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Transfusion Reactions.ppt
- 2. Adverse Reactions Transfusion reactions are untoward events which could be mild to life threatening Majority uneventful 10% of transfusion recipients may suffer from untoward effects
- 3. Types of Transfusion Reactions Immune reactions Non immune reactions Immediate During or within few hours of transfusion Delayed Days or weeks after the transfusion
- 4. Immune Transfusion Reactions Due to : Patient Abs against donor Ags or vice versa Red cells White cells Platelets Reaction to plasma proteins
- 5. Immune Reactions Haemolytic Transfusion Reactions (HTR) Acute Delayed Febrile Non Haemolytic Transfusion Reactions Allergic / Anaphylactic reactions Allo-immunization TRALI (Transfusion Related Acute Lung Injury) TA-GvHD PTP (Post Transfusion Purpura) Immunomodulation
- 7. Hemolytic Transfusion Reactions Increased destruction of donor red cells Acute - Intravascular hemolysis ABO incompatibility – due to activation of complement cascade Delayed - Extravascular hemolysis Rh/minor grp.incompatible - IgG/C3d coated cells removed in RES
- 8. Causes for acute hemolysis Red cell incompatibility – ABO incompatibility Accidental heating or freezing of RBC Red cells in contact with water or 5% Dextrose Bacterial contamination Administering red cells through small gauge needle
- 9. ABO incompatible Transfusion Reactions Mainly due to misidentification of the patient Most occur in emergencies, in ICU, OTs In unconscious & anaesthetized patients
- 10. ABO Incompatibility Causes – Clerical errors – commonest cause Misidentification of pt / recipient Wrong samples / blood packs – Technical errors In Grouping of pt. / donor blood In crossmatching
- 11. Clinical Features Symptoms Signs Chills Fever Chest / back pain Rigors Headache Flushing Itching Tachycardia Palpitations Hypotension Dyspnoea Haemoglobinuria Nausea Oozing Vomiting Urticaria
- 12. INVESTIGATIONS IN HTR Samples 1. Pre- transfusion samples – stored upto 7 days 2. Post-transfusion blood sample 3. Post-transfusion urine sample 4. Blood bag with infusion set used
- 13. TRANSFUSION REACTION WORK UP Clerical Check records Pre transfusion Post transfusion Compatibility report Check labels Blood bag Blood samples
- 14. TRANSFUSION REACTION WORK UP Serological investigations Repeat blood grouping / cross matching Pre transfusion Post transfusion Donor Perform DAT Perform antibody screening
- 15. TRANSFUSION REACTION WORK UP Biochemistry Serum Bilirubin Urine – Hemoglobin / blood Microbiology Blood culture at 4o C, 22o C & 37o C from blood bag, tubing and recipient’s blood for bacteria & fungi
- 16. Management of AHTR (Acute HTR) Stop transfusion immediately Maintain an I.V. line Provide cardio respiratory support Ensure diuresis Maintain BP, HR and airway Collect first urine sample for haemoglobinurea Check the patient’s identification and the blood pack
- 17. Management of AHTR…. Report the reaction immediately to BTS Record Type of reaction Length of time Volume, type & unit number Send post transfusion sample of blood & remaining blood pack with filled reaction form to the BB Check any other pt. receiving blood transfusion
- 18. Delayed Hemolytic Transfusion Reaction (DHTR) Days or weeks after the blood transfusion Due to secondary immune response Rh or minor blood group Abs Extra vascular hemolysis
- 19. LABORATORY FEATURES – DELAYED HTR Fall in haemoglobin Appearance of new allo antibody Spherocytosis Positive DAT Antibody detected in eluate
- 20. Clinical Features of DHTR Gradual red cell destruction Occurs 5-10 days after transfusion Jaundice appear 5-7 days after transfusion Fall in Hb level Prevention - screening for alloAbs - selection of appropriate red cells
- 21. Non-hemolytic Febrile Transfusion Reactions (NHFTR) Definition Temperature increase of 1oC, rigors & tachycardia in the absence of any other demonstrable cause Clinical manifestations Fever /chills Nausea /vomiting Hypotension / shock Management Slowing of the infusion Antipyretic Leucocyte poor red cells
- 22. Non Hemolytic Febrile Transfusion Reactions (NHFTR) Due to – Abs in recipient against Ags of donor platelets or WBC o HLA Ags o Granulocyte specific Ags o Platelet specific Ags – Presence of cytokines in blood components More common in multi-transfused pts
- 23. Allergic / Anaphylactic Reactions Mainly due to plasma proteins Severity is variable o Mild – urticaria o Severe – anaphylactoid o Due to IgA deficiency o Occurs within minutes of commencing transfusion Common in pts with repeated plasma component therapy
- 24. Clinical Features Mild – urticaria to Severe - Anaphylactoid Cough Respiratory distress Bronchospasm Nausea, vomiting, diarrhea Circulatory collapse Hypotension & shock
- 25. IgA Deficiency Commonest isolated immunodeficiency Incidence is 1 : 1000 Anti IgA – reacting with transfused IgA Anaphylactic reaction Dramatic reaction with few ml. of blood or plasma Can result in death unless managed promptly
- 26. Management Mild – slow down rate & antihistamine Severe - Stop the transfusion Adrenaline – 0.5ml IM (1 : 1000), Antihistamine, Steroids Treat hypotension Prevention Transfuse at slow rate Use Washed blood Blood from IgA deficient donor Autologous blood transfusion
- 27. ADVERSE EFFECTS OF CONTAMINATING LEUCOCYTES HLAAlloimmunisation Platelet Refractoriness Graft Rejection Viral Transmission CMV EBV HTLV-I HTLV-II Immune Suppression Post operative infections Reactions Cancer Recurrence NHFTR GVHD Contaminating Leucocytes
- 28. Transfusion Related Acute Lung Injury (TRALI) 1:5,000 - 1:190,000 WBC antibodies in donor (occasionally in recipient) Respiratory failure hypotension bilateral pulmonary edema WBC Ab screen in donor/recipient WBC Xmatch, Chest X-ray Supportive care until recovery
- 29. Chest X-Ray in TRALI Bilateral pulmonary infiltrates in hilar region
- 30. Graft versus Host Disease (GVHD) Clinical Features Fever Diffuse erythematous rash Diarrhoea BM suppression – pancytopenia Infection Donor lymphocytes engraft, proliferate and attack recipient’s tissues
- 31. Rarely reported but almost always fatal More common in immunosuppressed patients In normal patients : first degree relatives HLA similarity between donor and recipient allows proliferation of donor lymphocytes More common with - restricted genetic pool eg. Japan - fresh blood TA-GVHD
- 32. Prevention of GVHD Irradiated blood 25 Gy
- 33. Post-transfusion purpura (PTP) Recipient platelet Ab (anti-HPA-1a,1b,3a and 5b) destroy transfused as well as autologous platelets More in multiparous women S/s: Thrombocytopenic purpura/ bleeding, 8-10d post- Tx Diagnosis: Platelet antibody screen and identification Treatment: IV Ig, HPA-1 -ve platelets, Plasmapheresis
- 34. Immunomodulation Tumour recurrence Increased risk of post operative infections
- 35. Non immune transfusion reactions Circulatory overload Heart failure, pulm. oedema Iron overload Iron deposit in tissues Chelation - Desperrioxamine Hyperkalaemia Hemolysed blood Septicemia TTI (Transfusion Transmissible Infections)
- 36. PREVENTION OF CIRCULATORY OVERLOAD Use packed cells Use small aliquots at a time Transfuse at slow rate Prop up the patient Keep patient warm Use diuretics
- 37. IRON OVERLOAD Excess iron deposits in tissues - organ failure, esp. heart and liver Management Iron chelation – S. ferritin < 2000 ug/L Desferrioxamine
- 38. Bacterial contamination I Infections caused by cryophylic bacteria: Pseudomonas aeruginosa, E.coli, Klebsiella II Infections caused by bacteria that grow at Room temperature (Contamination of blood and blood products) Staphlyococcus epidermidis and aureus, Serratia III Bacteria that rarely cause blood borne infections Yersinia, Salmonella, Campylobacter Rapid bacterial detection technologies
- 39. Clinical Features High grade fever Nausea, vomiting Diarrhea Abdominal cramps Haemoglobinurea Shock DIC
- 40. PREVENTION OF BACTERIAL CONTAMINATION Cleaning and sanitation – GMP Aseptic cleaning before phlebotomy Use sharp needle to avoid skin entering blood Use of bags with sampling pouch Use of heat sealer for sealing the tubing Storage temperature Do not enter bag before use /use segments Microbiological QC
- 41. PREVENTION OF TRANSFUSION TRANSMISSIBLE INFECTIONS Repeat regular voluntary donations Donor screening – Questionnaire /private interview Testing of donated blood Autologous blood Inactivation of virus/pathogen in blood products Judicious use of blood Alternatives to hemotherapy
- 42. RECORDS OF TRANSFUSION REACTIONS Records of all reactions Results of investigations Consequences and mortality Maintained for 5 years At the end of the year evaluated by hospital transfusion committee (HTC) Steps to prevent these reactions
- 43. Precautions to Avoid Transfusion Reactions Avoidance of clerical errors Proper identification of pt. Correctly labeled samples Proper identification of the recipient and the blood pack Careful & close observation of the pt. while transfusion Avoid unnecessary blood transfusion
- 44. Transfusion of Blood ??? Therapeutic Benefits of blood Tx o Improve O2 carrying capacity o Ensure hemostasis o Enhance resistance against infection Risks in blood Tx o Immunological risk o Infection risk o Procedural risk Prescribe only when the benefits clearly overweigh risks