1492 “Transfusion to a Pope”

1. 1492 “Transfusion to a Pope”

2. Who performs the most transfusions in a hospital? ___ The Surgeon ___ The Hematologist ___ The Anesthetist

3. What is the likelihood of receiving a HIV positive unit of blood? ___ 1:50,000 units transfused ___ 1:3,500,000 units transfused ___ 1:7,000,000 units transfused

4. What is the likelihood of receiving an ABO incompatible transfusion? ___1:3000 ___1:33,000 ___1:600,000

5. Adverse Reactions to BloodTransfusions • Approximately 3% - 5% of individuals receiving blood components will have an adverse effect or "transfusion reaction".   Immunological Non-immunological Immediate –within 24 hours Delayed - days/months/years later • Many reactions are avoided by careful pretransfusion testing, preparation of components, appropriate caution, or prophylaxis.

6. What products do we most frequently transfuse? • Red cell concentrates • Platelets • FP • What reactions are most commonly seen? • Febrile, nonhemolytic: platelets/ red cells • Allergic: platelets/plasma/red cells • What reactions do we always worry about? • Acute hemolytic transfusion reactions due to ABO incompatibility

7. Risk of Transfusion Complications RiskEvent 1/100 Hives 1/300 Fever 1/700 Circulatory overload 1/5000 Lung Injury 1/7000 Delayed Hemolysis 1/33,000 ABO mismatch 1/40,000 Death bacterial sepsis (Plats)

8. Comparison Risks in Canada HazardProbability 1/10 Dying of lung cancer(30pyrs) 1/100 Death associated with THR 1/60,000 Annual risk of being murdered 1/200,000 Death from anesthesia in the fit 1/1,000,000 Annual risk of accidental electrocution

9. Case 4 A woman of 53 years undergoes a hysterectomy, which is carried out uneventfully. She is slightly hypotensive in the recovery room, and the blood losses have been moderately high, so it is decided to proceed with a blood transfusion. The first unit is started. Following it, the patient is noted to be more hypotensive, and so the second unit is given. Ten minutes into the second unit, the patient has a cardiac arrest, from which she does not recover. Following the incident, it is discovered that the patient is blood group 0, whereas the transfused blood is group A. Please say what you think happened, and comment on the circumstances.

10. ACUTE HEMOLYTIC TRANSFUSION REACTION • Symptoms: • Fever • Constriction of the chest • Lumbar pain • Signs: • Fever* • Hypotension* • Hemoglobinuria* • Bleeding, oozing intraoperatively* • Renal failure • NB* The unconscious or young patient

11. ACUTE HEMOLYTIC TRANSFUSION REACTIONS: • ABO incompatibility • Naturally occurring antibodies • IgM • Intravascular hemolysis • Complement activation • Vasodilation • DIC • Renal failure

13. Acute Hemolytic Transfusion Reaction • Treatment:STOP Transfusion Immediately • KEEP IV Open with Normal Saline • Maintain volume and blood pressure • with crystalloids • Monitor urine output, cardiac function • Diuretics if oliguric and manage renal failure • Monitor and treat DIC

15. Blood Mix-ups Can Be Deadly! “But are also easily prevented....” Wall Street Journal February 27, 2003 You are 100 X more likely to receive wrong blood than to pick up a disease from blood.

16. INFORMED CONSENT The issue of informed consent around the transfusion of blood and blood components has become a major point of discussion. It is important to: (1) Avoid the transfusion of blood/blood products that are not medically indicated and (2) To document in the patient record that a discussion of the risks, benefits, and indications for transfusion has taken place, and that alternatives to transfusion have been discussed. PENNY ALLISON.mpg

17. Another Dilemma ! (Case 1) • 7 year old girl with immune thrombocytopenia (ITP) • Platelet count of 10 x 109/L. • Recent gastrointestinal bleed; this has now stopped and she is stable. • Hemoglobin is 80g/L. A decision is taken to transfuse 2 units of red blood cells. The transfusion runs overnight, and during it nursing staff calls you because the patient has developed red urine. You attribute this to the ITP, and order the transfusion be continued.

18. On the next morning, you are called urgently by the blood bank who informs you that your patient has received group A Rhesus-positive blood. Your patient is group B Rhesus-negative, They say this occurred because of a clerical error. What went wrong and what can you do?

19. Did this girl need a red cell transfusion? • Probably not • Young and basically healthy • IVIg or steroids generally produce good platelet responses in ITP • Condition was stable • Type and Hold would be appropriate

20. What lessons can we learn? Beware the signs and symptoms of a transfusion reaction ! In non urgent settings, red cells should not be transfused at night. Reassess after each unit of red cells – a single unit might be enough What about Rhesus sensitization?

22. HemolyticDisease of the Newborn (HDN) The Players Father Mother Baby

23. The Action Rhesus Hemolytic Disease of the Newborn Baby inherits red cell antigens from father that are "foreign" to mother Fetal red blood cells cross placental barrier and "sensitize" the mother with the production of IgG alloantibodies ( eg. D positive baby may stimulate production of anti D antibodies in Mum) IgG alloantibodies cross back to baby and may cause fetal red cell haemolysis

24. Worse Case – fetal hydrops

25. ABO Hemolytic Disease of the Newborn • usually mild hemolysis and jaundice within 24 hrs of delivery • most often occurs in babies who are group A with Mums who are blood group O • naturally occurring anti A antibodies cross the placenta • baby may have a positive DAT at birth – antibody identified as anti-A

26. Treatment ABO Incompatibility: Supportive Phototherapy Rhesus HDN: Close monitoring throughout pregnancy Intrauterine transfusion Early delivery Prevention: The use of Rhesus immune globulin prophylactically – anti D Immune globulin “WinRho” A Canadian discovery – 1968 Winnipeg

27. CASE 3 A man of 53 years receives 4 units of packed red cells during a right hemicolectomy. 5 days later, he becomes jaundiced, but the AST and ALT remain normal. His hemoglobin falls from 120 g/L over a 24 hour period to 83 g/L, and spherocytes are reported on the blood film. He was transfused with blood 3 months previously, and no problems were encountered. The patient is group O Rh-positive, and has received blood of that group only.

28. Delayed Hemolytic Transfusion Reaction (DHTR) How does this happen? Undetectable levels of antibody at pretransfusion testing (historical records are very important) Amnestic response within several days to weeks post transfusion Transfused RBCs have shortened life span

29. DHTR • Symptoms:Falling hemoglobin in absence of bleeding, jaundice, fever, 3 days to 2 weeks post transfusion • Lab: Positive antibody screen, positive DAT Consequences: Not usually serious, but rarely acute hemolysis can occur (Kidd antibodies). Must identify antibody so that subsequent units are negative for offending Ag

30. CASE 5 A 43 year old man presents with fever, cough, dyspnea, tachypnea, and a pulmonary infiltrate. Pneumocystis carinii pneumonia is diagnosed. He has a positive serological test for HIV. He received a number of blood transfusions 5 years previously during coronary artery bypass surgery. What are the chances of acquiring HIV infection through a blood transfusion? What other risk factors should you inquire about?

32. CURRENT CANADIAN BLOOD SERVICES TESTING • Donor screening and confidential self exclusion • ABO • Rhesus group • Screen for unexpected alloantibodies • Transmissible Disease Screen: • Syphilis • Hep Bs Ag / core antibody • HIV 1/2 • Hep C • HTLV I/II • West Nile Virus and CMV

33. Screening the blood supply • Hep B 1973 • Donor Screening 1984 • HIV 1985 • Hep C 1990 • HTLV 1990 • P24 Ag 1996 (d/c in 2003) • NAT 1999 • WNV 2003 As each new test is introduced the overall risk decreases

34. Current Transmissible Disease Risks Residual Risk of Infection/unit HIV 1/7,800,000 HTLV 1/4,300,000 HCV 1/2,300,000 HEP B 1/153.000 WNV 1/1,000,000 Malaria 1/400,000 Bacterial (red cells) 1/100,000 Bacterial (platelets) 1/10,000

36. West Nile Virus testing 2003 • July 2003, the CBS introduced a nucleic acid test for WNV across the country • Unprecedented rapidity of response to a new pathogen with a diagnostic test available for screening blood donors! • Risks for WNV unknown and a shifting scene.

38. Other Transmissible Disease Risks • Other hepatitis viruses • Epstein Barr Virus • Parvovirus • Creutzfeld-Jacob Disease • Malaria • Chagas disease

39. Other Adverse Reactions CASE 9 A woman of 46 years is transfused with red cells because of a severe anemia from marrow infiltration by breast cancer. Shortly before the end of the second unit, she develops a temperature of 38.5oC, and a rigor ensues. (a) What has happened? (b) What would you do about it? (c) Two weeks later she requires more blood. She expresses concern about a repetition of the same events. What would you tell her, and what would you do?

40. FEBRILE NON HEMOLYTIC TRANSFUSION REACTIONS • Very frequent adverse event • 2-3% of all transfusions • 5-30% of platelet transfusions • Chills, fever towards end of transfusion • Temp rise > 1 deg on 2 or more occasions

41. DIFFERENTIAL DIAGNOSIS OF FEVER DURING TRANSFUSION • FNHTR • Immune-mediated hemolytic reaction • Bacterial contamination • Preliminary hypersensitivity reaction • Fever due to underlying disease

42. FEBRILE NON HEMOLYTIC TRANSFUSION REACTIONS Mechanism I: Donor WBCs + antileukocyte alloantibodies in recipient Mechanism II: Bioreactive substances released into supernatant plasma during storage - Interleukins/other cytokines Treatment: Stop the transfusion and assess the patient Antipyretics - Acetaminophen Leukodepletion prestorage (now routine)

43. Allergic Reactions • Since the universal leukodepletion of blood, allergic reactions are now the most common reactions • Attributable to soluble substances in donor plasma which reacts with IgE antibody in the recipient. • Histamine release causes hives, itching, and rarely laryngeal edema Treatment: Stop transfusion, monitor carefully, antihistamines If symptoms resolve, resume transfusion If recurrent problem, may need to prophylactically treat with antihistamines

44. CASE 10   A child age 1 year has beta thalassemia major. It is decided to institute a regime of blood transfusion to maintain his haemoglobin at approximately 120 g/l. List the main potential adverse consequences of such a policy. What can be done to prevent them?

45. Complications of Chronic Transfusions • Iron overload • Alloimmunization • Transmissible disease risks

46. Bacterially Contaminated Red Cells and Platelets This is the oldest problem in blood banking Still is a problem Almost always unrecognized Patients develop sepsis for a number of reasons Blood is often not the suspect Other Adverse Reactions

47. Why Blood Components May Be Bacterially Contaminated: Bacteria in the donor’s blood due to unrecognized infection undiagnosed SBE Skin flora introduced at the time of phlebotomy Contamination introduced by processing

48. Diversion pouch implementation completed Feb./2004 Tubes Diversion pouch Skin fragment

49. OTHER ADVERSE REACTIONS Circulatory overload (TACO) • The very young or old, underlying heart failure, chronic anemia and an expanded blood volume • Identify patients at risk BEFORE transfusion. Transfuse slowly. Half units may be appropriate. Transfusion Related Acute Lung Injury (TRALI)

50. Case 12 • A 54 year old woman is admitted for a right total • hip replacement. General health is good and she • is only on medication for the pain associated with • osteoarthritis. Her hemoglobin post-op is 70g/L • and 2 units of blood are ordered. The first unit is • transfused uneventfully. Toward the end of the • second unit she becomes acutely short of breath. • A CXR shows bilateral infiltrates. Her oxygen • saturation is 85% on room air. • What is your differential? • 2. What is the likely outcome?