Transfusion reactions

Transfusion reactions

Jan 19, 2015 0
anaesthetics,emergency,haematology,onthepods

James talks to Dr Ibrahim Tohidi about transfusion reactions.

Script Writer:  Jenny Liu

Summary Writer:  Jenny Liu

Editor:  James Edwards

Interviewee: Ibrahim Tohidi

About Dr Ibrahim Tohidi

Dr Tohidi is a Haematology Advanced trainee at Royal Prince Alfred Hospital and Concord Hospital. He is a Clinical Associate Lecturer at the University of Sydney, and a member of the RACP Working party for the use of stem cells in cerebral palsy. He graduated from the University of Newcastle with Distinction, and has a special interest in cellular therapies and blood banking.

Transfusion reactions

With Dr Ibrahim Tohidi, Advanced Trainee in Haematology at Royal Prince Alfred Hospital/Concord Hospital and Clinical Associate lecturer at the University of Sydney, New South Wales, Australia

Case

You are a JMO covering the orthopaedic ward after hours and are called by nursing staff to review a patient who has been receiving a blood transfusion who has developed a temperature of 38.5°C and has a blood pressure 95/55.

  • Potential high risk situation for the patient.
  • How does the patient look?
  • What was the observations and temperature before the blood transfusion started?
    • If significant increase in temperature (say >1°C) and BP has dropped after transfusion started this is an urgent situation and need to review patient ASAP.
    • Instruct nursing staff to stop transfusion, disconnect and flush the line.
  • Common:
    • Febrile non-haemolytic transfusion reaction.
    • Transfusion associated circulatory overload (TACO).
    • Urticarial allergic reactions.
  • Less common but more dangerous:
    • Acute haemolytic transfusion reaction
    • Transfusion related acute lung injury (TRALI)
    • Sepsis
    • Anaphylaxis
  • With febrile non-haemolytic transfusion reaction you expect an asymptomatic rise in temperature (1°C or more).
  • Generally a benign condition.
  • However, if patients have symptoms (SOB, chest tightness/pain, loin pain, diaphoresis) these are warning signs a more serious reaction could be occurring.
  • If any features are present in addition to a rise in temperature, upon rapid review by the JMO they should contact the medical registrar
  • If together they demonstrate this is a reaction to the transfusion they should contact the haematology registrar for further advice as well as the blood bank
  • Assess vitals and temperature before and after transfusion started
  • Assess onset of signs of symptoms – if they develop soon after transfusion started, including any pain at IVC access site, consider the more serious haemolytic transfusion reactions.
  • STOP transfusion reaction and assess patient.
  • Examination:
    • Assess ABCs (anaphylaxis causing airway compromise).
    • Assess vitals.
    • Look for evidence of bibasal crepitations or wheeze on chest auscultation (for TRALI).
    • Look for a change in the colour of urine: dark urine suggests haemolysis.
    • Look for urticarial skin reactions.

 

  • Reason for presentation to hospital and reason for transfusion.
  • Current clinical condition (current infections?)
  • PMHx especially previous transfusion reactions and allergies, and CCF (risk of overload).
  • Presence of red cell antibodies on electronic medical record (the higher the antibodies the greater the risk of transfusion reaction).
  • Once established the patient is well apart from temperature rise, after discussion with the haematology registrar who agrees it is likely a non-haemolytic transfusion reaction:
  • Stop transfusion at time of fever.
  • Give paracetamol.
  • Once temperature <38°C restart the transfusion (same unit). Consider running at a slower rate if the bag is not going to expire.
  • Notify blood bank a reaction has occurred.
  • IIMS (Incident Monitoring System) should be entered by one of the staff looking after the patient.
  • Should there be any question regarding the type of reaction, should manage as if it an acute haemolytic reaction.
  • Repeat FBC, haemolytic screen (haptoglobin (would be reduced), reticulocytes, bilirubin, lactate dehydrogenase, direct antiglobulin test) and blood cultures.
  • Disconnect the blood and flush the line.
  • All the blood given to the patient in this episode should return to the blood bank for repeat crossmatch and cultures.
  • Start IVF to protect kidneys.
  • Assess patient for circulatory compromise and resuscitate as appropriate.
  • Manage TACO the same as that for acute pulmonary oedema.
  • TRALI is a very difficult management situation, mainly supportive measures.
  • TRALI: expect patients to be febrile and hypotensive with reduced JVP.
  • TACO: expect patients to be hypertensive, with raised JVP and absence of fever..
  • Both have same findings on chest auscultation and chest X-Ray.
  • As a JMO any blood transfusion reaction should be discussed with a senior.
  • Blood bank and haematology registrar should be made aware in all circumstances.
  • Up to the medical registrar to ascertain whether care needs to be escalated (e.g. intensive care review).
  • Blood products are high risk therapies with very specific indications and guidelines for transfusion should be adhered to in order to minimise the risk of these reactions.

Related Podcasts

Tags: #acute haemolytic transfusion reaction,#anaphylaxis,#antibodies,#blood,#blood pressure,#blood products,#blood transfusion,#BloodSafe,#haematology,#haemolysis,#sepsis,#TACO,#TRALI,#Transfusion Reactions

If you enjoyed listening to this week’s podcast feel free to let us know what you think by posting your comments or suggestions in the comments box below.

 

If you want to listen to this episode while not connected to WiFi or the internet, you can download it. To find out more go to Apple support (https://support.apple.com/en-us/HT201859)

Leave a comment:

Your email address will not be published. Required fields are marked *

onthewards is a registered trademark (1784140) which is approved by the ACNC as a registered charity | ABN 51 198 764 539
 
This work is licensed under a Creative Commons Attribution 2.0 Generic License