بسم رب نور

1. بسم رب نور

2. Prevention & Management of transfusion reaction Dr.sh.sharifi 20-21 th feb 2008

3. Febrile Rxn • Management • Give antipyretics (e.g. aspirin – except children – Reyes Syndrome) • Avoid aspirin in thrombocytopenic pt’s • Do not restart transfusion

4. Febrile Rxn • Prevention; • Antipyretics • Prestorage leukoreduced blood products

5. Allergic Rxn • Management • Premedicate Pt with antihistamines (e.g. Benadryl) • If signs/symptoms mild &/or transient, restart transfusion after treatment • Do NOT restart transfusion if pulmonary symptoms/signs, fever present

6. Allergic Rxn • Prevention • Prophylactically treat with antihistamines

7. TRALI • Management • Steroids • Aggressive ventilatory support • Hemodynamic support

8. TRALI • Prevention • Typically ,TRALI is adonor specific phenomen so donor deferred from donating plasma products. • Transfuse washed RBC’s from which plasma is removed • Platelet units can also be washed, but platelet function is significantly reduced

9. Circulatory Overload • Management • Slow rate of infusion • Place Pt in upright position, if possible, with feet in dependent position • Diuretics • Oxygen • Morphine (if necessary)

10. Circulatory Overload • Prevention • Vigilant assesment of patients input and output • Slow rate of infusion • Pretransfusion and/or intratransfusion diuretic adminstration

11. Septic Rxn • Management • Obtain blood cultures from Pt • Return blood component bag(s) to blood bank for further laboratory work-up • Treat septicemia with antibiotics • Treat shock with fluids & vasopressors

12. Septic Rxn • Prevention • Collect, process, store, transport, and transfuse blood components according to contemporary standards of practice (e.g. for FDA standards adhere to cGMP’s – current good manufacturing practices – found in Code of Federal Regulations) • Transfuse blood components within 1 to 2 hrs – do not exceed 4 hrs

13. Acute Hemolytic • Management • Treat hypotension, renal failure, DIC, etc. • Submit blood samples for blood bank/laboratory tests • Avoid, if possible, further transfusions till work-up complete and/or Pt recovered from rxn

14. MANAGEMENT OF ACUTE HEMOLYTIC TRANSFUSION REACTION • 1-Stop the transfusion and maintain intravenous access. • 2-make initial rapid assessment of patient and requirements for basic and advanced support. • 3-notify transfusion service,collect transfused units(full or partially),tubing,etc.,and return them to blood bank. • 4-Reconfirm identity of blood units and patient. • 5-collect appropriate patient blood specimens • 6-pending results of initial evaluation,consider the following supportive approches: • A-IV fluid resuscitation to treat hypotension. • B-maintenance intravenous fluids at 3000 ml/m2/day with adminstration of sodium bicarbonate to keep PH>7.0

15. Continue…. • C-diuretics:mannitol(20%),100 ml/m2 give over 30-60 min,then 30 ml/m2/hr for text 12 hours;furosemide(adults 20-80 mg;infants and children 1-2 mg/ kg to an adult dose) • D-low-dose dopamine,1-5 mcg/kg/min. • E-replacement of procoagulant factors and fibrinogen with fresh frozen plasma and cryoprecipitate and platelets with platelet concentrate. • F-heparin:50-100 u/kg,(unfractionated heparin)and infusion 15-25 u/kg/hr to keep heparin level 0.4-0.7 u/ml.

16. prevention • The best way to prevent AHTR is to avoid transfusion • Defining clear-cut and defendable indication for transfusion • Careful determination of the Hb or HCT level for ordering TRX • patient-donor identification • Autologousblood safer than homologous

17. Serious Hazards of Transfusion Reporting Scheme Overview of cases from 2004 Report (n=541)

18. Serious Hazards of Transfusion Reporting Scheme Distribution of Errors in IBCT Category (2004 Report)

19. Requesting Procedure • Check the patient’s case note • Transfusion history • Special requirements • e.g., irradiated, CMV negative • Complete request form or order com

20. Sampling Procedure Step 1: Ask the patient to tell you their: Full Name + Date of Birth Check this information against the patient’s ID wristband Be extra vigilant when checking the identity of the unconscious / compromised patient

21. MACDONALD MORAG 11/07/1956 100198E ITU ANAEMIA NOT KNOWN NOT KNOWN Sampling Procedure Step 2:Check the patient’s ID wristband against documentation e.g., case notes or request form for: • First name • Surname • Date of birth • Hospital number EXAMPLE REQUEST FORM ANY HOSPITAL

22. Sampling Procedure • Only bleed one patient at a time • Do NOT use pre-labelled tube • Hand write the sample tube beside the patient • Send the sample to the laboratory in the most appropriate way for the clinical situation, i.e. routine / emergency

23. Labelling the venous blood sample • Hand written label to include:- • Full name • Date of birth • Hospital number • Gender • Date • Signature of person who has taken the sample • At the bedside • By the person taking the sample

24. Storage Component • Red blood cells • Platelets • Fresh Frozen Plasma • Cryoprecipitate 

25. Collection Procedure Step 1: Complete the Blood Collection Form (or follow your local collection procedure) with the following information: • First name • Surname • Date of birth • Hospital number Follow procedure for each blood component collected

26. Collection Procedure Step 2: Check the patient’s ID details against compatibility/ traceability label attached to the blood bag Step 3: Document removal of unit on blood fridge register or electronic release system Ensure prompt delivery of the blood component to the clinical area

27. Pre-administration Procedure Step 1: Check the blood component has been prescribed Step 2: Undertake baseline observations Step 3: Undertake visual inspection LEAKS DISCOLOURATION CLUMPING EXPIRY DATE If there is ANY discrepancy - DO NOT transfuse

28. Pre-administration checks • Personal checks: - clean your hands - wear personal protective equipment • Equipment checks: - Personal protective equipment is available and is clean and sterile - A correctly completed prescription chart - Observation chart - Giving set - Disposable bags - Trolley

29. Administration Process • Equipment • Venous access devices • Blood administration sets • Infusion fluids • Infusion devices 

30. Administration Procedure Step 1: Ask the patient to tell you their: Full Name + Date of Birth Check this information against the patient’s ID wristband Be extra vigilant when checking the identity of the unconscious / compromised patient

31. Administration Procedure Step 2: Check the patient’s • First name • Surname • Date of birth • Hospital number on the compatibility/ traceability label against the patient’s ID wristband

32. Administration Procedure Step 3: Check the compatibility/traceability label with the blood bag label DONOR COMPONENT NUMBER BLOOD GROUP RhD GROUP If there is ANY discrepancy - DO NOT transfuse

33. Documentation Procedure EXAMPLE COMPATIBILITY/TRACEABILITY LABEL EXAMPLE COMPATIBILITY REPORT FORM COMPLETE DOCUMENTATION Ensure that you sign the transfusion documentation to say you have checked the blood component against the patient’s wristband G101 602 597 229 N Red Cells MACDONALD MORAG 11/07/19566 FEMALE 25 HILL STREET TOWN CENTRE 100198E 20/12/2006 Red Cells O Rh POS G101 602 597 229 N Ensure donor component number is recorded on the transfusion documentation Complete documentation for every blood component transfused MACDONALD MORAG 100198E G101 602 597 229 N Red Cells

34. Monitoring Procedure • Communicate with patient • Record vital signs *Early Check* • Each unit must be infused within four hours • Complete documentation

35. Immediate Action to Take for Txn Rxn: • 1. STOP THE TRANSFUSION • 2. Keep IV open with Normal Saline • 3. Check all blood component(s) labels, forms, Pt. ID for errors • 4. Notify Pt.’s physician as appropriate • 5. Treat rxn • 6. Notify Blood Bank; submit work-up specimens; submit report forms

36. Investigations of transfusion reaction are necessary for : • Diagnosis • Selection of appropriate therapy • Transfusion management • Prevention of future transfusion reaction. • Investigations should include correlations of clinical data with • laboratory result . • Important clinical data : • Diagnosis • Medical history of pregnancies, transplant, and previous transfusion. • Current medication • Clinical signs and symptoms of the reaction.

37. 5. Question related to the transfusion: Amount of blood transfused to cause the reaction. How fast , how long ? The use of blood warmer. Any filter used ? Other solutions. Any drugs given at the time of transfusion

38. 2. As recquired procedures • ABO grouping and RH typing, pre and post transfusion • Major compatibility testing , pre and post transfusion • Antibody screening test , pre and post transfusion • Alloantibody identification • Antigen typings • Free hemoglobin in first voidedurine post transfusion • Unconjugated bilirubin 5 – 7 hours post transfusion.

39. 3. Extended procedures • Gram stain and bacterial culture of unit • Quantitative serum Hemoglobin. • Serum Haptoglobin , pre and post transfusion • Peripheral blood film. • Coagulation and renal output study • Urine hemosiderin

40. Haptoglobin Plasma HEMOGLOBIN Urine Hemoglobin Incompatible Transfusion Serumbilirubin 12 6 18 24 30 Hours

41. Delayed Hemolytic Trn Rxn • Management • Send specimen(s) to Blood Bank for antibody identification work-up • Provide good Pt history

42. Delayed Hemolytic Trn Rxn • Prevention • Transfuse RBC’s that are phenotype negative for known clinically significant RBC antibodies in Pt • Delayed Hemolytic Trn Rxn’s can not be predicted • Good Pt records and Blood Bank records are essential • Clinical treatment usually not necessary

43. DHTR • In the futureDHTR may be prevented; • Artificial blood substitutes • More sensitive antibody screening method

44. In all cases in which transfusion is thought to be the cause of death,the FDA must be notified by phone within 24 h after discovery and this must followed up with a written report within 7 days(21 CFR 606 .170)