dr claire barrett division clinical haematology
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Dr Claire Barrett Division Clinical Haematology. Transfusion cases. Learning objectives:. Follow the correct process of ordering and administering blood. Identify and manage an acute haemolytic transfusion reaction Identify and manage TRALI (transfusion related acute lung injury).

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dr claire barrett division clinical haematology
Dr Claire Barrett

Division Clinical Haematology

Transfusion cases

learning objectives
Learning objectives:
  • Follow the correct process of ordering and administering blood.
  • Identify and manage an acute haemolytic transfusion reaction
  • Identify and manage TRALI (transfusion related acute lung injury)
case 2 ordering and administration of blood products
Case 2: Ordering and administration of blood products:

FOCUS:The right specimen from the right patient.

The right blood product for

the right patient.

case 2
Case 2:
  • Picture the scene:
  • It’s your first call at this hospital.

YOU

are HERE

slide6

THE DEEP RURAL HOSPITAL

250 km from ANYWHERE

the patient
The patient:
  • 22 year old man brought into casualty by ambulance with stab wounds in his abdomen.
  • BP 80/45mm Hg, pulse 145/minute.
  • Tachypnoeic and weak.
  • He is actively bleeding and shocked.
  • Ward haemoglobin is 8.
the decision
The decision:
  • What do you do?
  • Due to delays in arranging an anaesthetist, your patient bleeds further, his Hb is now 5.
  • Patient’s blood group = O+
the solution almost
The solution... Almost.
  • Order blood from your hospitals small blood bank.
  • No group O blood.
  • The blood bank has 2 units of group B+ blood that has been kept on standby for another patient’s elective theatre case...
  • What now?
the villain
The villain!

Your colleague decides that it

would be better to give the

patient some blood rather

than none at all, and

administers 1 unit of

group B blood to the patient

without your knowledge.

the problem
The problem:
  • What do you think will happen now?

12123

diagnosis of ahtr
Diagnosis of AHTR:
  • Fever
  • Sweating
  • Chills/ or rigors
  • Hypotension
  • Tachycardia/ bradycardia
  • Pain (chest/ flank/ back)
  • Dyspnoea
  • Agitation
  • Haemoglobinuria (pink urine)
  • Oliguria
  • Bleeding
management
Management:
  • Recognise symptoms and signs.
  • Respond:
    • STOP transfusion
    • Remove blood giving set and bag
    • KEEP ivi line open and running with 0,9% saline.
      • Maintain urine output of 100ml/hr for 24 hours.
      • Furosemide/ mannitol may be neccessary to maintain output
    • Insert second ivi line
    • Oxygen by face mask
    • Record vital signs
slide17

Recheck:

    • Correlate patients name, hospital number and date of birth with wrist band, unit and form accompanying blood.
    • Ask blood bank to recheck compatibility.
  • Return
    • Return the offending unit to the blood bank.
slide18

React:

    • Send post reaction samples to blood bank
      • (1 red (clotted) tube, 1 purple (EDTA) tube and urine specimen.
    • Send the following tests to confirm haemolysis:
      • Raised unconjugatedbilis,
      • Urine haemoglobin and haemosiderin,
      • Decreased haptoglobin,
      • Increased LDH,
      • Increased AST,
      • Decreased Hb, or insufficient rise in Hb.
      • Coombs.
    • Send Blood cultures (to exclude infection)
refer icu
Refer ICU:
  • Management/ support of
    • Renal failure
      • Maintain intravascular volume and renal blood flow.
      • Monitor input and output
      • Consult nephrology
    • Cardiac failure
      • Inotrope support may be neccessary
    • Respiratory failure
      • Possible intubation and ventillation
    • DIC (consult haematology)
      • Monitor INR, PT, PTT
      • FFP, platelets, cryoprecipitate
      • Heparin 10u/kg/hr if thrombotic features predominate.
record keeping and reporting
RECORD KEEPING and REPORTING:
  • Date and time transfusion started and stopped.
  • Date and time symptoms appeared.
  • Exact clinical findings (detail)
  • Interventions and outcomes.
  • Report to SANBS and complete the TRANSFUSION REACTION FORM.
  • Report to Hospital Transfusion Committee.
risk reduction
Risk reduction:
  • Review hospital policy for administration of blood products.
  • Train clinical staff members.
  • If patient has alloantibodies, give a written card specifying the identified antibodies.
haemolytic transfusion reactions
Haemolytic transfusion reactions:
  • Possibly fatal complication of a blood transfusion.
  • Need to be recognised early.
  • Prevented by ALWAYS ensuring that the right blood is administered to the right patient.
case 31
Case 3:
  • Mr ABC: 40 year old male patient.
  • Known HIV positive, CD4 530.
  • Presents with convulsions, fever, oliguria.
  • Mucosal bleeds.
  • FBC shows platelet count of 5 and Hb of 8.
  • Haematopathologist reports fragmentation haemolysis. (red cell fragments = 20%)
what do you think
What do you think?
  • What is the diagnosis?
  • Which blood product would you would not use?
  • Which blood products would you use?
  • Why?
the progress 3 days later
The progress, 3 days later:
  • Mr ABC is doing really well.
  • Platelets increased to 70.
  • Fragmentation is now 5%.
  • Renal function is improving.
but then 5 days later
But then, 5 days later:
  • Mr ABC suddenly becomes short of breath and distressed. Saturation 76%.
  • The nursing staff call you.
  • You listen to his chest and hear bilateral crepitations.
  • What do you think?
  • What do you do?
x ray
X-Ray:

Admission:

3 days later:

what is trali 1 in 5000 10000 tx fatality 5 10
What is TRALI: 1 in 5000- 10000 TxFatality 5 – 10%
  • Serious, life threatening syndrome that presents with:
    • Acute respiratory distress
    • Pulmonary oedema
    • Hypoxaemia
    • Hypotension
  • 2- 6 hours after transfusion
  • Usually resolves 96 hours after transfusion.
implicated blood products
Implicated blood products:
  • Whole blood
  • Red cell concentrate
  • FFP
  • Platelet concentrates
  • Cryoprecipitate
  • IVIG
  • Granulocytes.
definition and diagnosis
Definition and diagnosis:
  • NEW ALI
    • Acute onset
    • Hypoxaemia
      • PaO2/ FiO2 < 300mmHg
      • SpO2 < 90% on room air
      • Other clinical evidence of hypoxaemia
    • Bilateral chest infiltrates on PA CXR.
    • No evidence of LA hypertension.
  • No pre-existing ALI before transfusion
  • Onset within 6 hours of transfusion
  • No other risk factors for ALI present.
differential dx
Differential dx:
  • Congestive cardiac failure/ acute left ventricular failure.
  • TACO (Difficult to differentiate)
    • TACO causes raised BP.
  • Pulmonary embolism
  • Rapidly progressing pneumonia
    • Especially viral/ fungal
  • ARDS.
management of trali
Management of TRALI:
  • Stop infusion
  • Supportive:
    • Maintain oxygenation(intubation and ventillationprn)
    • Haemodynamic monitoring
    • Fluid support to maintain BP
    • Diuretics not useful (may worsen picture)
    • No evidence for use of steroids.
  • 2 patterns of resolution:
    • Resolve in 96 hours (Unlike ARDS)
    • Some take longer (7 days) to resolve.
investigation of trali
Investigation of TRALI:
  • Notify SANBS immediately.
  • Fill in Transfusion Reaction Form.
  • Send blood to SANBS for
    • HLA I/II Ab. NeutrophilAb in the donor supports the diagnosis.
      • Lymphocyte cross match between donor and recipient.
      • HNA/ HLA Ab-Ag reaction between donor and recipient must be present.
you should now be able to
You should now be able to:
  • Order and administer blood safely.
  • Identify and manage an acute haemolytic transfusion reaction
  • Identify and manage TRALI.
  • Any questions?
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