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

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Presentation on theme: "بسم رب نور. Prevention & Management of transfusion reaction Dr.sh.sharifi 20-21 th feb 2008."— Presentation transcript:

1 بسم رب نور

2 Prevention & Management of transfusion reaction Dr.sh.sharifi 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 min,then 30 ml/m2/hr for text 12 hours;furosemide(adults 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: u/kg,(unfractionated heparin)and infusion u/kg/hr to keep heparin level 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 Distribution of Errors in IBCT Category (2004 Report) Serious Hazards of Transfusion Reporting Scheme

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 Be extra vigilant when checking the identity of the unconscious / compromised patient Check this information against the patient’s ID wristband

21 Sampling Procedure EXAMPLE REQUEST FORM 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 ANY HOSPITAL MACDONALDMORAG ITU ANAEMIA 11/07/1956 NOT KNOWN E

22  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 Sampling Procedure

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 Component  Red blood cells  Platelets  Fresh Frozen Plasma  Cryoprecipitate  Storage

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

26 Collection Procedure Ensure prompt delivery of the blood component to the clinical area 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

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

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

31 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 Administration Procedure

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

33 Documentation Procedure 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 EXAMPLE COMPATIBILITY/TRACEABILITY LABEL Ensure donor component number is recorded on the transfusion documentation Complete documentation for every blood component transfused G N MACDONALD MORAG 11/07/19566 FEMALE 25 HILL STREET TOWN CENTRE E G N 20/12/2006 Red Cells O Rh POS G 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 : 1.Diagnosis 2.Selection of appropriate therapy 3.Transfusion management 4.Prevention of future transfusion reaction. Investigations should include correlations of clinical data with laboratory result. Important clinical data : 1.Diagnosis 2.Medical history of pregnancies, transplant, and previous transfusion. 3.Current medication 4.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 Incompatible Transfusion Hours Plasma HEMOGLOBIN Haptoglobin Urine Hemoglobin Serum bilirubin

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 )


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