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Safe and Appropriate Use of

Blood in Transfusion:
Focus on dyspnea & fever
complications
Djumhana Atmakusuma
Division of Hematology Medical Oncology,
Department of Internal Medicine
University - Indonesia
Dyspnoe during and after
blood transfusion

Anaphylaxis reactions:
Bronchospasm
TRALI: Dyspnea
Dyspnea TACO:
Dyspnoe
Non
Cough
productive Acute hemolytic
cough reaction
Bronchospasm
Resp Dyspnea
distress
Haemolytic Transfusion Reactions

Haemolytic transfusion reactions: acute and delayed

Acute reactions: fever and other symptoms/signs of


haemolysis within 24 hours of transfusion, confirmed
by a fall in Hb, rise in LDH, positive DAT and positive
crossmatch

Delayed reactions: fever and other symptoms/signs of


haemolysis more than 24 hours after transfusion,
confirmed by one or more of: a fall in Hb or failure of
increment, rise in bilirubin, positive DAT and positive
crossmatch not detectable pre-transfusion. Simple
serological reactions (development of antibody without
pos DAT or evidence of haemolysis) are excluded.
Simplified Complement
Pathway in Hemolytic
Reaction

IgM or complement-fixing IgG, Fixation of C5-9 complex pores /


either Anti-A or Anti-B, both holes on erythrocyte membrane
activate complement system water entering this canal
binding of components of C5- osmotic intavascular lysis
9 complement (membrane hemoglobinemia
attack complex) hemoglobinuria
Acute Hemolytic Reactions
Shock, hypotension , bronchospasm :
due to the generation of C3a dan C5a
anaphylatocine complement fragment, and other
inflammation mediators
Kidney ischemia Acute tubular necrosis (ATN)
renal failure due to nitric oxide binding to free Hb
Coagulation cascade are activated DIC
Clinical symptoms & signs are mostly caused by
activation of cytokine network: IL-1, IL-6, IL-8, TNF
febrile , hypotension , leukocyte activation and
coagulation cascade
Delayed Transfusion Reactions
Mechanism
Antibodies that exist in low titers prior to the transfusion
Typically to the Kidd or RH system
Upon reexposure, titer increases from memory B-cells
Clinical Picture:
Decrease in hgn, fever?, unconjugated bilirubin,
spherocytosis
Happens 2-10 days post transfusion
Delayed Transfusion Reactions
Treatment
As long as clinically mild, no treatment necessary
Monitor renal function, hgn
PREVENT it from happening the next time
REPORT TO THE BLOOD BANK
Acute Hemolytic Reaction is Suspected:
WHAT TO DO?
After Stop transfusion Determine: What kind
of complication? Clinically & laboratory ?
1. Observe VITAL STATUS: blood pressure, pulse,
respiratory rate, temperature
shock? prepare the emergency kit
support blood pressure / treat shock
2. Observe AIRWAYS need respiratory support?
3. See DIURESIS (urin output) renal failure?
need HD ?
4. SIGNS OF DIC bleeding or thrombosis ?
treat DIC
Table Workup of an acute transfusion reaction (1)
If an acute transfusion reaction occurs
1. Stop blood component transfusion immediately
2. Verify the correct unt was given to the correct patient
3. Maintain IV access and ensure adequate urine output with
an appropriate crystalloid or colloid solution
4. Maintain blood pressure and pulse
5. Maintain adequate ventillation
6. Notify attending physician and blood bank
7. Obtain blood / urine for transfusion reaction workup
8. Send report of reaction, samples, blood bag, and
administration set to blood bank
9. Blood bank performs workup of suspected transfusion
reaction as follows :
A. A clerical check is performed to ensure correct blood
component was transfused to the right patient
B. The plasma is visually evaluated for hemoglobinemia
C. A direct antiglobulin test is performed
D. Other serologic testing is repeated as needed (ABO, Rh, crossmatch)
Table Workup of an acute transfusion reaction (2)
If intravascular hemolytic reaction is confirmed :
1. Monitor renal status (BUN, creastinine)
2. Initiate diuresis; avoid fluid overload if renal failure is
present
3. Analyze urine for hemoglobinuria
4. Montor coagulation status (D-dimer, PT, aPTT, fibrinogen,
platelet count)
5. Monitor for signs of hemolysis (LDH, bilirubin, haptoglobin,
plasma
hemoglobin)
6. Monitor hemoglobin and hematocrit
7. Repeat compatibility testing (crossmatch)
8. Consult with blood bank physician before further transfusion
Table Workup of an acute transfusion reaction (3)
If bacterial contamination is suspected :

1. Obtain blood culture of patient

2. Return unit or empty blood bag to blood bank for culture


and Grams stain

3. Maintain circulation and urine output

4. Initiate broad-spectrum antibiotic treatment as appropriate:


revise antibiotic regimen on the basis of microbiological
results

5. Monitor for signs of DIC, renal failure, respiratory failure


How to prevent acute
hemolytic reactions or other
transfusion
complications ??
Avoid clerical reactions !!!
Avoid blood transfusion !!!
Dyspnoe during and after
blood transfusion

Anaphylaxis
reactions:
TRALI: Bronchospasm
Dyspnea TACO: Dyspnea
Dyspnoe
Non
Cough
productiv
e cough
Resp
distress
Acute transfusion reactions

Acute transfusion reactions are defined in this


report as those occurring at any time up to 24
hours following a transfusion of blood or
components, excluding cases of acute reactions
due to incorrect component being transfused,
haemolytic reactions, transfusion-related acute
lung injury (TRALI) or those due to bacterial
contamination of the component.
Transfusion Related Acute Lung Injury
(TRALI)

Transfusion Related Acute Lung Injury


was defined in this report as acute
dyspnoea with hypoxia & bilateral
pulmonary infiltrates during or within 6
hours of transfusion, not due to
circulatory overload or other likely cause.
Fever during or after blood
transfusion

Causes of fever ???


Febrile non
Hemolytic Acute Hemolytic
Bacterial Sepsis
Transfusion Reactions
Reactions (FNHTR)
Transfusion transmitted infections

A report was classified as a TTI if, following investigation:

The recipient had evidence of infection post-transfusion,


and there was no evidence of infection prior to transfusion
and no evidence of an alternative source of infection;
and, either
At least one component received by the infected recipient
was donated by a donor who had evidence of the same
transmissible infection,
or
At least one component received by the infected recipient
was shown to contain the agent of infection.
How to avoid bacterial
contamination ??
No inward blood storage !!!
No bedside blood warming !!!
(except in massive transfusion using blood
warmer)
TIME LIMITS FOR INFUSION

START INFUSION COMPLETE INFUSION

Whole blood/red cells Within 30 minutes of Within 4 hours (or


removing pack from less in high ambient
refrigerator temperature)

Platelet concentrates Immediately Within 20 minutes

Fresh frozen plasma Within 30 minutes Within 20 minutes


Febrile non-Hemolytic
Transfusion Reactions (FNHTR)
Febrile non-Hemolytic Transfusion Reactions
(FNHTR)
Definition of FNHTR:
- temperature rise of more than 10 C (1.80F)
- typically accompanied by chills and rigors
- occuring during transfusion or up to 6 hours
after transfusion has ended
- not attributable to another cause
DD/ Acute hemolytic reactions
Bacterial sepsis
Febrile non-Hemolytic Transfusion Reactions
(FNHTR)
Prophylaxis:
- Antipyretics: Acetaminophen as prophylaxis:-
evidence supporting the efficacy is
questionable

- Antihistamines: no role in prophylaxis (do not


prevent FNHTR)
Prevention of FNHTR
Prevention
Leukoreduction

Decrease storage time


= During storage platelets release CD40 ligand (CD154)
stimulate endothelial cells produce
prostaglandin E2 (simiar to pyrogen cytokines)
Leukocytes Reduced Blood
Components
1. Patients who have repeated febrile
reactions in associations with the
transfusion of RBCs or Platelets
2. As prophylaxis against alloimmunization for
patients whom intensive or long term
hematherapy is anticipated (Anemia
aplastic, Myelodisplastic Syndrome = MDS)
(patients who have received frequent transfusions &
females who multiple pregnancies may become
alloimmunized to leukocyte antigens)
Leukocytes Reduced Blood
Components (LRBCs)
3. Still controversy: clinical studies LRBCs are
as effective in preventing transmission of
CMV infection
(as are blood components obtained from CMV-seronegative
donors) in Indonesia ???
4. Prospective randomized studies:
the use of LRBC lowers the incidence of
wound infections in selected surgical patients
Leukocytes Reduced Blood
Components (LRBCs)
5. LRBCs:
= not indicated to prevent post transfusion
graft versus host diseases (GVHD) (cases of
GVHD have been reported after LRBCs use)
6. Irradiation of blood products: approved for
the prevention of post transfusion GVHD
Blood transfusion in Patients with Allogeneic
Bone Marrow Transplantation
Leukocytes Reduced Blood
Components
A decision to use leukocyte reduced
RBCs or leukocyte reduced Platelets
prophylactically in effort to prevent
alloimmunization
should be made BEFORE the FIRST
blood transfusion
LRBCS: - PRCs Bedside filter
- Platelets Bedside filter
Thrombapheresis
Donor Apheresis
Donor Thrombapheresis
Non remunerated, voluntary donors

Donor Plasmapheresis c
ommercial donors plasma products (factory: human
albumin, Factor VII, IX, VII concentrate, IvIg, anti rhesus,
etc)
Apheresis Platelets Reduce
Patient Exposure to Multiple
Pooled
Pooled platelets
Donors
platelets contain
contain platelets,
platelets, plasma,
plasma, and
and
many
many white
white cells
cells from
from 6-8
6-8 donors
donors
Apheresis
Apheresis platelets
platelets contain
contain platelets,
platelets, plasma,
plasma, and
white
white cells
cells from
from only
only one
one donor
donor

Apheresis
Apheresis Platelets:
Platelets: Pooled
Pooled Platelets:
Platelets:
One
One Donor
Donor 6-8
6-8 Donors
Donors
Single donor platelets
(Thrombapheresis}
Reduced Plasma volume burden more
plasma , more complications (eg.TACO, TRALI)

Leuco-Reduced Platelets to prevent


alloantibodies which result in refractory to
platelet transfusion
Matched platelets for refractory patients to
increase response rate to platelet transfusion
Increase mean time between transfusions

Leuco-Reduced Platelets to prevent febrile


non-hemolytic transfusion reactions
(FNHTR)
Leuco-Reduced Platelet to prevent CMV
transmision