Transfusion CC Flashcards by Meghan May

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

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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!

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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)

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– 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

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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)

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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

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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

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Prevention of FNHTR for future transfusions-

Leukoreduced blood products

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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

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Child bearing females who
are Rh(D) Negative Rh(D)  should Avoid

Rh(D)+ if at all possible

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Incidence of Acute hemolytic transfusion reaction

Incidence:
– Approximately 1 in 40,000
– Fatal Acute HTR: 1 in 600,000 – 2,000,000

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Whats happening in AHTR: Accelerated clearance of transfused red cells due to

red

cell incompatibility

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Deaths from AHTR caused by ABO incompatibility are
declining; but ________increasing!
• Clerical/human errors major contributing cause!

non-ABO incompatibility

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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

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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

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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

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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

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Most common cause of ABO AHTR:

clincal error with 2/3 d/t pt misidentification

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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

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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

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What symptoms are present in pts with Circulatory overload (TACO)?

Dysnea
pulmonary edema
Hypertension
TAchycardia
Increased CVP
peripheral edema
responds to meds

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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

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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 1. ____ depletes auto-antibody to ADAMTS13 2. Plasma infused during TPE replaces 3. 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

• Coagulopathy due to an inhibitor – Bleeding related to heparin, target-specific anticoagulants Plasma transfusion?

Congenital defects where there is a concentrate – Hemophilia, von Willebrand disease, AT deficiency --Get a plasma transfusion?

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