagnosis
• FNHTR = Febrile Nonhemolytic TransfusionReaction
• Hemolytic Transfusion Reaction
• Septic Transfusion Reaction
• TRALI = Transfusion Related Acute Lung Injury
• Related to underlying Disease in Patient
• Allergic Reaction (infrequent)
– Chills/rigors
– Fever (at least 1ºC or 2increase F elevation and ≥ 38ºC/100.4ºF)
– increased blood pressure; increased heart rate
– Hypotension not seen
– Headache, malaise, vomiting
– Back or chest pain
Febrile Nonhemolytic Transfusion Reaction
Febrile Nonhemolytic Transfusion Reaction
•____ of red cell transfusions
• Typically see in :
• Usually occurs at
0.5 -1.0 %
multiparous females or multi-transfused patients
end of transfusion or beginning of 2nd unit (if given back-to-back)
Cause of FNHT:
• Antibodies in recipient directed against :
—-Triggers phagocytes to release____ cause fever and chills or rigors
donor WBCs
endogenous pyrogens
*also caused by passive infusion of cytokines
Treatment - FNHTR
Antipyretics initially (DO NOT GIVE BENEDRYL)
• If significant rigors - 25-50 mg Demerol IV
• Often see resolution of fever and chills within 30 minutes of discontinuation of unit
Prevention of FNHTR for future transfusions-
Leukoreduced blood products
You remember that although hemolytic reactions are rare;
80% or more have predominant symptom of fever thus order a Transfusion Reaction workup to r/o Hemolytic
Reaction (in previous pt) You are told pt is peeing red and was given the wrong unit of blood! you suspect what?
Acute Hemolytic Transfusion Reaction
Child bearing females who are Rh(D) Negative Rh(D) should Avoid
Rh(D)+ if at all possible
Incidence of Acute hemolytic transfusion reaction
Incidence:
– Approximately 1 in 40,000
– Fatal Acute HTR: 1 in 600,000 – 2,000,000
Whats happening in AHTR: Accelerated clearance of transfused red cells due to
red
cell incompatibility
Deaths from AHTR caused by ABO incompatibility are
declining; but ________increasing!
• Clerical/human errors major contributing cause!
non-ABO incompatibility
Signs/ Symptoms of AHTR
- Fever, chills, nausea
- “Impending doom”
- Hypotension
- Back pain, chest pain. orpain at infusion site
- Hemoglobinemia, hemoglobinuria
- Coagulopathy and/or DIC
- Renal failure
Labs in AHTR: Coombs: Hemolysis: Bilirubin: Haptoglobin Hemoglobin: LDH:
Positive Direct Coombs – May be Neg if all transfused cells destroyed • Visible hemolysis in serum/plasma • Increased Bilirubin • Decreased haptoglobin • Fall in hemoglobin; hemoglobinuria • Increased LDH
Time relationship for clearance of Hgb and its
byproducts following acute hemolytic episode
Haptoglobin:
LDH:
Plasma HgB
Haptoglobin: immediate decline
LDH: Peak at 18 then decline
Plasma HgB; Peak at 6 then decline
Tx for Acute hemolytic Transfusion Reaction
• Promote adequate renal blood flow – Keep urine output >100mL/hr with IVFs and IV diuretics, as necessary • Support blood pressure with low dose dopamine, as necessary • Administer platelets, FFP, and/or cryoprecipitate as needed for DIC
Most common cause of ABO AHTR:
clincal error with 2/3 d/t pt misidentification
Shortly after start of FFP transfusion (only 40 mL
infused) your patient notices a couple hives on his
arm and then abruptly develops difficulty breathing
with wheezing. He becomes hypoxic (O2 sats drop
to 80% on RA) and his BP declines to 80/55 from
120/65. He remains afebrile
You suspect the patient is having a transfusion
reaction. What clues do we look at?
Hives hard to breath/wheezing Hypoxic Hypotension afebrile
Pt has: Hives hard to breath/wheezing Hypoxic Hypotension afebrile What do we suspect as transfusion related issue (pt from before)
Severe Allergic anaphylactic reaction
What symptoms are present in pts with Circulatory overload (TACO)?
Dysnea pulmonary edema Hypertension TAchycardia Increased CVP peripheral edema responds to meds
When reaction presents with predominant symptom of dyspnea or SOB –
Your Top 3 Diagnosis Should Be:
- TACO = Transfusion Associated Circulatory
Overload - TRALI = Transfusion Related Acute Lung
Injury - Severe Allergic/Anaphylactic Reaction
leading causes for transfusion related fatalities reported to FDA
- TACO and TRALI
Symtoms we see in TRALI?
Dysnea pulmonary edema HYPOtension fever tachycardia
Telling difference btwn TRALI and TACO
CXR:
– Bilateral infiltrates? Yes
• Enlarged heart; vascular prominence :
• Normal heart size and vasculature :
– Unchanged or hyperinflated
Dx:
TACO
TRALI
Allergic/Anaphylactic
Response to medication: ( to differentiate btwn SOB transfusions)
– Did symptoms improve or resolve?
• Quickly improve after steroids, antihistamines,
epinephrine :
• Improve after given Lasix (diuretic)
Allergic/Anaphylactic
TACO
Thrombotic microangiopathy
A non-specific pathogenic process seen in:
DIC
TTP/HUS
HTN
Pt with TTP will have blood smear with:
schistocytes and spherocytes
What do we see on PB smear in Vit B 12 deficiency
A. Bizaare RBC morphology
Lack sharp points
B. Macro-ovalocytes
C. Hypersegmented neutrophil
These three things all occur d/t what syndrome?
• Consumptive Thrombocytopenia
• Red Cell Fragmentation
- Hemolytic Anemia, hyperbilirubinemia
• Multiple organ ischemia
Microvascular occlusion syndrome
– Small vessel platelet aggregates
Labs suggestive of Thrombotic microantiopathy CBC smear: LDH: Coagulation studies: DAT, Coombs test:
CBC smear: abnormal
LDH: ELEVATED
Coagulation studies: nl
DAT, Coombs test: Negative
Labs suggestive of Thrombotic microantiopathy
Haptoglobin:
Bilirubin
Creatinine:
Haptoglobin: Decreased
Bilirubin: Increased
Creatinine: +/-
At what HgB level do we consider givng pt RBC transfusion?
When HgB is 6-8 IF symptoms are present
• Anemia due to nutritional deficiency
– Iron deficiency
– Vitamin B12 or Folate deficiency
Should this pt get RBC transfusion?
Consider AVoiDING
• Endocrine deficiency
– Chronic renal insufficiency
–should this pt get RBC transfusion
consider avoiding
Should teh below get RBC transfusion • Hemolytic anemias if “compensated” – Sickle Cell Anemia – Autoimmune hemolytic anemia – Paroxysmal nocturnal hemoglobinuria (PNH)
surprise, NO
Thrombocytopenia Situations where prophylaxis is NOT recommended • Consumptive states with thrombosis – Heparin-induced thrombocytopenia – Thrombotic thrombocytopenic purpura • Consumptive states refractory to prophylaxis – Immune thrombocytopenia --WHen would I transfuse?
• Only transfuse for active bleeding
Does this pt need transfusion?
Replacement of Plasma Proteins for hemostasis:
– Abnormal bleeding with documented
coagulopathy
YES
Do we do transfusion for these pts?
– Multiple factor deficiency
• Liver Disease
• Vitamin K deficiency/reversal of warfarin
• DIC
• Isolated factor deficiency if no factor concentrate available
(factor XI)
YES
Does this require prophyslaxsis plasma transfusion:
• Replacement Fluid in Therapeutic Plasma
exchange (TTP)
yes
ADAMTS13 is usually very low in
TTP
Absence of ADAMTS13 allows formation of unwanted
VWF/platelet thrombi: results in
• Resulting in microvascular obstruction
efficacy of treatment of TTP
- ____ depletes auto-antibody to ADAMTS13
- Plasma infused during TPE replaces
- Immunotherapy suppresses____ production
TPE
ADAMTS13
auto-antibody
Does this dude get plasma transfusion?
Nutritional coagulation defects
– Vitamin K deficiency or inhibition (warfarin)
• Supplement vitamin K or withhold warfarin
• If bleeding: consider prothrombin complex concent
NO
• Coagulopathy due to an inhibitor
– Bleeding related to heparin, target-specific anticoagulants
Plasma transfusion?
NO
Congenital defects where there is a concentrate
– Hemophilia, von Willebrand disease, AT deficiency
–Get a plasma transfusion?
NO
What transfusion is used for the following:
– Fibrinogen, von Willebrand Factor, Factor XIII
Cryoprecipitate
Fresh frozen plasma is used for:
– Myriad coagulation factors
Platelets
– May or may not be necessary if you give cyro or FFP, why?
– Bleeding/oozing may cease once cryo and FFP are given
If a patients INR increases while on Warfarin, what are some causes?
dietary or damage to bacterial flora
~ in this case pt started on antibiotics
(if you add this to poor diet, you can increase INR)
• Two sources of Vitamin K
- Dietary
* Synthesized by intestinal flora
What effect can antibiotics have on Vit K
• Broad spectrum antibiotics can decrease
number of bacteria in intestine
• Coupled with poor diet, this can lead to
increased INR
• Frequently occurs in hospitalized patients
• Oral supplementation
• Add to parenteral nutrition
What tx can we do for elevated PT/ INR
- Hold or decrease warfarin dose
- Replace Vitamin K
- Replace coagulation factors
If we were going to replace coag factors in pt with elevated PT or INR what would we give and why?
• Fresh frozen plasma – risks associated with
transfusion, large volume required
• Prothrombin complex concentrates – expensive,
concern for thrombosis, currently for patients who
are bleeding or cannot tolerate FFP
In patient w/ artificial heart valve on warfarin with elevated INR, what is our best way to lower INR?
• Hold warfarin dose, recheck INR before restarting • In a non-bleeding patient use the least aggressive treatment with fewest side effects
What benefit would FPP or PCC offer pt with elevated INR?
What about Vit K?
temorary reversal
long term reversal, takes time
