1. CRITICAL ACTIONSMSMENISUSTAINIMPROVE Pt greets new doctor, “I was feeling weak for several weeks. Now I’m feeling chills since transfusion started.” Recognize AHTR—classic triad: F, flank px, dark urine PC1- 2 Stop transfusion, check name & type, return blood to lab and order repeat T&C PC5- 2 BP drops to 80/40 at ~5 mins. Pt states, “I’m feeling kind of bad now, really dizzy”. Vigorous supportive care— Repeat VS, O2 mask, 2 nd line, pressure bag, lay pt flat PC1- 3 Hydrate with NS @ 100-200 mL/h. GOAL: UOP 100-200 PC5- 2 Start low dose pressor for hypotension (DA > NE?) PC5- 3 If pressor not started by ~10 mins, pt’s BP drops to 70/30. If not started by ~13 mins, pt goes asystolic arrest. Order labs– Coombs, plasma free Hb, haptoglobin, LDH, DIC panel PC3- 2 Alert blood bank for second pt at risk SBP 2-2 Admit to ICU, Heme consultPC7- 3 TOTAL SCENARIO ALGORITHM SET UP Sim man & monitor; BP cuff & leads on Critical—Blood labeled with “Mrs. Jones—A+”, foley w/ dark urine, IVF, pressor gtt, O2 mask Additional—Crash cart incl intub equp Confederates—Resident plays signing out doc, transitions to nurse BACKGROUND “Mrs. Smith” is a stable sign-out, admitted to medicine, leaving ED in 10’ Dx– LGIB 2/2 colon CA; H/H 6/18 Feels weak otherwise stable Blood is hanging (she’s O-) CURRENT SITUATION HR 100, BP 100/60 (MAP 73) Receiving A+ blood Patient reports she feels chills Nurse verifies T 101.5 SCENARIO PROGRESSION BP drops to 80/40 w/ HR 110 at 5 mins If low dose pressor started, then BP stabilizes If pressor not started, BP drops to 70/30 w/ HR 120 at 10 mins If pressor not started, BP disappears and patient goes asystolic at 13 mins Does not recover w/ ACLS LABS & IMAGES NET 10 mins Coombs test +, plasma free Hb 35 Hapto 0, LDH 1000 H/H 20/6.5 END CASE NLT 15 mins Dispo to ICU Simulation Training Assessment Tool (STAT)– Acute Hemolytic Transfusion Reaction Date: 27 MAR 13Instructor(s): Learner(s): Learning Objectives: 1. Recognize acute hemolytic transfusion reaction (AHTR) 2. Manage AHTR appropriately 3. Respond appropriately to systemic error of wrong blood transfusion

2. Admission Labs WBC 6.5 Hb 6.0 Hct 18 Plt 270 Na 139 K 5.0 Cl 102 HCO3 24 BUN 25 Cr 1.1 Glu 105

3. iSTAT – Na 140 – K 5.2 – Cl 100 – iCa 1.20 – TCO2 28 – Glu 105 – BUN 26 – Cr 1.3 – Hct 20 – Hb 6.5 – AnGap 18 Hemolysis Labs Coombs test + Plasma free Hb 50 mg/dL – Ref range 1-4 mg/dL Haptoglobin 0 – Ref range 5-20 mg/dL LDH 1000 – 50-150 U/L Urine hemoglobin +

4. VasopressorMechanismIndicationsDosing Norepinephrine (Levophed) Action on alpha-1 and beta-1 receptors produces potent vasoconstriction Hypotension/ShockInitial: 8-12 mcg/min; titrate to effect. Usual maintenance range: 2-4 mcg/min. Post cardiac arrest care0.1-0.5 mcg/kg/min (7-35 mcg/min in 70 kg pt); titrate to effect Sepsis and septic shock0.01-3 mcg/kg/min (0.7-210 mcg/min in 70 kg pt)– range from clinical trials Phenylephrine (Neo- Synephrine) Purely alpha-adrenergic agonist activity results in vasoconstriction with minimal cardiac inotropy or chronotropy Hyperdynamic sepsis (low SVR + high CI  “warm sepsis”) Neurologic disorders Anesthesia-induced hypotension 100-500 mcg/dose Q10-15 mins prn Epinephrine (Adrenalin)Potent beta-1 adrenergic receptor activity and moderate beta-2 and alpha-1 adrenergic receptor effects Most often used for anaphylaxis Second line for septic shock Hypotension s/p CABG 0.1-0.5 mcg/kg/min (7-35 mcg in 70 kg pt); titrate to effect Dopamine (Intropin)Activates dopamine-1 receptors in renal, mesenteric, cerebral and coronary beds No proven indication1-2 mcg/kg/min Stimulates beta-1 adrenergic receptors and increases cardiac output w/ variable effects on heart rate 5-10 mcg/kg/min Stimulates alpha-adrenergic receptors and produces vasoconstriction with increased SVR Second line to norepinephrine in patients with absolute or relative bradycardia 10-20 mcg/kg/min Dobutamine (Dobutrex)Predominant beta-1 adrenergic effect increases inotropy and chronotropy and reduces LV filling pressure Severe, medically refractory heart failure and cardiogenic shock Should not be used in sepsis due to vasodilatory effects 2.5-20 mcg/kg/min, max 40 mcg/kg/min; titrate to effect Isoproterenol (Isuprel)Primarily inotropic and chronotropic, acts on beta-1 receptors Bradyarrythmias, AV block, refractory Torsades de Pointe Limited utility in hypotensive pts 2-10 mcg/min; titrate to effect

5. Acute hemolytic transfusion reaction Results from infusion of incompatible RBCs Transfused RBCs are destroyed by pre-formed antibodies – Usually anti-A or –B, but also anti-Rh, anti-Jka that are capable of fixing complement Signs and symptoms include fever, chills, flank pain, hemoglobinuria, shortness of breath May progress to shock, DIC, respiratory failure, ARF NB– Delayed hemolytic transfusion reaction is an entity

6. Acute hemolytic transfusion reaction Treatment Stop transfusion Brisk hydration to avoid acute renal injury – Goal= UOP 100-200 cc/h Vigorous supportive care while labs pending confirmation Labs Free hemoglobinemia and hemoglobinuria Haptoglobin is decreased (binds to free hemoglobin) Coombs testing of pre- and post-transfusion blood – Test for globulin antibodies on the surface of RBCs

7. Febrile nonhemolytic transfusion reaction – Most common transfusion reaction – Manifests with fever and chills May be hard to distinguish from early acute hemolytic reaction Must stop transfusion and rule out hemolysis – Treat with antipyretics & antihistamine while labs are pending No evidence to support pre-treatment – Caused by interleukin release from leukocytes Leukoreduction is an effective preventive therapy – 40% of patients with one FNHTR will have another? – 75% of PRBC in US are pre-reduced

8. Allergic Transfusion Reactions – Range from minor to anaphylaxis – Due to plasma protein incompatibilities – Erythema, urticaria, pruritus, bronchospasm, vasomotor instability – Reaction severity is not dose-related – Treat urticaria with antihistamines – Discontinuation of transfusion is not always required

9. Delayed Transfusion Reactions Delayed hemolytic transfusion reaction Infections – Severe bacterial infection Platelets 1:50,000 PRBCs 1:500,000 – Risk of hepatitis B = 1:200,000 – Risk of hepatitis C or HIV = 1:2,000,000 – Risk of West Nile virus and Creutzfeldt-Jakob disease is unknown Transfusion Related Acute Lung Injury (TRALI) – Pulmonary edema due to incompatibility of passively transferred leukocyte antibodies – 50% of transfusion related deaths Other transfusion-related risks – Volume overload – Hypothermia