Transfusion Medicine III Complications and Safety of Transfusion Practices

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Transfusion Medicine IIIComplications and
Safety of Transfusion Practices

• Salwa Hindawi
• Medical Director of Blood Transfusion Services
• KAUH

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Donor Patient
The risks associated with transfusion can be
reduced by - Effective blood donor
selection. - Screening for TTI in the blood
donor population. high quality blood
grouping, compatibility testing. - Component
separation and storage. -
Appropriate clinical use of blood and blood
products. - Quality assurance
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Principles of Clinical Transfusion Practices

• Avoid blood transfusion
• Transfusion is only one part of the
  patients management.
• Prevention and early diagnosis and treatment of
  Anemia underlying condition
• Use of alternative to transfusion.
• eg. IV fluids
• Good anesthetic and surgical management to
  minimized blood loss.

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• Prescribing should be based on national
  guidelines on the clinical use of blood taking
  individual patient needs into account.
• Hb level should not be the sole deciding Factor
  Clinical evaluation is important

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• Consent form to be obtained from the patient
  before transfusion.
• The clinician should record the reason for
  transfusion clearly.
• A trained person should monitor the transfused
  patient and if any adverse effects occur respond
  immediately.

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Blood Donors
Homologous
Paid
Directed
Volunteers
Autologous
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Blood Donation

• WB every 8 weeks, Hct gt 38
• Plateletpheresis every 3 days or 24 times per
  year, Hct gt 38
• Autologous Blood
• WB every 3 days (twice/week)
• up to 3 days prior to surgery
• Hct gt 33

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Donor Selection
Is Important
To Be Sure That The Donor Is Fit To Donate The
Required Amount Of Blood
Blood Donation Will Not Harm The Donor
The Donated Blood Should Be Safe And Free From
Transfusion Transmitted Infections TTI
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Donor Selection
I. Interview
Donor safety
II. Questionnaires
Patient safety
III. Physical examination
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Single Donation Testing
Different countries screen for different
organisms. Each country has to set its own
policies for screening of donors.
i. Serological screening
ii. Microbiological screening
HIV I II (Ag-Ab), HBV, HCV, Syphilis
HTLV-I II HBcAb
Special donors for CMV Malaria screen (in some
countries)
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Confirmatory tests
Any reactive donation should repeat testing in
duplicate. If any of the repeated tests is
reactive, a sample should be send to a reference
laboratory and the donation will be destroyed by
autoclaving or used for batch validation or
quality control purposes.
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Complications of Blood Transfusion

• Immediate Delayed
• HTR GVHD
• FNTR PTP
• TRALI Iron
  overload
• Bacterial
  Infectious
• contamination diseases
• Allergic, Anaphylaxis Alloimmunization

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Acute Hemolytic Transfusion Reaction

• a clerical error (wrong specimen, wrong patient)
• 1 in 6,000 to 25,000 transfusions
• back pain, chest pain, fever, red urine,
  oliguria, shock, DIC, death in 1 in 4
• stop the transfusion

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Work up of An AHTR

• start normal saline
• treat patient symptomatically
• send blood bag and tubing to culture
• send red top and purple top tubes
• urine specimen for hemoglobinuria
• DAT is positive

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Non Hemolytic Febrile Transfusion Reaction

• NHFTR (1100)
• Recipient has WBC antibodies to Donor WBCs
  contained within RBCs and Plateletpheresis
  products
• DAT is negative
• rise in temperature by 2F or 1C
• other causes for fever are eliminated

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Allergic (Urticarial) Transfusion Reaction

• Recipient has antibodies to the Donors plasma
  proteins (1 in 1000)
• offending protein is not identified
• urticaria, itching, flushing, wheezing
• this is the only transfusion reaction where the
  blood that is hanging can be restarted after
  treatment with Benadryl
• if symptoms continue then STOP

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Anaphlyactic Transfusion Reaction

• anaphylactic reaction (1 in 150,000)
• 1 in 700-900 people never made IgA
• occurs when exposed to normal blood products
  which contain IgA
• bronchospasm, vomiting and diarrhea and vascular
  collapse
• treat with Epinepherine, Solu-Medrol,

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Circulatory Overload

• marginal cardiovascular status
• given blood components too rapidly
• develops acute shortness of breath, heart
  failure, edema (1 10,000)
• systolic BP increases 50 mm
• infuse slowly, not to exceed 4 hours
• split the unit of RBC and give half

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Transfusion Related Acute Leukocyte Lung Injury

• TRALI reaction (110,000)
• Donor plasma contains WBC antibodies that when
  transfused to the recipient cause agglutination
  of recipients WBC in the pulmonary capillary
  beds
• Chest X ray looks like ARDS
• Donor removed from donating blood

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Transfusion - Related Acute Lung Injury (TRALI)

• A potentially fatal transfusion reaction
• Manifested usually within 6hrs after transfusion
• Characterised by
• Hypoxemia PaO2/ FiO2lt 300mmhg O2 sat lt90 on room
  air
• Chest X-rayBilateral hilar infiltrates
• Absence of evidence of circulatory overload
• Toronto TRALI Concensus Conference 1 April 2004
• Transfusion,441774-91 Dec 2004

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Diagnosis
High Index of suspicion / Timing of
Transfusion Blood Gases Chest X-ray hypoxia
and pulmonary oedema most consistent
findings. Diagnosis of exclusion
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TRALI Non-cardiogenic pulmonary oedema (result of
increased vascular permeability) The first sign
of the reaction can be Production of copious
quantities of frothy blood-tinged fluid from the
endotracheal tube during intubation
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Differential Diagnosis

• Other courses of pulmonary oedema
• Volume Overload
• Congestive heart failure
• Myocardial infarction
• Response to diuretics?

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• Other Differential Diagnosis
• acute reaction
• Acute haemolytic transfusion reaction
• Bacterial infection(TTI)
• Acute anaphylaxis IgA def with anti-IgA

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Management

• Adequate respiratory support
• 100 patients need O2 support
• 71 required mechanical ventilation
• Steroids not beneficial
• Important to distinguish TRALI from volume
  overload
• Treatment with diuretics may have a detrimental
  effect /reduced cardiac out put.
• May need fluid support.

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Sepsis from Bacterial Comtamination

• Platelets
• skin contaminants most common cause
• plateletpheresis 1 in 5000
• pooled platelets 1 in 1000
• RBC
• Sepsis from RBC due to Yersinia, Enterics or
  Gram Positive 1 in 3,000,000

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Transfusion Transmitted Disease (TTD)

• HBV 1 in 63,000
• HCV 1 in 103,000
• HTLV-I 1 in 641,000
• HTLV-II 1 in 641,000
• HIV-1 1 in 587,000
• HIV-2 lt 1 in 1,000,000

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Adverse Effects of TransfusionDelayed Effects
Immunological Etiology

• Delayed Haemolysis
• Graft Vs Host disease
• Post-Transfusion Purpura
• Alloimmunization

• RBCs Antibody Reaction
• Engraftment of Functional Transfused Lymphocytes
• Anti platelet Abs
• Exposure to Antigens of Donor Origins

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Adverse Effects of TransfusionsDelayed
EffectsNon-Immunological Etiology

• Iron Overload
• Hepatitis
• AIDS
• Protozoa Infection

• Multiple Transfusion
• HVB, HCV, and Non-A, Non-B, and Non-C
• HIV -I / HIV-2
• Malaria, Babesia Trypanosomes

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Thanks