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.

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

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