NON INFECTIOUS TRANSFUSION REACTIONS

CLASSIFICATION Transfusion reaction acutedelayed ImmunologicNonimmunologic

A. Hemolytic transfusion reactions (HTR)  Accelerated clearance or lysis of red cells in the transfusion recipient. Usually d/t immunological incompatibility b/w blood donor and the recipient A. C LASSIFICATION WITH RESPECT TO TIME OF OCCURRENCE  Acute (AHTRs ) During or within 24 hours of transfusion  Delayed ( DHTRs ) After 24 hours of transfusion.( 5-7 days )

Signs and Symptoms of Acute HTR Inder GA Hypotension Hemoglobinuria (This may be masked in patients undergoing GU surgeries due to hematuria) Undue bleeding from surgical site Abrupt onset Nausea, Vomiting AnxietyShock Facial flushing Oliguria Fever, chills Hemoglobinuria Pain in back or flanks Bleeding Dyspnoea Under GA Conscious patient

Complications of AHTRS Renal failure :- 36 % Thrombus formation in renal arterioles DIC :- 10 %

Immediate Mx of suspected AHTRs A. Action for nursing staff In presence of fever > 38 0 C and / or any S/s Stop the transfusion Stop the transfusion Check the pt identity and unit transfused Check the pt identity and unit transfused Save any urine the pt passes Save any urine the pt passes Monitor pulse, BP and temp at 15 min interval Monitor pulse, BP and temp at 15 min interval

Immediate Mx of suspected AHTRs B. Action for medical staff 1. Isolated fever / fever & shivering, stable observations, correct unit given :- FNHTR = Paracetemol 1 g orally, observe P, BP and T every 15 min for 1 hr, then hourly. If no improvement call hematology medical staff

Immediate Mx of suspected AHTRs 2. Fever with pruritis, urticaria :- Allergic transfusion reaction = Chlorpheniramine 10 mg iv 3. Any other s/s, hypotension, incorrect unit :- AHTR = discontinue transfusion, N saline to maintain urine output 1ml /kg / h. full and continuous monitoring

Mx of AHTRs  Take immediate note and inform blood bank  Seek help immediately from skilled anaesthetist or emergency team  Complete the transfusion reaction form and appropriately record the following Type of transfusion reaction Type of transfusion reaction Time after the start of transfusion to the occurrence of reaction Time after the start of transfusion to the occurrence of reaction Unit No. of component transfused Unit No. of component transfused Volume of the component transfused Volume of the component transfused

Send the following lab investigations: Immediate post transfusion blood samples (clotted and EDTA) for:  Repeat ABO & Rh (D) grouping  Repeat antibody screen and crossmatch  Direct antiglobulin test  Complete blood count (CBC)  Plasma hemoglobin  Coagulation screen  Renal function test (urea, creatinine and electrolytes)  Liver function tests (bilirubin, ALT and AST) Blood culture in special blood culture bottles Blood unit alongwith BT set Specimen of patient’s first urine following reaction Investigation of suspected AHTRs

Other reactions characterized by hemolysis 1. Pts with autoimmune hemolytic anemia 2. Donor units m/b hemolysed due to Bacterial contamination Bacterial contamination Excessive warming Excessive warming Erroneous freezing Erroneous freezing Addition of drugs or iv fluids Addition of drugs or iv fluids Trauma from extracorporeal devices Trauma from extracorporeal devices Red cell enzyme deficiency Red cell enzyme deficiency

Maintain adequate renal perfusion by -Fluid challenges -Frusemide infusion -If hypovolumic – dopamine infusion Transfer to high dependency area Repeat coagulation and biochemistry screens ever 2- 4 hrly Repeat coagulation and biochemistry screens ever 2- 4 hrly If urinary output not maintained seek expert renal advice Hemofiltration or dialysis m/b required for acute tubular necrosis DIC development – component therapy may be required Mx of confirmed AHTRs

Due to secondary immune responses following re-exposure to a given red cell antigen -Ab most commonly involved – Rh, Kidd, Duffy and Kell -No clinical signs of red cell destruction but positive DAT -Rarely fatal DELAYED HEMOLYTIC TRANSFUSION REACTIONS

Sign and symptoms - fever - fever - fall in Hb concentration -Jaundice and hemoglobinuria Mx -Requires no Tt. -Hypotension & renal failure – may require expert medical advice DELAYED HEMOLYTIC TRANSFUSION REACTIONS

Diagnosis & Management Routine examination Routine examination Stop Tx immediately Stop Tx immediately Monitor vital signs, urine out put Monitor vital signs, urine out put Verify identification of the patient Verify identification of the patient IV line kept open with NS IV line kept open with NS Evaluate for evidence of HTR, septic shock, anaphylaxis Evaluate for evidence of HTR, septic shock, anaphylaxis TRALI other D/D fever Report and send transfusion set to B/B Report and send transfusion set to B/B Diagnosis of exclusion

Blood Bank: Recheck the records for clerical error check for identification error Visual check for hemolysis, appearance of returned unit Evidence of blood group incomparability Pre Tx sample Post Tx sample ABO,Rh group DCT ICT Repeat CxM Gram stain, culture HLA, Plt, Granulocyte specific Abs in recipient

Treatment Antipyretics Antipyretics acetaminophen ; mg orally (adult) 10-15mg/kg (children) (adult) 10-15mg/kg (children) Meperiedine Meperiedine severe chills mg IV contraindication: renal failure Pts on MAO inhibitors Pts on MAO inhibitors Antihistaminics: not indicated Antihistaminics: not indicated Tx should not be restarted for 30 min. Tx should not be restarted for 30 min.

D. URTICARIAL AND ANAPHYLACTIC REACTIONS - Usually mild allergic reactions Treatment - Non systemic reaction = focal urticaria / angioedema : Antihistamine - Mild systemic = chest tightness, generalized urticaria / angioedema : Antihistamine, salbutamol and / or inhaled steroid

URTICARIAL AND ANAPHYLACTIC REACTIONS Moderate systemic = wheeze / breathlessness / obstructive laryngeal oedema : All above including prednisolone, consider adrenaline Severe systemic = Severe breathing difficulty, shock arrhythmias, loss of consciousness : Adrenaline im and all above

E. BACTERIAL CONTAMINATION Most common microbiological complication of transfusion Higher incidence after platelet transfusion Higher incidence after platelet transfusion

Apparent infrequency of clinical events of ba cterial contamination Non pathogenic bacteria - Insufficient no. of bacteria - Premedication with steroides - Pts already on antibiotics - Immunosuppressed pts underinvestigated

Clinical features - usually appear immediately during transfusion - S/t symptoms delayed until after the end of transfusion - - fever ( inc > 2 o C ) - - chills / rigors - Hypotension, collapse, shock - Nausea, vomitting - DIC, intravascular hemolysis, renal failure

Management - Stop transfusion. Retain unit for investigation - Give general supportive Tt (iv fluids, inotropic agents, diuretics to maintain urine output ) - Broad spectrum antibiotics until blood culture report comes - Assess need for intensive care bed

How to Prevent Errors in the Transfusion Chain  Where in the process do errors occur?  Who is making the errors?  Why are the errors occuring – which elements of good transfusion practice are failing Sample Error Technical Error Wrong Blood Issued Issued Storage Error PatientMisidentificationAdministrativeError

Error Prevention in the Transfusion Services  Adherence to Standard Operating Procedures (SOPs) for pre-transfusion testing  Antibody screen in patients at risk of alloimmunization; preferably universal screen  Antibody identification when required  Appropriate storage and transfusion instructions on labels  Clerical checks prior to issue

Prevention of transfusion reaction Education and training of nurses health care assistants, doctors at every level Education and training of nurses health care assistants, doctors at every level Proper communication at all level should be appropriate, timely and effective. Proper communication at all level should be appropriate, timely and effective. Promoting the knowledge in hospital, raising awareness by having more educational sessions and poster available to hospital Promoting the knowledge in hospital, raising awareness by having more educational sessions and poster available to hospital