Blood Transfusion tutorial

1. Blood Transfusion tutorial MBBS Curriculum IOD II Dr Dupe Elebute Consultant Department of Haematology

2. Case Presentation 1 • A patient with Aplastic Anaemia arrived for hertwice weekly infusion of platelets • On receiving the platelets from theblood bank and checking the unit theproduct appeared to be “greenish” in colour • The unit was checked and wascorrect for this particular patient • 15 minutes into the transfusion she collapsedand the transfusion wasstopped What is the diagnosis? What actions would you take?

3. Case 1: Actions taken • Platelet transfusion stoppedimmediately • ABC • Given hydrocortisone 100mg IV andpiriton 10mg IV • Started on IV broad-spectrum antibiotics • Platelets returned to the lab andcultured • Culture of platelets: Bacillus Cereus

4. Case 1: Actions taken • Returned unit to NBS; unit re-cultured and also grew Bacillus Cereus • NBS recalled the 3 donors of theplatelet pool and swabbed thedonors’ arms • One ofthe swabs also grew Bacillus Cereus • NBS reviewed technique for swabbing of arms ofdonors and implemented new national guidelines

5. Acute transfusion reactions Acute haemolytic transfusion reaction due to ABO incompatible blood or bacterial contamination • difficult to differentiate clinically • causes: • acute intravascular haemolysis • shock • acute renal failure • DIC • extremely serious, can be fatal

6. Management of AHTR A medical emergency: • Stop transfusion immediately • Keep line open with N/Saline using new giving set • Monitor pulse, BP, temp • Call member of medical staff • Check identity of patient against blood bag • Take urgent blood samples: FBC, cross-match, U & Es, clotting screen, blood cultures • Save any urine • Send blood unit back to the blood bank

7. Febrile non-haemolytic transfusion reactions • ‘Allergic’ reaction caused by white cells in blood bag • Symptoms: • Fever • Urticaria • Anaphylaxis (rarely) • Management: Hydrocortisone and Piriton • Very rare in UK now following universal leuco-depletion of red cells (vCJD initiative)

8. Case Presentation 2 • A 45 year old was admitted for hysterectomy • Normal blood count preoperatively • Received three units of blood perioperatively • Pale and jaundiced on the 10 day postoperatively • What is the diagnosis? • What haematological tests would you request?

9. Delayed haemolytic transfusion reactions Due to secondary immune response following re- exposure to a red cell antigen • Patient previously sensitised to a red cell antigen by transfusion or pregnancy • Antibody not detected on routine screening for X-match • Patient given transfusion with blood containing same antigen • Provokes an anamnestic (secondary immune) response • Within days, antibody level rises and transfused red cells removed from circulation

10. Delayed transfusion reactions: 2 • Occurs 24hr after transfusion (7-10 days) • Causes extravascular haemolysis • Red cells destroyed in liver, spleen; occurs slowly • Few clinical signs: fever, anaemia, jaundice • Investigations: • Coomb’s test positive • Re-testing of patient’s serum will now detect antibody • In future, patient must be transfused with antigen negative blood

11. Case Presentation 3 • A woman is bleeding profusely post partum • On examination, she is agitated, sweating and cold to the touch • What would you do first ? • What baseline haematological tests are indicated ? • How should she be managed ?

12. Massive blood loss • Medical emergency • Loss of one blood volume within 24 hour • 50% blood volume loss within 3 hours • Rate of blood loss  150ml/min • Any blood loss >2L (SGH) • Usually occurs in A&E, operating theatre or obstetric department • High morbidity & mortality

13. Massive Blood Loss (2) • Ensure adequate venous access • Attempt to maintain blood volume with saline, plasma expanders • ‘Flying squad’ blood (O Rh Neg, CMV neg) available if blood required in 15 minutes

14. Complications of Massive Transfusion • Hypothermia  acidosis • Hyperkalaemia: K+ leaks out of red cells during storage • Citrate toxicity: red blood cells kept in citrate plus additive solution (SAG-M) • Hypocalcaemia: Ca2+ ions bound by citrate • Depletion of platelets and coagulation factors • Fluid overload  acute respiratory distress syndrome (ARDS)

15. Case 3 • A health care assistant collected a unit of blood from the bloodbank fridge without taking any means of identification • The checking of the unit was undertaken only with thecompatibility slip and the blood unit at the nurses station • The patient was blood group B • Within 15 minutes of thetransfusion thepatient had received 50 mls ofGroup A blood • Within 30 minutes the patient became unwell What errors have occurred in the transfusion process?

16. Case 3: errors that occurred • HCA took no means of formalidentificationto collect the unit of blood • No other means of identificationwas taken for checking the unit of blood • No bedside check took place (must be done by 2 trained staff) • No checking of the wrist band

17. O † Errors in transfusion Wrong blood to wrong patient 1:3 ABO incompatible 1:10 fatal Fatal errors in approx 1: 600 000 (UK, USA) Non-fatal 1:12000 B blood  :

19. Further reading • Essential Haematology • ABC of Transfusion (BMJ books) • HMSO Handbook of Transfusion Medicine • SGH handbook of blood transfusion • policies and procedures