130330980 Probleme La Transfuzii

8/22/2019 130330980 Probleme La Transfuzii

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Blood Bank

Labsite

Frequently

Asked

Questions

(FAQ's)

Post

Transfusion

Instruction

Form

Circular of

Information for

Blood and Blood

Components

(pdf)

Preface

Table of

Contents

1: General

Information...

2: Providing

Blood to OR...

3: Emergency

Use...

4: Blood

Components...

5: Utilization

Review...

6: Transfusion

Procedures...

7: Adverse

Reactions...

8: Transfusion

& Apheresis...

MSBOs

Ant icoagu lan ts

Abbrevi at ion s

Phone Num bers

& Minimum

Samples

Component &

Compatibility,

Flow Rates

Updated 9/25/06

Version July 2004, Revised 11/5/08, 3/16/09, 11/12/09

7 ADVERSE REACTIONS TO

TRANSFUSION

Any adverse reaction to the transfusion of blood or blood components should be reported to Blood Bank personnel as soonas possible.

Speed is essential in such situations because of the possible life-threatening nature of acute transfusion reactions. Theevaluation of all adverse reactions to transfusion is the responsibility of the medical staff of the Blood Bank and thenotification of such a reaction by the patient unit serves as a request for Blood Bank physician consultation.

The Blood Bank is required to report any death resulting from transfusion to the Food and Drug Administration.

Reactions may be separated into reactions that present in proximity to the transfusion and those that present at some timesubsequent to the transfusion. Suspected post-transfusion disease, which may present at a considerable time fol lowingtransfusion, must also be reported to the Blood Bank. Investigation of these reports may result in identification of "carrier"

donors who are removed from the donor pool

A Blood Bank physician should be consulted regarding the evaluation of patients with reactions, as well as selection ofappropriate blood components for future transfusion.

In the case of a mild urticarial and febrile reactions, with no other signs or symptoms attributable to blood transfusion, itmay be possible to reinitiate the blood transfusion Such a decision must be arrived at through consultation between thephysician reporting the reaction and a Blood Bank physician

Premedication for Recipients of Granulocytes

It is suggested that patients receiving granulocytes who have a history of febrile reactions to blood components be pretreatedwith antipyretic agents if there are no contraindications to the use of these drugs. See Febrile Transfusion Reactions. Ingeneral, transfusion of Granulocytes should be terminated only for such complications as severe flank pain, chest pain,hemoglobinemia and hemoglobinuria, hypotension, laryngospasm, or acute pulmonary injury.

Reaction Type Symptoms Cause Frequency Prevention

Acute HemolyticReaction

Fever, chil ls and fever, thefeeling of heat along the veinin which the blood is beingtransfused, pain in the lumbarregion, constricting pain inthe chest, tachycardia, hypo-tension, and hemoglobinemiawith subsequent hemoglo-binuria and hyperbilirubin-emia.

A "feeling of impending

doom" is frequently reportedby the patient as an early signof this reaction.

In an unconscious or anesthe-tized patient: Uncontrollablebleeding due to disseminatedintravascular coagulation maybe the only sign of ahemolytic transfusion reaction

Human error such asmislabeledpretransfusionspecimen; thetransfusion of properlylabeled blood to thewrong person, orclerical errors occurringwithin the Blood Bank

transfused red cellsreact with circulating

antibody in therecipient with resultantintravascular hemolysis

Most likely to occurwhen a group O patientis mistakenlytransfused with groupA, B, or AB blood.Patients receiving amajor ABO-incompatible marrowor stem cell transplantwith sufficient red cell

content will likelydevelop an acutehemolyti c reaction

Rare proper identificationof patients,pretransfusion bloodsamples and bloodcomponents at thetime of transfusion

DELAYED the most common signs are a Many delayed Uncomon

Pagina 1 din 6Chapter 7: ADVERSE REACTIONS TO TRANSFUSION

23.10.2011http://www.pathology.med.umich.edu/bloodbank/manual/bbch_7/index.html


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HEMOLYTICREACTIONDelayedHemolytic Reaction

Notify the BloodBank at the time thereaction issuspected, to allowpromptinvestigation. Caremust be taken thatsubsequentlytransfused red cellslack the antigencorresponding to thepatient's antibody.

falling hematocrit (due toextravascular destruction ofthe transfused red blood cells)and a positive directantiglobulin (Coombs) test(DAT).

"delayed" hemolytic reactionscommonly occurs about 4-8

days after blood transfusion,but may develop up to onemonth later. There may alsobe hemoglobinuria and a mildelevation of the serumbilirubin. . Symptomaticpatients may manifest feverand leukocytosis thusappearing to have an occultinfection.

hemolytic reactionswill go undetectedbecause the red celldestruction occursslowly

Delayed hemolyticreactions occur inpatients who have

developed antibodiesfrom previoustransfusion orpregnancy but, at thetime of pretransfusiontesting, the antibody inquestion is too weak tobe detected by standardprocedures. Subsequenttransfusion with redcells having thecorresponding antigenresults in an anamnesti cantibody response andhemolysis of transfusedred cells.

Febrile fever or chill fever Atemperature rise of1.8 For1.0 C from the baseline

Cytokines andantibodies to leukocyteantigens reacting withleukocytes or leukocytefragments

1 in 8transfusions

Allergic- urticaria allergic reactions may beassociated with laryngealedema and bronchospasm.

If coupled with another sign,such as fever, evaluation for ahemolytic reaction may beindicated.

this reaction is causedby foreign plasmaproteins

1% of recipients

Allergic-Anaphylaxis

anaphylactic or anaphylactoidRespiratory involvement wi thdyspnea or stridor may bemore pronounced than isusuall y seen in typical all ergicreactions.

Reactions manifestcardiovascular instabili ty thatincludes hypotension,tachycardia, loss ofconsciousness, cardiacarrhythmia, shock and cardiacarrest.

may be due to anti-IgA Rare

TRALI abrupt onset ofnoncardiogenic pulmonaryedema Severe cases mayrequire assisted ventilationwith high FIO2..

TRALI has beenassociated with thepresence of antibodiesin the donor plasmareactive to recipientleukocyte antigens orwith the production ofinflammatory mediatorsduring storage ofcellular bloodcomponents

TRALI i s a rarethough underrecognizedcompli cation oftransfusion

Most cases of TRALIresolve within 72hours althoughfatalities may occurin approximately 10percent of cases.

Volume Overlead transfusion-relatedvolume overload

Infuse smallervolumes more slowly

BacterialContamination

hypotension, shock, fever andchills, nausea and vomiting,and respiratory distress.

Diagnosis is established byGram stain and blood cultureof both the blood componentand the recipient.distress

Bacterial contaminationoccurs when a smallnumber of bacteria

enter a bloodcomponent duringcollection orprocessing.. During

rare but dif fi cultto detect prior totransfusion

Autologousblood may becontaminatedwith bacteria,




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storage, bacteria mayproliferate, resulting ina large number oforganisms, and possibleendotoxin, being givenwith the transfusion

particularly if thepatient had anactive infectionat the time ofdonation.

Hypotension A drop of at least 10 mm Hgin systolic or diastolic arterial

blood pressure in the absenceof signs or symptoms of othertransfusion reactions

if the immediatepretransfusion blood pressureis elevated from the patient stypical blood pressure, andthe arterial pressure does notfall below the patient s usualblood pressure, it should notbe considered a hypotensivereaction. The onset ofhypotension is during thetransfusion, and resolvesquickly with discontinuationof the transfusion.

If hypotension persistsbeyond 30 minutes afterdiscontinuing the transfusion,another diagnosis should bestrongly considered.

Some reactions havebeen associated with

angiotensin convertingenzyme (ACE)inhibitor drugs or theuse of leukocytereduction filters.

Hypotensive reactionshave been associatedwith red cell andplatelet transfusions.

Graft-vs-HostDisease GVHD

rash, fever, diarrhea,cytopenia and liverdysfunction 3-4 weeks aftertransfusion

viable T lymphocytesin blood componentsare transfused, engraftand react against therecipient's tissues andthe recipient is unableto reject the donorlymphocytes because ofimmunodeficiency,

severeimmunosuppression, orshared HLA antigens

associated with bonemarrow transplantation.Transfusion associatedGVHD occurs. Ittypically. Transfusionassociated GVHDcarries a very poorprognosis.

Rare Irradiation of cellular components

The Blood Bankmust be apprised ofthe immune status, ordiagnosis, of thepatient so thatcellular components

intended fortransfusion ofimmunocompromisedpatients and bloodcomponents fromdirected (designated)donors will beirradiated. Irradiationof blood red cellcontainingcomponentsdecreases the red cellsurvival andincreases thepotassium of thecomponent. There isno apparent effect onplatelet survival.Fresh Frozen Plasma(FFP) andcryoprecipitatedAHG (CRYO) neednot be irradiatedbecause thesecomponents do notcontain enoughviable l ymphocytesto cause GVHD.

Non-immuneHemolysis

hemoglobinemia andhemoglobinuria Transienthemodynamic, pulmonary andrenal impairment may occur.

cardiac arrhythmia due toyyperkalemia may occur,particularly in patients withrenal failure.

Lysis of red cells canoccur due to improperstorage, handling, ortransfusion conditions.

mishandling or storageof blood components

Rare




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IF A TRANSFUSION REACTI ON IS SUSPECTED

Stopthe transfusion immediately!

Disconnect the intravenous linefrom the needle. Do not disconnect the unit from the IV set. Attach a new IV set and primwith saline, or flush the line with the normal saline used to initiate the transfusion and reconnect the line. Open the line toslow drip. In certain cases, such as a mild urticarial reaction or the presence of repeated chill-fever reactions, it may bpossible to restart the blood transfusion after evaluation and treatment of the patient. To reinitiate the transfusion using a neIV tubing set, enter the second port to reduce the chance of bacterial contamination.

Seek medical attention immediately. If the patient is suffering cardiopulmonary collapse, and medical attention is noimmediately available, press the blue "Code" button andtelephone the Cardiac Arrest Team (dial 911).

Check to ensure that the patient name and registration number on the blood bag label exactly with information on thpatient's identification

wristband attached to his/her wrist. DO NOT BYPASS THI S STEP BY ASSUMI NG THAT THE PATIENT'S TRUIDENTITY I S KNOWN.

Do not discard the unit of blood that has been discontinued because it may be necessary for the investigation of thtransfusion reaction.

Notify the Blood Bank that a transfusion reaction has occurred and briefly describe the nature of the reaction.

Blood Bank personnel wi ll identify the Pathology House offi cer or staff pathologist who wi ll assume responsibil ity forinvestigation of the reaction.

Delay the transfusion of additional units until the possibi lity of serological i ncompatibil ity has been investigated. Consult aBlood Bank physician if there is an urgent need or transfusion.

Initiate the Transfusion Reaction Report Form after Blood Bank personnel have been notified of a transfusion reaction. It isessential that this form be filled out completely, including the unit numbers of all blood transfused. The form will serve as awritten request for investigation of the reaction by a Blood Bank physician.

In the case of a suspected hemolytic transfusion reaction(not urticaria alone), the following items should be submittedpromptly to the Blood Bank:

completed Transfusion Reaction Form(white copy)

posttransfusion blood specimens(Adults: 7 mL Pink top tube, lesser volumes for pediatric patients), and

incriminated unit(s) of blood and attached tubing.

Restarting a Transfusion If the Blood Bank physician, after review of the clinical information, believes the transfusion can brestarted, do not disconnect theunit. Thismay apply to patients who might manifest urticarial reactions or repeated chil l-fever reactions.

the contents of theblood bags areavailable for study. Theblood bag together withattached tubing andintravenous fluidsshould be saved forfurther investigations.

Post-transfusionpurpura (PTP) thrombocytopenia that isfrequently profound, purpura,or bleeding

Febrile reactions have beenreported retrospectively withthe implicated transfusion

thrombocytopenia typicall y 7-48 days after transfusion

PTP must be differentiatedfrom the far more commonalloimmunization to plateletantigens. Consultation with aBlood Bank physician isrecommended in evaluating

such patients.

the patient makes analloantibody inresponse to plateletantigens in thetransfused blood thatfor a period of timecauses destruction ofautologous antigennegative platelets

Rare Platelet transfusion isof very little value inPTP; however,therapeutic plasmaexchange may bebenefi cial Sinceautologous plateletsdo not survive incirculation, there isno expectation thattransfused plateletsregardless of antigenmatching will do anybetter.

Reserved platelettransfusion for

patients with activebleeding.




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Additional blood specimens may be requested, depending on the serological findings. The venipuncture to obtain theseblood specimens must not be traumatic. Small lumen catheters should not be used to collect blood specimens for atransfusion reaction investigation. If red cells are hemolyzed during the venipuncture or collection, the serum will turn pinkand it may be erroneously concluded that intravascular hemolysis has occurred.

The IV tubing used to transfuse the blood components should be clamped and sentwithout the needle attached. A urinesample is not required for the routine evaluation of a transfusion reaction, but may be requested by the Blood Bankphysician in the course of f urther assessment.

Patient care personnel will be notified by telephone of significant findings of the reaction evaluation as soon as possible. A

written report of the investigation, on the Blood Transfusion Reaction Form, will be returned to the patient care unit at alater date for inclusion in the patient's chart.

TREATMENT OF TRANSFUSION REACTIONS

The following guidelines should be tailored to suit individual cases.

Reaction Type Treatment - Adult Pediatric Follow-up

AcuteHemolyticReactionsAcuteHemolyticReactions

Diuretic therapy:Initially, give 40-80mg Furosemide (Lasix) intravenously.This dose can be repeated once. Lackof response to furosemide in 2-3 hoursindicates the presence of acute renalfailure.

Pediatric dose: 1-2mg/kg/dose. Mayrepeat once at 2-4mg/kg.

Treat shock and disseminatedintravascular coagulation withappropriate measures if and when theyappear.

Water loading:The patient should behydrated to maintain urinary output ofat l east 100 mL/hr until urine is free ofhemoglobin.

Infuse a loading dose of 0.9% sodiumchloride or 5% dextrose in 0.45%sodium chloride. Chart hourly urineoutput. Maintain the urine output byadministering intravenous fluid at 100mL/hour until the urine is free ofhemoglobin. I f the patient's urinaryoutput does not increase, with thishydration any additional f luids shouldbe infused with caution.

Pediatric patientsshould receive asmaller loadingvolume of fluid inproportion to theirbody surf ace area.

DelayedHemolyticTransfusionReactions

Specific treatment generally is notnecessary

Supplemental transfusion of bloodlacking the antigen corresponding to theoffending antibody may be necessary tocompensate for the transfused cells thathave been removed from the circulation.

AllergicTransfusionReactions

Antihistamines(e.g., Benadryl). Give50-100 mg orally or intravenously. Ifurticaria develops slowly,antihistamines may be given orally.

Pediatric dose: 1-2mg/kgintramuscularly orintravenously for 25-50 mg per averagedose.

Routine use of Benadryl aspremedication for all transfusions,regardless of a history of allergicreactions, is discouraged.

Aminophyllinefor wheezing, at adose of 125-250 mg intravenouslyslowly over a period of about fiveminutes

Pediatric dose: 3mg/kg/dose inintravenous drip overof 20 minutes.

Epinephrine for severe, acutereactions including laryngeal edema orbronchospasm Give 0.1-0.5 mg (0.1-0.5 mL of a 1:1000 solution)subcutaneously. Subcutaneous dosemay be repeated at 10-15 minuteintervals. The total subcutaneous dosein a 24-hour period, with rareexception, should not exceed 5 mg.

Pediatric dose: 0.03mL/M2 (0.03 mg/M2of a 1:1000 solution)given subcutaneously.A single pediatricdose should notexceed 0.3 mg.

FebrileTransfusion

Reactions

Premedicate the patient withacetaminophen or other antipyreticagents when previous reactions havebeen extremely bothersome. Pediatricdose: 10 mg/kg to a maximum of 600

mg.

Aspirin will adversely affect the patient'splatelet function, so non-aspirinantipyretic agents are preferable.

Severe shakingchills

(rigors) can be controlled by thesedative effect of Benadryl or Demerol(25-50 mg given intramuscularly or

Note: Demerol may cause acuterespiratory arrest. An opiate antagonist(Narcan) should be immediately




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POSTTRANSFUSION DISEASES

All cases of suspected posttransfusion disease transmission encountered among inpatients or outpatients, in anycontext, must be reported to the Blood Bankso that they can be investigated. This allows the Blood Bank to notify theregional blood supplier so that blood donors who are thought to be infectious can be excluded from the list of eligibledonors.

Because of the risk of posttransfusion infection, the benefits associated with blood transfusion must always be weighedagainst possible risks.

Units of blood and blood components transfused in the University of Michigan Hospitals are obtained from volunteerdonors. Screening tests are performed on all units, including those obtained from designated/directed donors.

Current testing: syphilis, HBsAg, antibodies to HIV-1/2, Hepatitis C virus, anti-HBc and HTLV-I/II, as well as, nucleic acidtesting (PCR) for HIV, hepatitis C virus and West Nile Virus.

Additional tests for transfusion transmitted disease wil l be implemented in response to federal or accrediting agencyregulations or changes in the standard of care. Unfortunately, no specific screening test is currently available to detect allforms of hepatitis.

Under extremely rare circumstances it may be necessary to transfuse blood or a blood component to a patient before theabove screening tests for disease transmission have been completed. In such situations, the physician treating the patient willbe made aware of the available options by Blood Bank medical staff and will be informed of the test results as soon as theyare avail able.

Units of blood negative for anti-CMV can be provided for selected patients undergoing allogeneic bone marrowhomotransplantation. CMV safe components may be provided through the use of leukocyte-reduced cellular bloodcomponents.

Guidelines for treatment of hospital personnel who have accidentally inoculated themselves with blood are available inEmployee Health Service and Emergency Services.

Look Back Notification

When donors of previously transfused units are found, at a subsequent donation, to be positive for HIV, hepatitis C, HTLVor other diseases as determined by the public health service, the Blood Bank is required by federal regulation to notify thepatient. We usually wi ll noti fy the patient s physician for assistance in contacting the patient. This process is known as "lookback".

Version July 2004

intravenously available.

Sepsis Due toBacterialContaminationof Donor Blood

Treatment of septic shock includes:terminating the suspected transfusionimmediately, cardio-vascular andrespiratory support, blood culture ofthe patient, and administration ofbroad spectrum antibiotics includinganti-pseudomonas coverage if the

blood component involved is RedBlood Cells.


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