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Blood Transfusion Reactions Haemovigilance Serious Hazards of Transfusion ( SHOT )

Blood Transfusion Reactions Col.Dr.Mohamed H Khalaf,MD Head, Department of Haematology Maadi A F Medical Compound. Blood Transfusion Reactions Haemovigilance Serious Hazards of Transfusion ( SHOT ). Blood Transfusion Reactions Haemovigilance Serious Hazards of Transfusion ( SHOT ).

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Blood Transfusion Reactions Haemovigilance Serious Hazards of Transfusion ( SHOT )

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  1. Blood Transfusion ReactionsCol.Dr.Mohamed H Khalaf,MDHead, Department of HaematologyMaadi A F Medical Compound

  2. Blood Transfusion ReactionsHaemovigilanceSerious Hazards of Transfusion ( SHOT )

  3. Blood Transfusion Reactions HaemovigilanceSerious Hazards of Transfusion ( SHOT ) 65% Incorrect Blood Component10% Acute Transfusion Reaction10% Delayed Transfusion Reaction5% Transfusion Lung Injury3% Post-transfusion purpura3% Transfusion Transmitted Infection1% Transfusion-GVHD

  4. Blood Transfusion: ImmediateReactions • Acute Haemolytic Transfusion Reactions • Febrile Non-Haemolytic Transfusion Reactions • Allergic Reactions: • Anaphylaxis • Skin Reaction • Transfusion-related Acute Lung Injury • Bacterial Contamination • Circulatory Overload • Citrate Intoxication

  5. Blood Transfusion: Delayed Reactions • Delayed Haemolytic Transfusion Reactions • Post- transfusion Purpura • Infection Transmission • Transfusion-related Graft-versus-Host Disease • Immune Modulation • Iron Overload

  6. Immediate Blood Transfusion Reactions: Acute Haemolytic Transfusion Reactions • Intra-vascular • Extra-vascular

  7. Immediate Blood Transfusion Reactions: Acute Intra-vascular Haemolytic Transfusion Reactions • Trigger: ABO antigens on transfused red cells Not shared by the Recipient • Reactor: Anti-A or Anti-B of Ig M type

  8. Immediate Blood Transfusion Reactions: Acute Intra-vascular Haemolytic Transfusion Reactions Pathophysiology Full Complement cascade Activation • Complement Components C3a,C5a • Cytokines: IL-1, IL-6,IL-8, TNF • Free Haemoglobin – ATN • DIC

  9. Immediate Blood Transfusion Reactions: Acute Intra-vascular Haemolytic Transfusion Reactions Clinical Picture • Fever, Flushing, Rigors • Headache • Heat or pain at cannulated vein • Restlessness • Bronchospasm • Hypotension • Back or loin pain • Oozing in the surgical field • Red urine ( haemoglobinuria ) • Oliguria or anuria

  10. Immediate Blood Transfusion Reactions: Acute Intra-vascular Haemolytic Transfusion Reactions Diagnosis • Clinical picture • Transfusion Mistake • Red urine • Red plasma • Lab Confirmation

  11. Immediate Blood Transfusion Reactions: Acute Intra-vascular Haemolytic Transfusion Reactions Laboratory Workup • Obtain Blood and urine samples, inspect color • Check paper work • Repeat cross Match • CBC • Direct Coombs’ test • DIC screen: PT,PTT, Fibrinogen • BUN, Cr, electrolytes • Haemolysis screen: LDH, Haptoglobin • Blood culture if sepsis is suspected

  12. Immediate Blood Transfusion Reactions: Acute Intra-vascular Haemolytic Transfusion Reactions Management • Stop transfusion Immediately • Replace giving set, keep IV line with Normal saline • Check patient ID against donor unit • Cardio-pulmonary support • Insert urine cath. And start Forced Diuresis ( ensure 100 ml/h for 24 h to get rid of free Hb and prevent renal VC)

  13. Immediate Blood Transfusion Reactions: Acute Intra-vascular Haemolytic Transfusion Reactions Management Saline Diuresis • If urine < 1.5 ml/kg/h + Low CVP: More Fluid • If urine < 1.5 ml/kg/h + Normal CVP: • Fluid Challenge + 80 -120 mg Frusemide + Renal dose Dopamine ( 1-2 ug/kg/min) • If No response: Consult Nephrologist

  14. Immediate Blood Transfusion Reactions: Acute Intra-vascular Haemolytic Transfusion Reactions Outcome Mortality ~ 10 %

  15. Immediate Blood Transfusion Reactions: Acute Extra-vascular Haemolytic Transfusion Reactions Trigger: Rh antigens not shared by the patient Reactor: Anti-Rh antibodies of Ig G type

  16. Immediate Blood Transfusion Reactions: Acute Extra-vascular Haemolytic Transfusion Reactions Response: Pathophysiology • Incomplete complement activation Coating of transfused red cells with C3b • Extravascular phagocytosis by RES • Cytokines from activated RES

  17. Immediate Blood Transfusion Reactions: Acute Extra-vascular Haemolytic Transfusion Reactions Clinical Features • Less severe, may be no signs • Onset > I hour • Fever • + Jaundice • Rarely Haemoglobinuria or renal dysfunction

  18. Immediate Blood Transfusion Reactions: Acute Extra-vascular Haemolytic Transfusion Reactions Laboratory • Anti-complementary Coombs positive

  19. Immediate Blood Transfusion Reactions: Acute Extra-vascular Haemolytic Transfusion Reactions Managment • Stop Transfusion • Supportive • Mortality very rare

  20. Immediate Blood Transfusion Reactions: Febrile Non-Haemolytic Transfusion Reaction ( FNHTR) Trigger: Leucocyte antigens on infused blood not shared by the patient Reactors: Leuco-agglutinins in the patient from previous exposure

  21. Immediate Blood Transfusion Reactions: Febrile Non-Haemolytic Transfusion Reaction ( FNHTR) Pathophysiology • Cytokine released from the transfused activated leucocytes

  22. Immediate Blood Transfusion Reactions: Febrile Non-Haemolytic Transfusion Reaction ( FNHTR) Clinical Features • Fever after 30-90 min • + Rigors • + Headache • No Hypotension • No Bronchospasm • No flank pain • No haemoglobinaemia • No Haemoglobinuria

  23. Immediate Blood Transfusion Reactions: Febrile Non-Haemolytic Transfusion Reaction ( FNHTR) Management • If Temp < 40 + Stable patient: • Stop transfusion • Antipyretics ( No rule of Anti-histamines ) • Check the bag and cross match • Exclude red urine or red plasma • Resume transfusion at a slower rate • If recurrent: Leucodepleted transfusion in the future

  24. Immediate Blood Transfusion Reactions: Febrile Non-Haemolytic Transfusion Reaction ( FNHTR) Management • If Temp 40 or more + Unstable patient: • Stop transfusion • Manage as possible acute haemolytic reaction till lab. Confirmation or exclusion

  25. Immediate Blood Transfusion Reactions: Transfusion- Related Acute Lung Injury ( TRALI) Sudden onset of acute respiratory distress within 6 hours( u. 1-2h) of transfusion

  26. Immediate Blood Transfusion Reactions: Transfusion- Related Acute Lung Injury ( TRALI) Rare: 1/5000 transfusions

  27. Immediate Blood Transfusion Reactions: Transfusion- Related Acute Lung Injury ( TRALI) Pathophysiology • Trigger: Leucoagglutinins in the bag against patient’s leucocytes • Reactors: Patient leucocytes • Result: massive Leucocyte activation  Cytokine storm  Pulmonary Endothelial and Epithelial Injury  ARDS

  28. Immediate Blood Transfusion Reactions: Transfusion- Related Acute Lung Injury ( TRALI) Clinical Features • Fever, chills • Acute Respiratory Distress • Normal CVP • CXR: Pulmonary Infiltrate

  29. Immediate Blood Transfusion Reactions: Transfusion- Related Acute Lung Injury ( TRALI) Management • Cardio-Pulmonary Support • Steroids • Diuretics of No value Mortality High

  30. Immediate Blood Transfusion Reactions: Allergic Acute Transfusion Reactions Pathophysiology • Trigger: Plasma proteins in the transfused blood • Reactors: Patient antibodies of IgE type • Response: • Mast cell degranulation • + Complement Activation • + Cytokines

  31. Immediate Blood Transfusion Reactions: Allergic Acute Transfusion Reactions Clinical Features • Mild / Skin-restricted ( common: 1%): • Pruritus, Uerticaria, No fever or Hypotension • Severe / Systemic ( Anaphylaxis): • As above + • Fever • Hypotension • Bronchospasm, Angio-edema

  32. Immediate Blood Transfusion Reactions: Allergic Acute Transfusion Reactions Management • Mild / Skin-restricted : • Stop transfusion temporary • Anti-histamines • Resume Transfusion

  33. Immediate Blood Transfusion Reactions: Allergic Acute Transfusion Reactions Management • Severe / Systemic ( Anaphylaxis): • Stop transfusion • Anti-histamines ( H1+H2 blockers) • Epinephrine: 1 ml of 1/1000 IM • Hydrocortisone 100 mg IV • Cardio-pulmonary support

  34. Immediate Blood Transfusion Reactions: Acute Pyrogenic Transfusion Reactions Pathophysiology • Trigger: Bacterial Pyrogens/Endotoxins in the transfused blood contaminated with cold-growing organisms as: • Psudomonas • Yersinia • Some Staph • Reactors: Patient Mono-nuclear cells • Response: • Cytokine Storm

  35. Immediate Blood Transfusion Reactions: Acute Pyrogenic Transfusion Reactions Clinical Features Like : • Acute Haemolytic reaction BUT: • No Hemoglobinuria • No Hemoglobinaemia • FNHTR BUT More Severe

  36. Immediate Blood Transfusion Reactions: Acute Pyrogenic Transfusion Reactions Management • As Acute Haemolytic reaction BUT Add Broad- spectrum Antibiotics

  37. Immediate Blood Transfusion Reactions: Acute Circulatory Overload • Acute cardiogenic pulmonary edema • In rapidly transfused, non-bleeding ( euovolemic) patiens • More in infants, elderly or cardiac patients

  38. Immediate Blood Transfusion Reactions: Acute Circulatory Overload D.D. from other Acute transfusion reactions: • No Fever ( DD from TRALI, FNHTR) • No red urine or plasma and Negative Coombs ( DD from Acute haemolytic reaction)

  39. Immediate Blood Transfusion Reactions: Acute Circulatory Overload Prevention • Never exceed 2-3 ml/kg/hour Unless Bleeding • Pre-medicate with Diuretics in Cardiac or severely anemic patients Management • Diuretics • + Inotropics • Consider Haemodialysis • Supportive

  40. Other Immediate Blood Transfusion Reactions: • Hypothermia • Citrate Intoxication

  41. Delayed Blood Transfusion Reactions • Delayed Haemolytic transfusion reactions • Post-transfusion Purpura • Infection transmission • Transfusion GVHD • Iron Overload • Immune Modulation

  42. Massive Blood Transfusion

  43. Massive Blood Transfusion • Definition • Transfusion of Blood ~ Blood Volume within 24 hours • 20 units whole blood • 10 units packed cells

  44. Massive Blood Transfusion • Complications • Dilutional Thrombocytopenia • Dilutional Coagulopathy • Metabolic • Hypothermia

  45. Massive Blood Transfusion • Complications • Dilutional Thrombocytopenia • Common after 10 units • Severe after 20 units • Give platelet transfusion if < 80,000 + bleeding

  46. Massive Blood Transfusion • Complications • Dilutional Coagulopathy • Particularily if blood stored > 2 weeks • Monitor Coagulation profile • FFP if Abnormal lab • DIC is Rare

  47. Massive Blood Transfusion • Complications • Metabolic: Citrate Intoxication • Acidosis, Hypocalacemia, Hyperkalaemia • Rare Except in Infants or Hepatic patients

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