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adverse effects of transfusion.ppt
- 2. TRANSFUSION TRANSMITTED DISEASES ACUTE HEMOLYTIC TRANSFUSION REACTIONS TRANSFUSION RELATED ACUTE LUNG INJURY ANAPHYLAXIS
- 3. HIV HBV HCV •HTLV •CMV •EBV •HHV-8 HAV HEV Parvovirus B 19 SEN Torque Teno Virus •DENGUE •LCMV •SFV •WNV •COAGULASE NEGATIVE STAPH,S.AUREUS.B.CEREUS •SERRATIA •YERSINIA •ENTEROBACTER •E COLI •PSEUDOMONAS PRIONS TREPONEMA PALLIDUM BORRELIA •PLASMODIUM •BABESIA •LEISHMANIA •T.CRUZI •RICKETTSIAE
- 4. Questionairre MANDATORY TESTS HIV HBV Malaria Syphilis HCV
- 5. Serological Assays (Ag/Ab/both) *ELISA/ CHEMILUMINISCENCE IMMUNOASSAY Rapid Card Test Molecular Assay(DNA/RNA) Nucleic Acid Test Rapid antigen card test & Peripheral smear for malaria RPR(Rapid Plasma Reagin) for syphilis
- 6. Enzymatic reaction associated with immune complexes. Enzyme may be linked to either the antigen or the antibody. Types Indirect Competitive Sandwich Capture Solid Phases Base & sides of polystyrene well Nitrocellulose Membrane Enzyme substrate combinations Horseradish peroxidase +o-phynxylencdiamine dihydrochloride (OPD) and TMB Alkaline phosphatase +4-nitrophenylphosphate
- 8. Antigens are attached on the solid phase support allowing antibodies in the specimen to bind and these bound antibodies are subsequently detected by enzyme labeled AHG and specific substrate. If test specimen contains antibodies, color reaction takes place. Indirect ELISA Enzyme labeled AHG Solid phase antigen Test antibody It is most commonly used system
- 9. Antigen bound to the solid phase binds antibody in the test specimen in first step. Since antibody molecules are bivalent they are still able to bind to another molecule. Next similar enzyme labeled viral antigen if added, will attach to the antibody molecule, already bound to the solid phase antigen with one arm. Thus sandwich of antigen-antibody-enzyme labeled antigen complex is formed. Addition of substrate results in development of color which is measured by ELISA reader. Solid phase antigen Test antibody Enzyme labeled antigen Sandwich ELISA Higher sensitivity& specificity Detects all types of antibody HbSAg
- 10. Simple single-use assays Robust and easy to use Test time in minutes Minimal or no equipment Minimum technical skill Electricity free Used as supplementary Immunochromatography Immunoconcentration Particle agglutination
- 11. Window period HIV HBV HCV Gap from Infection to antibody (days) 22 56 70 Gap from Infection to NAT 2 9 2 Reduced by NAT (days) 10- 15 32 – 45 41 – 60 Period between entry of virus and detectability by laboratory test
- 12. HBV-1:1 lakh HCV-1:5 lakh HIV-1:10 lakh Malaria -5-50/million
- 13. Avoid unnecessary transfusion Use of latest screening technology in blood bank Careful donor selection Vaccination if available in risk population
- 14. ABO grouping & Rh typing Slide,tube,gel,microplate,glass bead Major Crossmatching Tube Method , Gel Card , Slide Method Saline Crossmatch AHG crossmatch
- 15. DCT ICT Antibody sceening panel Antibody elution in AIHA Alloantibody identification
- 16. Starts from the request for transfusion History Patient blood group(Forward & Reverse) Patient antibody screening Donor red cell unit selection(already grouped and labelled) Group specific Confirm donor blood group Crossmatch –Major (IS & AHG;only IS for emergency) Labelling of blood/components with recipient id Issue
- 17. Info in the request must match with the sample Signed by the doctor Date Full name of the patient DOB Age Hospital number(UNIQUE IDENTIFIER) Ward & bed number Patients address
- 18. Identifiers-Name Age IP Number Clinical diagnosis Blood group if known Presence of any antibodies Obstetric history History of previous transfusion History of transfusion reaction No of units & the component required Date & time when required Type of request( emergency/routine/group& screen)
- 20. Final check of ABO compatibility To detect Ab in pts serum that reacts with donor RBC but not with reagent screening cell panel Comprehensive check for any antibody Irregular antibody-non A non B(Anti kell,anti kidd etc) Major cross match is done(Recipient plasma with donor red cell) Minor not routinely done
- 21. When no clinically significant unexpected Ab are detected & no previous records of such antibodies Mix the recipient’s serum & donor RBCs and centrifuging immediately (i.e., immediate spin). Absence of hemolysis or agglutination – compatibility 99% effective in preventing HTR,1 % chance to miss
- 22. Begins as IS crossmatch, continues to a 37C incubation, and finishes with AHG test To detect IgG antibodies Complete crossmatch Takes time
- 23. Hemolytic Transfusion Reactions Allergic Reactions Anaphylactic/Anaphylactoid Febrile Non Hemolytic Transfusion Reactions TRALI(Transfusion Associated Lung Injury) TACO(Transfusion Associated Circulatory Overload) Bacterial Contamination Air embolism-now rare
- 24. Transfusion Transmitted Diseases Transfusion Related Immuno Modulation RBC alloimmunisation Delayed Hemolytic Transfusion Reaction Post transfusion Purpura Iron over load TA GVHD
- 25. Antigen antibody reaction Mismatched blood group Donor Antibodies-Rare Dangerous O Hemolysing irregular Ab
- 26. Lysed RBCs transfused Chemical Adding drugs inline Thermal freezing Overheating Non approved warmers Mechanical Needles Rollers Pressure infusion pumps Storage contamination
- 27. Fever Chills Urticaria Flushing Pain at transfusion site Chest/back/flank/abd pain Nausea ,vomiting,dyspnoea Oliguria Hemoglobinemia Hemoglobinuria Generalised bleeding Hypotension DIC
- 28. STOP KEEP IV OPEN HYDRATE WITH SALINE PROTECT KIDNEY WATCH FOR DIC
- 29. Stop and do not restart PROMPT IDENTIFICATION AND TREATMENT Send the unit and sample to BB Liberal fluids-saline for hypotension and RBF Keep urine flow rate 1ml/kg/hr Furosemide 40-80 mg IV(1-2mg/kg) Mannitol (20%) 100ml/ M2 given over 30-60 min, then 30 ml/M2/hr for next 12 hrs. Low dose dopamine(1-5microgram/mt) Inotropic cardiac Improve renal blood flow Limited trials Antipyretics ,anti histamines ,hydrocortisone
- 30. No response ? NO URINE OUTPUT after 1 litre infusion Suspect ATN,Pt may be at risk of Pulm.oedema Consult nephro-Dialysis may be needed Watch for DIC,hyperkalemia(oliguric RF),cardiac arrest,metabolic acidosis. Exchange Document
- 31. Difficult to treat Traditional therapy- Remove cause Supportive care-platelets,FFP,cryo Heparin ? Underlying condn CI Ppting factor different from usual cases Self sustaining vicious cycle? Large amount of incompatible cells(happens in OT) Red cell exchange with antigen negative cells-consult blood bank.
- 32. Bag and tubes –BB R/o clerical errors Group,cross match and antibody screening DCT Urine Hb PS,S.Bilirubin,plasma Hb,Haptoglobulin,LDH- additional evidence of hemolysis
- 33. Follow the guidelines for administration www.bcshguidelines.com Recheck details-pt ID,blood group etc Know the history Inspect BE THERE at least 15 mts Stop if in slightest doubt Many others…… Heating Storage
- 34. Allergic-1 in 33 to 1 in 100 FNHTR-1 in 100 Anaphylactic -1 in 20,000 to 50,000 HTR-1 in 12,000-20,000 TRALI-1 in 5000-10,000 TACO-1 in 150
- 35. Type 1 immediate hypersensitivity reaction Immediately after transfusion Atopic individuals more prone Histamine and leukotriene mediated MILD ALLERGIC SEVERE systemic ANAPHYLACTIC
- 36. IgE antibodies in recipient react with proteins in transfused plasma IgE antibodies in donor Reacts with proteins in recipient plasma Rarely due to chemicals in bag/tubing
- 37. Mild Localised rashes(hives)-mainly upper trunk and neck Erythema Pruritus NO fever usually Severity increase with successive episodes Note the timing and drugs-often creates confusion Document the reaction Rule out Hemolytic Transfusion Reaction-contact BB if in doubt
- 38. Transfusion temporarily discontinued IV /oral antihistaminic Diphenhydramine 25-50mg PM/CPM Resume within 30 minutes in presence of doctor Develops generalised urticaria,hypotension,facial /laryngeal edema -discontinue Adrenaline if needed
- 39. Premedication with anti histamine(oral/parenteral) -only for those with >2 episodes of allergic reactions May be donor induced Masks some hemolytic symptoms 25-50 mg Pheneramine/diphenhydramine half to 1 hr before transfusion if found ineffective -hydrocortisone 100 mg Remove plasma by washing from other products(RBC,Platelets)
- 40. Rapid Serious Life Threatening Transfusion of few ml is enough Systemic nature and severity differentiates from allergic
- 41. Anaphylactic Allergen in plasma reacts with Ig E in recipient Anaphylactoid Allergen in plasma reacts with non IgE antibodies in recipient
- 42. The best documented reason for anaphylactoid reactions IgA deficient individuals-1 in 700 Reaction frequency lower- 1 in 20,000-50,ooo Mechanism –antibodies against IgA in recipients body Other protein deficiencies Complement VwF Haptoglobin
- 43. URTICARIA GENERALISED ITCHING PRURITUS ANGIOEDEMA COUGH HOARSENESS OF VOICE STRIDOR ,RESPIRATORY OBSTRUCTION WHEEZING, CHEST TIGHTNESS CRAMPS NAUSEA VOMITING DIARRHOEA HYPOTENSION TACHYCARDIA ARRYTHMIA CARDIAC ARREST •IMMEDIATE DRAMATIC ONSET •SYSTEMIC& CUTANEOUS SYMPTOMS •OTHER CAUSES SHOULD BE RULED OUT INVESTIGATIONS NOT MUCH,MAINLY CLINICAL Β TRYPTASE LEVELS IgA LEVELS SKIN RESPIR ATORY ABDOMI NAL CARDIAC
- 44. STOP the Transfusion,should not RESTART Medical emergency Same for anaphylactic and Anaphylactoid Adrenaline .3-.5 ml , 1:1000 s/c or IM Severe hypotension,laryngel edema/resp.failure IV 1:10000 Oxygen,B agonist &/theophylline Maintain BP Trendelenberg Fluids, Dopamine CONSIDER COINCIDENTIAL OCCURRENCE MyocardiaI Infarction? PulmonaryEmbolism? Or something else?
- 45. Saline washed blood components- RBC&Platelets Plasma Transfusion -only If unavoidable Only IgA deficient plasma should be given to IgA deficient individuals Screen the family members WHAT TO DO WITH NON IgA DEFICIENT RECURRENT SEVERE ANAPHYLACTICS?
- 46. Increase in body temperature of 1ºC or more During or within several hours of transfusion Unrelated to hemolysis, sepsis, or other known causes of fever. Frequency 1 in 100
- 47. Early in transfusion or delayed Fever Chills and Rigors Important d/d –bacterial contamination,HTR RARELY…….. HYPOTENSION TACHYCARDIA TACHYPNOEA,DYSPNOEA,CYANSIS AND COUGH LEUKOPENIA
- 48. 1.Antibodies in recipient plasma (usually anti HLA) Acts against transfused HLA carrying cells- Lymphocyte,Granulocyte,platelets. Cytokine Release 2.Antibodies in donor plasma-Rare Acts agains recipient cells Cytokine release 3.Infusion of Cytokines already accumulated in plasma during storage. •H/O BLOOD TRANSFUSION •H/O PREGNANCY
- 49. Transfusion discontinued IV line kept patent Antipyretics –Paracetamol ANTIHISTAMINES Are not of Use-most FNHTRs doesn’t involve histamine release Restart ?Yes –only once if mild and other causes ruled out • Try another unit
- 50. Leucoreduction Prestorage is better 5 x 107 leukocytes needed If LR facility is not there-washing/volume reduction Premedication with ANTIPYRETIC to ease the patient but masks the hemolytic symptoms
- 51. 50-250 fold more risk than TTD Important cause of transfusion morbidity and mortality Immediate or hours later,depends on the load Maximum with platelets-PC and PRP(room temperature) 1 in 1000 Staph epidermidis Bacilleus cereus
- 52. Fever Chills Rigor Tachycardia Hypotension Low back pain SHOCK DIC SEND THE UNIT FOR GRAM STAIN- MAY NOT PICK UP CULTURE BLOOD CULTURE OF PATIENT
- 53. Delay in diagnosis if symptoms occur hours later Start IV antibiotics and other supportive treatment
- 54. FNHTR IHTR BACTERIAL CONTAMINATION FEVER,CHILLS FEVER,CHILLS FEVER,CHILLS Mild to moderate subside with antipyretic All invg.NEGATIVE ANTI HLA Ab + Mild to Severe MAY NOT RESPOND DCT + Ab screen positive Mild to severe May not respond to antipyretic Evidence of Hemolysis GRAM STAIN CULTURE + See the product Other recipients
- 55. Non cardiogenic Pulmonary edema 1 in 5000 to 10,000 5-10% fatal SIMILAR TO ARDS RDP WBC APHERESIS FFP CRYO GRANULO
- 56. A /c respiratory insufficiency and sudden deterioration in lung function Hypoxemia PaO2/FIO2 <300 mm Hg During /within 6 hrs of transfusion X ray findings suggestive of b/l pulmonary oedema No evidence of cardiac failure/circulatory overload No other risk factors for ALI Disproportionate to the volume of blood used
- 57. Chest tightness Breathlessness Dry cough Tachypnoea Tachycardia Hypotension Widespread creps on chest auscultation Nausea Dizziness fever -may develop later Rigor -not always Copious frothy tracheal exudate on suction Like lightly whipped egg white Hall mark of severe TRALI CHEST X RAY Nodular Shadowing BAT’ WING pattern (ARDS) Hypoxia Hypercapnea Leukopenia Anti HLA antibody Normal BNP PA occlusion Pressure less
- 58. Antibodies in donor react with recipient antigens HLA class 1 or 11 HNA-neutrophil antigens Antgens on Monocytes /pulmonary macrophages/Platelets Antibodies in Recipient reacts with donor antigens
- 59. COMPLEMENT • Direct lung injury C3 a C5a • Histamine and serotonin released from basophils &platelets LEUCO AGGLUTIN ATES • Clog the pulmonary capillary bed CAPILLARY DAMAGE AND LEAK ↓ INTERSTITIAL EDEMA OF LUNG ↓ FLUID IN ALVEOLAR SPACE ↓ TRALI
- 60. 2 HRS 24 HRS TRALI
- 62. In all A /c pulmonary reactions transfusion should be stopped TRALI-Should not be restarted even after symptoms abate Correct hypoxemia O2 therapy Ventilatory assistance if necessary Symptomatic Most patients recover within 2-4 days
- 63. Leuco reduced products No need of special products if donor induced-may not recur Donor tracing-hence reporting is important HLA crossmatch/antibody detection
- 64. More risk in Cardiac insuffi ciency, Renal impairment, Chronic anemia. Restricted blood volumes-neonates Elderly More risk with rapid infusion
- 65. Dyspnoea Orthopnoea Tachypnoea Tachycardia Hyper tension Crepitations Raised JVP ECG changes
- 66. Stop the transfusion. If transfusion is critical use the slowest possible rate Sitting position Diuretics-(frusemide 40 mg) O2 as needed
- 67. Rapid transfusion -into a patient who is not actively hemorrhaging produces no benefit and can cause Harm Infusion should be at a rate not to exceed 2 to 4 mL/kg/hour Patients at high risk of circulatory overload. Rate should be lower (1 mL/kg/hour) Furosemide can be given prophylactically Aliquoting can be tried Centrifugation and plasma removal
- 68. FEATURE TRALI TACO BODY TEMPERATURE FEVER NO FEVER BLOOD PRESSURE HYPOTENSION HYPERTENSION RESPIRATORY SYMPTOMS A/C DYSPNEA A/C DYSPNOEA NECK VEINS UNCHANGED DISTENDED AUSCULTATIONS RALES RALES,S3 CHEST RADIOGRAPHS DIFFUSE B/L INFILTRATES DIFFUSE B/L INFILTRATES P/A OCCLUSION PRESSURE <18 mm Hg >18mm Hg RESPONSE TO DIURETICS MINIMAL SIGNIFICANT WHITE CELL COUNT TRANSIENT LEUKOPENIA UNCHANGED BNP <200 pg/ml >1200 pg/ml LEUKOCYTES DONOR LEUKOCYTE ANTIBODIES PRESENT MAY/MAY NOT BE PRESENT
- 69. Immune mediated reaction-delay 24 hr if possible –circulating immune complex If unavoidable try under premed.
- 70. Increased Recurrence of Resected Malignancies Increased Risk of Postoperative Bacterial Infection
- 72. Stop the transfusion Keep IV line open with saline call BB and r/o clerical error Try to diagnose the cause Mild ?allergic/FNHTR R /o identification error Restart within 30 mts if suspected allergic& do not re start in case of suspicion Manage according to provisional diagnosis
- 73. Name,IP,Ward,Unit History of previous transfusions Time of reception,time of transfusion Amount of transfusion Reaction occurred at----hrs Signs and symptoms Clinical diagnosis of patients original disease Investigations sent Enclose 3 cc plain and EDTA samples from a different limb
- 76. Patients and bystanders Where to go? Whom to ask?
- 77. Blood bank should store adequate amount of safe blood to cover emergency needs of the population covered. 100% of this stock should be collected from Volunteer donors
- 83. Cancer Accident Delivery Surgeries Burns Blood Disorders Pediatric ALL BLOOD GROUPS ARE PRECIOUS!!! 0.5 million in Kerala!!!
- 86. Is my blood safe? No diseases No harmful medicines No drugs No alcohol DONATE ONLY SAFE BLOOD
- 88. Voluntary Donor-The best Replacement Donor Professional Donor Altruistic Nothing to hide Less chance of diseases Coercion Compulsion Obligation BANNED
- 89. Number of voluntary blood donors per 1,000 population Switzerland-113 Japan- 70 India -8 Only if 1-2% of our population donates, scarcity will disappear Why don’t we have a voluntary donor pool like most of the developed countries? Barriers Communication gap Lack of coordination Lack of Health awareness Demand at Trivandrum district-350 units of whole blood/day
- 90. Prepare yourself
- 91. Should be able to donate 350ml/450 ml of blood without any problem to donor/recipient
- 92. Good Health on the day of donation Age 18-55 yr (NACO latest guideline 18-65 yr) Hemoglobin minimum 12.5g% Minimum 45 kg weight Should have had meal within 4 hours
- 93. Continuous sleep at least 6 hours Minimum Gap between last blood donation 3 months for males 4 months for females High BP>140/90 mm Hg(latest NACO) Low BP <100/60 mm Hg Pregnancy,lactation,Menstruation
- 94. Major Surgery-1 yr Minor Surgery-6 months Blood Transfusion-1 yr Typhoid –1 year Dengue/Chikunguniya-6 months Jaundice -1 yr or lifetime(at medical officers discretion) Vaccinations-Various periods Anti Rabies and Hep B Ig-1 yr
- 95. Cold /sore throat /cough : No On antibiotics – No Active wound –No Recent diarrhoea/abdominal pain-No
- 96. Once tested positive for HIV,Hepatitis B or C HIV related symptoms High risk History Serious illnesses-heart,liver,lung,kidney,cancer etc Bleeding disorders Polycythemia vera(very high Hb)-blood donation as a treatment only.Not used for donors
- 97. Weight Fluid intake Hb should be qualified Change your Dietary preferences Iron rich foods may help if u have low Hb Avoid strenous activity before/after No smoke/alcohol A proper meal is mandatory in 4 hrs
- 99. Sleep well;at least 6 hrs in previous night Take a bath if possible Relax !! Can go as a group first time If u need someone to stand by,tell
- 100. Any high risk history Any recent drugs Vaccinations within one year Any discomfort(symptoms) recently Please do not give wrong information If tested positive ever for diseases Severely ill or injured people are counting on you to be honest
- 101. What will happen there? Will it take much time? Will I faint? Will I be tired? Can I go to gym? Will parents get offended?
- 102. 350 ml /450 ml blood (<7% of total blood volume) Plasma and platelets replenished in 48 hours Red cells in 56 days
- 103. Very beneficial for those with high hemoglobin >16g% Iron levels are balanced-protective against stroke/heart attack(moderate) Mini check up regularly Rejuvenation of cells;new cells are released from the store in bone marrow But Above all……..SATISFACTION
- 105. 16 G 6-8 mts
- 106. Keep the bandage for a few hours Drink lot of fluids Do not lift heavy weights with the donated arm Avoid strenuous exercise;heights Do not smoke Call if you don’t feel well
- 107. Not Having food/sleep properly Not taking adequate rest after donation in the couch Less fluid intake/getting dehydrated Premature removal of dressing/rubbing the area/excessive use of the arm Clothes with very tight sleeves Alcohol intake prior to donation(24 hrs) Avoid high fat meal just before donation
- 108. All the time watching your blood being collected is not advised Prolonged standing in queues etc after donation Heights
- 109. Always give feed back Improvement is possible Keep connected Update
- 111. For Young people aged 18–25 Pledge to give 20 donations of blood before the age of 25 Lead healthy lifestyles to protect both themselves and the recipients of their blood from HIV and other infectious agents.
- 112. Youngsters are the Best blood donor pool! Encourage your friends Help them to overcome their fears Reassure Set an example Stand by them Convince their parents Appreciate them Teach them healthy habits Stay connected with us!!! SIMPLY WALK-IN;DON’T WAIT FOR A CALL!