Transfusion OSCE Flashcards
What is TACO?
Transfusion associated cirulatory overload
What blood is given in an emergency?
Type O D-
When administering blood, what should you do?
Ensure that baseline observations of temperature, pulse, respirations and blood pressure are recorded within 60 minutes before the blood component is administered.
What should occur before setting up a transfusion?
Visual inspection of the pack to check for signs of damage
Check the unit for signs of discolouration, leaking, clots
Check donation number on laboratory generated label attached to unit matches the donation number on the unit
Expiry date and time of the unit (if no time is indicated the component expires at midnight of the date shown. Check the ABO group and D group on the laboratory generated label with the component pack label are the same or appropriate for the patient’s blood group
Check the component type is the unit is the same as that on the label and the authorisation document
Check the component meets any specific requirements indicated on the authorisation. If you detect any discrepancies or have any concerns - DO NOT PROCEED - contact the HTL.
Through what should the blood be administered through?
Must be CE-marked transfusion sets with an integral mesh filter to remove microaggregates. It is unnecessary to prime the administration set 0.9% sodium chloride (unless checking patency of line). Do not administer medication or other IV fluids through a lumen used for transfusion of blood as there is a risk of incompatibility (e.g. dextrose & calcium containing solutions can cause haemolysis or lead to clotting of the transfusion components.
What are the signs of a transfusion reaction?
Transfusion reactions
Acute transfusion reactions can present in a number of ways with any of the following signs or symptoms:
Fever, chills, rigours, myalgia, nausea
Urticaria, rash, pruritus, flushing
Angioedema
Respiratory symptoms including dyspnoea, stridor, wheeze, hypoxia
Hypo- or hyper-tension, tachycardia
Pain
Severe anxiety or feeling of ‘impending doom’
Bleeding with acute onset
(British Society of Haematology (2012); Investigation and Management of Acute Transfusion Reaction)
How should you manage a moderate transfusion reaction?
BSH (2012) recommend if you suspect a moderate transfusion reaction:
STOP the transfusion
Seek medical advice immediately
Check is it the correct component for the patient: check laboratory produced label attached to blood component against the patient?s identification band, and with the patient themselves (if possible)
Assess the patient
How should you manage a severe transfusion reaction?
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
What are the signs of a delayed reaction?
This is a rare type of transfusion reaction usually seen in patients who have developed red cell antibodies in the past from transfusion or pregnancy. A combination of the features occurs days after the transfusion, suggesting that the red cells are being destroyed abnormally quickly.
Signs and symptoms include:
Fever
Falling haemoglobin or a rise in Hb less than expected
Jaundice
Haemoglobinuria.
What is the recommendation for timing a blood transfusion?
It is recommended that red blood cells are transfused over 90-120 minutes, but must be completed within 4 hours of removal from temperature controlled storage.
What might be evidence of haemmorhage?
Bleeding which leads to a heart rate of >110 bpm and/ or a systolic BP < 90 mm Hg is a useful indicator of major blood loss of 1000 mL or more in an adult.
How should major haemmorhage be managed in adults?
Activate major haemorrhage protocol
Administer high flow oxygen
Insert 2 wide bore peripheral cannulae and provide fluid resuscitation.
Contact key personnel, including experts to treat bleeding cause.
Arrest bleeding and treat underlying cause as soon as possible.
Request laboratory investigations and perform Point of Care Tests where available, including blood gas analysis and viscoelastic tests (ROTEM/ TEG).
Transfuse red cells to maintain a haemoglobin level of 70-90 g/L
Administer tranexamic acid within 3 hours of onset of haemorrhage unless complicated by disseminated intravascular coagulation
Transfuse FFP empirically if estimated blood loss greater than 20% blood volume or if microvascular bleeding
Anticipate the need for additional blood components (including red cells, FFP, platelets and cryoprecipitate)
Use cell salvage where available and appropriate
When bleeding is under control additional doses of FFP should be based on results
How long does FFP take to thaw?
30 minutes
What is FFP used for?
Despite its widespread use, studies have demonstrated that fresh frozen plasma is often misused.
FFP is indicated in:
Inherited coagulation factor deficiency where no suitable factor concentrate is available, e.g. Factor V deficiency
Acute disseminated intravascular coagulation (with evidence of bleeding)
Thrombotic thrombocytopenic purpura (TTP)
Major haemorrhage*
Prophylaxis before surgery (or another invasive procedure) if abnormal coagulation test results AND one or more additional risk factors for bleeding:
When should FFP not be prescribed?
FFP should NOT be administered:
As a plasma expander to correct hypovolaemia.
For the reversal of warfarin anticoagulation, treatment of bleeding in this circumstance is vitamin K, with or without prothrombin complex concentrate.
To non-bleeding patients with liver disease*
To critically ill patients with prolonged PT or APPT in the absence of bleeding.
For patients with liver disease: there is no evidence that prophylactic FFP reduces the risk of bleeding from percutaneous liver biopsy or variceal haemorrhage.
How should FFP be prescribed?
Prophylaxis before a surgical or invasive procedure - suggested dose of FFP is 15 ml/kg body weight (although not evidence based) in a non-bleeding patient with abnormal coagulation test results AND one or more additional risk factors for bleeding.
Treatment of major haemorrhage - initial recommended dose is 15 to 20ml / kg body weight
What is cryopreciptate for?
Low fibrinogen levels
What are the two types of albumin solution?
terile isotonic and concentrated solutions of pooled human albumin contain at least 95% albumin and electrolytes but no clotting factors or blood group antibodies, so cross matching against a patient’s blood group is not required.
4.5% and 5% human albumin solutions are isotonic with plasma. These are supplied in a range of volumes from 50-500 mL bottles, depending on the manufacturer and can be stored at room temperature (< 25oC), for up to 3 years.
Concentrated 20% human albumin solution expands the circulation by 3-4 times the infused volume (by drawing in extravascular fluid). It is supplied in 50 ml and 100 ml bottles, which should be stored in a fridge at 2-8oC for up to 3 years.
What is Prothrombin complex concentration for?
- Prothrombin Complex Concentrate (PCC)
PCC is a freeze-dried concentrate of three or four inactivated clotting factors (II, IX and X or II, VII, IX, X, depending on the commercial product) and Protein S and C anticoagulant factors.
It is licensed for:
Treatment of bleeding or peri-operative prophylaxis of bleeding in patients with congenital deficiency of vitamin K-dependent clotting factors or when no specific factor concentrate is available
Treatment of bleeding or peri-operative prophylaxis of bleeding secondary to warfarin or other drugs that inhibit production of vitamin K-dependent clotting factors.
When is IVIG given?
Intravenous Immunoglobulins (IV IgG)
Immunoglobulins, produced by plasma cells, act as antibodies when the body is exposed to an infection such as a virus. Intravenous immunoglobulin (IV IG) is derived from healthy human blood that has a high titre of antibodies. It must be prepared aseptically at room temperature and administered within 4 hours of reconstitution, as it is an excellent medium for bacterial growth.
Rationale for use:
In immunocompromised individuals to raise the IgG antibody level and so reduce the risk of serious infections or;
To produce supra-normal levels of IgG which can suppress excessive autoimmune activity.
What are side effects of IVIG?
Fever, muscle pain and headache are the most common adverse reactions associated with the administration of IV IgG.
What is the TACO?
Does the patient have a diagnosis of ‘heart failure’ congestive cardiac failure (CCF), severe aortic stenosis, or moderate to severe left ventricular dysfunction? Is the patient on a regular diuretic?
s the patient known to have pulmonary oedema?
Does the patient have respiratory symptoms of undiagnosed cause?
What are the steps a doctor should take in a transfusion reaction?
Call for urgent medical help
Initiate resuscitation - ABC
Disconnect the blood component and attached IV giving set from the patient. Do not dispose of the unit or giving set.
Maintain venous access with suitable IV crystalloid administered via new giving set.
Monitor the patient e.g. temperature, pulse, blood pressure, urinary output, oxygen saturations
Inform Hospital Transfusion Laboratory (HTL) immediately
Return the implicated component and any other units issued for the patient to HTL (either transfused or not transfused units)
What are some complications of transfusion?
Acute haemolysis including ABO incompatibility
Bacterial contamination of the unit
Transfusion Related Acute Lung Injury (TRALI)
Transfusion Associated Circulatory Overload (TACO)
What does SHOT stand for?
Serious hazards of transfusions
What is a problem with transfusion in the elderly?
Red cell transfusions are given more frequently in the elderly.
Individuals who are of small stature or who have significant co-morbidity are particularly at risk. There is a particular risk of Transfusion Associated Circulatory Overload (TACO).
Bone marrow failure syndromes are more common in the elderly, carrying additional risks for multi-transfused patients including development of red cell antibodies, and the risk of delayed transfusion reactions.
What problems might be with sickle cell have when undergoing transfusions?
Patients with sickle cell disease or other haemoglobinopathies, who are frequently transfused, are more likely to make antibodies, and are more at risk of presenting with a delayed transfusion reaction (DHTR). Sickle cell patients may present with a severe form of DHTR, hyperhaemolysis, in which case there is evidence of haemolysis but no detectable antibody may be present.
What should you do in an acute tranfusion reaction (ATR)?
STOP the transfusion
Maintain IV access
Undertake rapid clinical assessment including ABC (Airway, Breathing, Circulation)
If appropriate, call for help
Check identification details between the patient, their identity band and the compatibility label of the blood component
Visually assess the unit looking for evidence of unusual clumps or discolouration and check the expiry date
Check standard observations.
