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


Transfusion cases

THE DEEP RURAL HOSPITAL

250 km from ANYWHERE


Transfusion cases

The patient:


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


Identify the ahtr

Identify the AHTR:


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 of ahtr

Management of AHTR:


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


Transfusion cases

  • 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.


Transfusion cases

  • 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 3

Case 3:


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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