醫療安全暨品質討論會 血品使用與急性反應處理

1. 醫療安全暨品質討論會血品使用與急性反應處理醫療安全暨品質討論會血品使用與急性反應處理 朱芳業 臨床病理科主任 品質管理中心主任 (14:10~14:35 台大醫院第七講堂 ) 精神 誠勤樸慎 創新 宗旨 持續提升醫療品質 善盡社會醫療責任 願景 成為民眾首選的醫學中心

2. 大綱 • 什麼時後該輸血 • 急性輸血反應之處置 • 結語

3. 案例 (TPR通報案例) • 病患因疑似輸血過敏呼吸喘0:00AM，停止輸血，通知值班醫師，予藥物Solucortef 100mg IV → Brircayl 1Amp IH → Solu-medrol 40mg IV → Bosmin 3mg SC → Bricanyl IH仍未改善，喘、wheezing重，ABG呈酸中毒，經醫師評估予家屬解釋，預on endo緩解，並聯絡轉床 • ICU表示先於病房中on上endo後再轉，所以先on endo（1AM左右）。於on endo中，on上時發現病人心搏變緩且至停止（1AM30）故call 9595並予2Am轉床 • 病人血品（PRBC 2U）只輸約150ml，已請值醫key過敏通報，詢問血庫人員是否須將剩餘血品退回血庫檢驗，血庫人員表示應是白血球過敏，直接將剩餘血品丟掉即可 • 輸血150 ml呼吸喘，要懷疑什麼輸血反應，進行那些評估 • Solucortef, Bricanyl, and Bosmin是適當的處置嗎? • ABG呈酸中毒， Ventilatory support 適當嗎? • 直接將剩餘血品丟掉恰當嗎? • 什麼是輸血過敏?

4. 案例 • A 81 year-old female • 2012/08/02 14:45 Transfused 2U PRBC (CPD-SAGM) • 2012/08/02 16:40 SOB, room air SPO2 79~86%, rales (+) developed after transfusion of 320 ml of PRBC • Gave O2 mask 10 L/min, Furosemide 40 mg IV stat, Atrovent + Bricanyl inhalation • CXR : Cardiomegaly • 2012/08/03 14:45 ~ 16:27 • Transfused 1U of LPR 2U and discarded the remaining 1U • Diphenylhydramine 30 mg IV stat before transfusion • 2012/08/04 12:00 ~ 15:15 • Transfused 1U of LPR 2U and discarded the remaining 1U • Furosemide 40 mg IV stat after transfusion • 2012/08/04 23:11 SOB, four limbs edema I/O +700ml • 血品的選用恰當嗎? • 輸血前給予Diphenylhydramine 30 mg IV stat是恰當的嗎? • 丟棄1U LPR是必要的嗎?

5. No TransfusionNo Transfusion Reaction

6. A+ Safe Transfusion : Processes Not Just Product Process Product Recruit Issue Monitor & Evaluate Screen donor Administer Pre-transfusion testing Collect & Process TTD test Reason for Tx 2 3 1 Patient sample (Adapted from Dzik, W. H. Hematology 2005;2005:476-482) 6

7. Reason for Transfusion

8. General Recommendations for Appropriate Hemoglobin Transfusion Thresholds • American Society of Anesthesiologists task force, 1996 • British Committee for Standards in Haematology, 2001 • Australian and New Zealand Society of BloodTransfusion, 2001 Why not transfused It Depends… Why transfused 6 7 8 10 g/dL None of these guidelines recommended a specific transfusion trigger 8

9. Red Blood Cell TransfusionA Clinical Practice Guideline From the AABB • Recommendation 1:The AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients(Grade: strong recommendation; high-quality evidence) (Ann Intern Med. 2012;157:49-58.)

10. Red Blood Cell TransfusionA Clinical Practice Guideline From the AABB • Recommendation 2:The AABB suggests adhering to a restrictive strategy in hospitalized patients with preexisting cardiovascular disease and considering transfusion for patients with symptoms or a hemoglobin level of 8 g/dL or less(Grade: weak recommendation; moderate-quality evidence) (Ann Intern Med. 2012;157:49-58.)

11. Red Blood Cell TransfusionA Clinical Practice Guideline From the AABB • Recommendation 3:The AABB cannot recommend for or against a liberal or restrictive transfusion threshold for hospitalized, hemodynamically stable patients with the acute coronary syndrome(Grade: uncertain recommendation; very low-quality evidence) (Ann Intern Med. 2012;157:49-58.)

12. Red Blood Cell TransfusionA Clinical Practice Guideline From the AABB • Recommendation 4:The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration(Grade: weak recommendation; low-quality evidence) (Ann Intern Med. 2012;157:49-58.)

13. Comment • Recent guidelines recommended a restrictive strategy (transfusion when the hemoglobin level is less than 7 g/dL) for adult trauma and critical care patients, with the exception of those with acute myocardial ischemia • Avoiding transfusion based only on a hemoglobin trigger. Instead, the decision should be guided by such individual factors as bleeding, cardiopulmonary status, and intravascular volume • European Society of Cardiology has recommended : Withholding transfusion in patients with the ACS unless the hemoglobin concentration decreases to below 8 g/dL

14. Current Prophylactic Platelet Transfusion Thresholds (AABB) Note : These levels are most commonly applied to inpatient. Adjustment of the transfusion threshold may be necessitated by unusual clinical situations. 14

15. Although platelet source, ABO compatibility, and duration of storage exert a modest impact on both absolute and corrected posttransfusion platelet increments, they have no measurable impact on prevention of clinical bleeding. (BLOOD 2012;119(23):5553-62)

16. What’s The Point? • Current studies favor a restrictive transfusion strategy • More RCT for some clinical situations

17. 急性輸血反應之處置

18. Adverse Effects of RBC Transfusion Contrasted with Other Risks (Ann Intern Med 2012;157: 49-58. ) 18

19. Acute Complications Of Transfusion • Occur during or shortly after (within 24 hours) the transfusion • Broadly classified into three categories according to their severity and the appropriate clinical response

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22. Key Recommendation • Initial treatment of ATR is not dependent on classification but should be directed by symptoms and signs. Treatment of severe reactions should not be delayed until the results of investigations are available. (1C)

23. Category 3 Life-threatening Reactions • Acute intravascular hemolysis • Bacterial contamination and septic shock • Transfusion-associated circulatory overload (TACO) • Anaphylactic shock • Transfusion-associated acute lung injury (TRALI)

24. Signs Rigors Fever Restlessness Shock Tachycardia Hemoglobinuria (red urine) Unexplained bleeding (DIC) Symptoms Anxiety Chest pain Respiratory distress/shortness of breath Loin/back pain Headache Dyspnea Category 3Life-threatening Reactions

25. Transfusion-associated Circulatory Overload (TACO) • When too much fluid is transfused, the transfusion is too rapid or renal function is impaired, fluid overload can occur resulting in heart failure and pulmonary edema • Patients with chronic severe anemia, underlying cardiovascular disease, and infants are particularly at risk, especially during rapid transfusion

26. Transfusion-associated Circulatory Overload (TACO) • Management • Stop the transfusion • Administer O2 and diuretics as required • Prevention • Avoid unnecessary fluids • Use appropriate infusion rates • Give diuretic before transfusion may be required

27. Transfusion-associated Acute Lung Injury • TRALI is usually caused by donor plasma that contains antibodies against the patient’s leucocytes • Donors are almost always multiparous women • Usually presents within 1 to 4 hours of starting transfusion • Rapid failure of pulmonary function with diffuse opacity on the chest X-ray

28. Transfusion-associated Acute Lung Injury • Incidence • In North America • Quebec  1/100,000-1/10,000 transfusions • United States  1/5,000-1/1,323 transfusions • In Europe (rarer) • 1.3/1,000,000-1/7,900 transfusions • True incidence remains unknown Blood Reviews (2006) 20, 139–159

29. Definition of TRALI • TRALI • Acute onset • PaO2/FiO2≤ 300 or SpO2< 90% on room air • Bilateral lung infiltrates on chest X ray • No evidence of left atrial hypertension • Occurrence during or within 6 hours of transfusion • No preexisting ALI before transfusion or temporal relationship to an alternative ALI risk factor • Possible TRALI • In cases of TRALI occurring in the setting of transfusion and an alternative risk factor for ALI • These alternative risk factors included a variety of conditions that may directly or indirectly induce lung injury, such as pneumonia, pulmonary contusion, and sepsis. 29 (Canadian Consensus Conference Panel on TRALI, 2004 )

30. Transfusion-associated Acute Lung Injury • Management • No specific therapy - Intensive respiratory and general support in an ICU is required • Symptoms generally resolve over 24 - 48 hours • Prevention • Diverting plasma units from multiparous women from the blood supply

32. Summary • No transfusion no transfusion reaction • Current studies favor a restrictive transfusion strategy,though more RCT for some clinical situations • TACO and TRALI should be considered and treated as in patients developing respiratory distress during or shortly after transfusion • Management of ATRs is not dependent on classification but should be guided by symptoms and signs

33. Thanks for Your Attention ! jacpha@mail/femh.org.tw