blood transfusion is a very important topic for healthcare professionals

Blood transfusion

1. CONTENTS Whole blood and blood components What is blood transfusion? Blood transfusion- Types, Indications Pre transfusion testing Transfusion Reactions: Classification Causes Clinical features Investigations

2. WHOLE BLOOD AND BLOOD COMPONENTS 350ml /450 ml of blood is collected from a donor is called 1 unit /pint of blood Whole blood can be used as it is, or is separated into “blood components” Red blood cell concentrate (packed red blood cells) Platelet concentrate Fresh frozen plasma Cryoprecipitate

3. BLOOD TRANSFUSION Transfer of blood or blood components from one person (donor) into another person (recipient)

4. TYPES OF BLOOD TRANSFUSION FRESH BLOOD TRANSFUSION Blood less than 24 hours old from the time of collection AUTOLOGOUS TRANSFUSION Blood collected from a patient for re-transfusion at a later time into the same individual MASSIVE TRANSFUSION Number of units transfused in a 24 hours period exceeds the recipient’s blood volume MULTIPLE TRANSFUSION Repeated transfusion of blood over a long period of time (months or year)

5. INDICATIONS OF BLOOD TRANSFUSION Whole Blood : Acute blood loss Shock Exchange transfusion in neonate Packed red blood cells: Chronic severe Anemia Leukemia Thalassemia Platelets concentrate : Thrombocytopenia Major surgeries

6. INDICATIONS OF BLOOD TRANSUSION (CONT….) Fresh frozen plasma : Liver disorders DIC Coagulation factor deficiency (V, VII) Cryoprecipitate : Hemophilia A Fibrinogen deficiency

7. SELECTION OF DONOR Free from all diseases No h/o of any transfusion for last 3 months Phsically healthy (age btw 18-65) Hb above 12gm/100ml No h/o of any recent surgeries

8. B LOOD GROUPS AND TYPES The determination of blood groups is based on the presence or absence of A and B red cell antigen The most important grouping for transfusion purpose is the ABO system , which includes A,B,O,AB blood types

9. THE Rh FACTOR Other consideration is the Rh factor , which is an antigenic substance in the erythrocyte of most people A person with the factor is Rh positive and a person without the factor is Rh negative

10. BLOOD GROUPING

11. PRE-TRANSFUSION TESTING ABO and Rh (D) blood grouping : Patient’s and donor’s blood sample Cross matching of blood sample: Major cross match- Pt’s serum + Donor cells Minor cross match- pt’s cells + Donor serum

12. PRE-TRANSFUSION TESTING (contd .) Screening for Transfusion transmitted diseases (Donor Sample) HIV 1 and 2 AIDS HBsAg Hepatitis B HCV Hepatitis C Treponema pallidum Syphilis Plasmodium species Malaria

13. PREPARATION OF DONOR Explain procedure Reassure donor Blood should not be collected in empty stomach Hydrate patient Check vital parameters

14. COLLECTION & STORAGE Blood - sterile container containing anti-coagulant solution Sterile articles Each unit of blood is labelled in clear , readable letters & be verified at time of administration Name of the donor Donor grouping Rh typing

15. COLLECTION STORAGE AND TRANSPORTAION(CONT …) Date of drawing blood Expiry date Results of tests for hepatitis & syphilis etc… Kept in refrigerator ( temp 1 to 6 degree Celsius) I nspected daily

16. SAMPLE COLLECTION Sample must be labelled properly at bed side Fresh samples A request form should be sent

17. FILLING UP OF DATA The recipients name Ward name /no Exact amount of blood component requested Diagnosis of patient Any blood transfusions earlier, if so the group and type of blood administered any reactions Name of physician

18. BEFORE BLOOD ADMINISTRATION Verification of blood by 2 persons before administration Record baseline vital signs Offer bed pan or instruct the patient to void before blood administration

19. BEFORE BLOOD ADMINISTRATION (CONT …) Make patient comfortable Instruct patient to report if any discomfort is present

20. STEPS OF PROCEDURE Wash hands ,wear gloves Identify the accessible vein Iv cannula (18/16)gauge needle Blood transfusion set should be sterile & pyrogen free containing a filter Avoid introduction of air

21. DURING BLOOD TRANSUSION Monitor vital signs. Adjust the drip rate No medication in the blood or same IV line

22. DURING BLOOD TRANSFUSION (CONT ..) If Iv infusion is needed always use normal saline to prevent haemolysis of the blood in the tubing Dextrose should be avoided

23. OBSERVATION DURING PROCEDURE Rate of flow Signs of any circulatory overload Urinary output The needle site for any infilitration , haematoma, & dislodgment of needle Reaction to transfusion Patency of infusion set

24. AFTER THE TRANSFUSION Make the patient comfortable Discard the blood bag and Iv set Record and document following A mount of blood Group and type Time when started & finished Any reactions observed Any medication administered

25. TRASFUSION REACTIONS Transfusion reaction is a systemic response by the body to a incompatible blood

26. ADVERSE EFFECTS (TRANSFUSION REACTIONS) - Immune mediated Acute Onset <24 hours Delayed Onset within days/months 1. Hemolysis Hemolysis 2. Febrile reactions Post transfusion purpura 3. Allergic Graft Vs Host disease 4. Anaphylaxis 5. TR.Ac.lung injury

27. Acute Delayed 1. Bacterial contamination HIV 1 & 2 2. Circulatory overload Hepatitis B & C 3. Physical/chemical damage Syphilis 4. Hyperkalemia Malaria 5. Hypocalcemia Iron overload ADVERSE EFFECTS (TRANSFUSION REACTIONS) – Non-Immune mediated

28. EMERGENCY MANAGMENT Stop transfusion immediately Notify physician/lab Connect I V line with 0.9%saline Monitor patient closely Anti anaphylatic drugs( vasopressors,anti histamine,steroids ,fluids) Prepare for CPR

29. EMERGENCY MANAGEMENT (CONT…)… Oxygen administration if needed Collect specimens Reassure patient Document the reaction & measure carried out

30. CAUSES OF TRANSFUSION REACTIONS Clerical errors: Inadequate labeling Wrong blood issued Technical errors: Error in grouping & cross matching Incorrect interpretation of test results

31. CAUSES OF TRANSFUSION REACTION(Cont .….) Others: Blood contamination during phlebotomy Blood infusion through small bore needle Concomitant administration blood & drugs through common set

32. TRANSFUSION REACTION FOLLOW-UP Clinical Information Needed: Recipient diagnosis Medical history of pregnancy &/or transfusion Current medications Signs & symptoms during transfusion reaction How many ml’s of RBC’s or plasma were transfused ?

33. CHECK LIST Were rbc’s cold or warm when transfused? Were red cells infused under pressure? What was the size of the needle used? Were other solutions given through the IV line at the same time? If so what? Were any other drugs given at the time of transfusion? If so, what? What were pre- & post- transfusion vital signs?

34. SAMPLES FOR POST REACTION FOLLOWUP Clotted specimen EDTA specimen Clotted specimen 1st voided urine specimen Repeat ABO, Rh, IAT and Cross match. Visual check for hemolysis and compare with pre transfusion sample. DAT (Direct Ant globulin Test ) Collect 5-7 hours post transfusion to check for bilirubin Free hemoglobin determination

35. TAKE HOME MESSAGE

36. SUMMARY What is it? Types Indications Pre-transfusion testing Record Causes Clinical features Laboratory investigations BLOOD TRANSFUSION TRANSFUSION REACTIONS

37. QUERIES???

38. Transfusion Reactions Acute (<24 hours) Transfusion Reactions - Immunologic Hemolytic; Febrile-non hemolytic; Allergic; Anaphylactic; Transfusion Reaction of Acute Lung injury(TRALI) Acute Transfusion Reactions - Nonimmunologic Hemolytic (Physical or Chemical destruction of RBC); Circulatory overload; Air embolus; Hypocalcemia; Hypothermia Delayed (>24 Hours) Transfusion Reaction - Immunologic Hemolytic ; Graft vs. Host Disease; Posttransfusion Purpura Delayed Transfusion Reactions - Nonimmunologic Iron Overload Infectious Complications of Blood Transfusion

39. Immunologic Hemolytic ; Febrile-non hemolytic; Allergic; Anaphylactic; Transfusion Reaction of Acute Lung injury(TRALI) Nonimmunologic Volume overload; Hemolytic (Physical or Chemical destruction of RBC); Air embolus; Hypocalcaemia; Hypothermia Acute (<24 hours) Transfusion Reactions

40. Acute Transfusion Reactions Immunologic Acute Hemolytic Transfusion Reaction Associated with Intravascular Hemolysis Etiology: Antibodies that activate complements in the vasculature: ABO antibodies are predominant / not the only ones. Prevention: Give ABO compatible blood.

41. Acute Transfusion Reactions Immunologic May also occur due to ABO incompatible plasma in platelet products Very rare; less than 20 case reports, all involving group O platelets Usually occurs in group A patients or those with anti-A titers greater than 1:1000 Can prevent by removing plasma from platelets, or limiting number of incompatible group O platelets in a 24 hour period ( Archives 2007;131:909 )

42. Intravascular Hemolysis Characteristics Within minutes IgM &/or IgG antibody Complement activation Release of histamine and serotonin Signs may include: Pain along infusion site Shock Abnormal bleeding/ DIC/ Hemoglobinemia/uria Release of cytokines: fever, hypotension Renal failure/ Oliguria, may progress to…anuria

43. Acute Transfusion Reactions Immunologic Febrile non-hemolytic TX Reactions An INCREASE in temperature of 1 O C during infusion of blood component Usually “mild & benign” = not life threatening Can have more severe symptoms, not usually Non-hemolytic Incidence of 0.1% of RBC transfusions, 0.1-1.0% of platelet transfusions Cause: Recipient antibodies to donor WBCs & Cytokines in the transfused blood component.

44. Febrile Transfusion Reactions Seen in… Multiply transfused patients Multiple pregnancies Previously transplanted Must rule out… Hemolytic transfusion reaction Bacterial contamination of unit Prevention Leukocyte reduction ( pre-storage reduction may be more effective than post-storage reduction) or plasma removal is also helpful .

45. Acute Transfusion Reactions Immunologic Allergic (Urticarial-Hives) Transfusion Reactions Etiology: Form of cutaneous hypersensitivity triggered by recipient antibodies directed against: Donor plasma proteins or Other allergens (food, medicines) in donor plasma Begins within minutes of infusion Characterized by rash and/or hives and itching . Common (1 per 2000 transfusions) Usually involves release of histamine.

46. MUST be sure that the only reaction is the development of urticaria Must rule out more severe symptoms that could lead to anaphylaxis: angioneurotic edema laryngeal edema bronchial asthma Prevention: Can pre-treat recipient with anti-histamines before transfusion. . Allergic (Urticarial) Reactions

47. Acute Transfusion Reactions Immunologic Anaphylaxis Life threatening!! Etiology: Recipient is IgA deficient & has anti-IgA in serum Recipient anti-IgA can react to even small amounts of donor IgA in the plasma in any blood component Idiopathic & Haptoglobin deficiency Reaction may occur within minutes : Onset of symptoms is SUDDEN Prevention: Wash cellular components or blood products from IgA deficients

48. Symptoms Burning sensation at infusion site Coughing, difficulty in breathing, and bronchospasms can lead to cyanosis Nausea, vomiting, severe abdominal cramps, diarrhea Hypotension which can lead to shock, loss of consciousness, & death MUST STOP TX IMMEDIATELY Anaphylaxis

49. Acute Transfusion Reactions Immunologic TX Reaction of Acute Lung Iinjury Etiology: Acute onset of hypoxemia and pulmonary edema on CX-RAY within 6 hrs of TX without evidence of cardiac failure. Mechanism’s Primary Suspect: Donor antibodies to recipient WBCs Another cause: Biologically active lipids in the lungs causing edema

50. Transfusion Reaction of Acute Lung Injury(TRALI) Symptoms Chills, fever, cough, cyanosis, hypotension , increased difficulty breathing Prevention: For recipients : give male products- For donors: watch/defer.

51. Acute Transfusion Reactions NON immunologic Circulatory Overload Etiology: Rapid increases in blood volume to patient . Risk factors: compromised cardiovascular function, current volume overload, small intravascular volume (elderly, young children), severe chronic anemia . Signs and Symptoms Dyspnea, cyanosis, severe headaches, hypertension or CHF (congestive heart failure ) Prevention: Slow Tx . Treatment : Stop infusion and place patient in sitting position.

52. Acute Transfusion Reactions NON immunologic Physically or Chemically Induced Red Cell Destruction Etiology: Destruction of red blood cells in the collection bag and infusion of free hemoglobin, etc. Improper temperatures: High or Low Microwave blood bag, malfunctioning blood warmer or water bath, inadvertent freezing of blood.

53. Physically or Chemically Induced Red Cell Destruction Osmotic Hemolysis Addition of drugs or hypotonic solutions (5% dextrose, deionized water, etc.) to transfusion. Mechanical Hemolysis Caused by rollers in blood pump Pressure infusion pumps Small bore needles Prevention: Adherence to procedures for all aspects of procuring, processing, issuing and administering red blood cell transfusions.

54. Acute Transfusion Reactions NON immunologic Hypocalcemia Excess citrate : When infused at rate >100 mL/minute or individuals with impaired liver function: Citrate is broken down by liver. Seen more in pediatric and elderly patients Signs and Symptoms: Facial tingling, nausea, vomiting. Prevention: Slowing or discontinuing infusion.

55. Acute Transfusion Reactions NON immunologic Hypothermia Etiology: Drop in core body temperature due to rapid infusion of large volumes of cold blood. Symptoms: Decreased body temperature and ventricular arrhythmias. Seen in small infants or massive transfusion Prevention: Reduce rate of infusion or use blood warmers .

56. Acute Transfusion Reactions NON immunologic Air Embolism Etiology: If blood in an open system is infused under pressure or if air enters the system while container or blood administration sets are being changed. Treatment: Place patient on left side with head down to displace air bubble from pulmonic valve.

57. Immunologic Hemolytic ; Graft vs. Host Disease; Posttransfusion Purpura Nonimmunologic Iron Overload Delayed (>24 Hours) Transfusion Reaction -

58. Delayed Transfusion Reactions Immunologic Delayed Hemolytic Transfusion Reaction ( Red blood cell alloimmunization ) Onset within days (>24 hours) Associated with Extravascular Hemolysis Etiology: Antibodies that usually do NOT activate Complements : Rh, Kell, etc . Prevention: Give antigen negative blood.

59. Extravascular Hemolysis Signs may include: No release of free Hgb, or enzymes into circulation May be immediate (hours) or delayed (days) Bilirubinemia or bilirubinuria Characteristics Reaction within days Antibody attaches to RBC: RBC destroyed in spleen or liver, etc. Commonly IgG May or may not activate Complement

60. Extravascular Hemolysis Signs & Symptoms continued… Fever or fever & chills Jaundice Unexpected anemia Some may present as an ABSENCE of an anticipated increase in Hemoglobin and hematocrit.

61. Delayed Transfusion Reaction Immunolgic Graft vs Host Disease (GVHD) Etiology: Donor CD8+ T -Lymphocytes attack recipient (host) tissues. Groups at risk: Immunocompromised patients (Cancer, fetus, neonatal, bone marrow transplant). Signs: Fever, dermatitis, or erythroderma, hepatitis, diarrhea, pancytopenia, etc. Prevention: Irradiation of blood products.

62. Delayed Transfusion Reaction Immunolgic Post-transfusion Purpura Etiology: Antibodies to platelet antigens ( HP1a ) causes abrupt onset of severe thrombocytopenia (platelet count <10,000/ l) 5-10 days following transfusion. Usually affects multiparous women . Signs: Purpura, bleeding, fall in platelet count . treatment : IVIG, plasmapheresis or corticosteroids; platelet transfusions usually NOT recommended

63. Delayed Transfusion Reaction NON immunolgic Iron Overload Etiology: Excess iron resulting from chronically transfused patients such as hemoglobinopathies, chronic renal failure, etc. Signs: Muscle weakness, fatigue, weight loss, mild jaundice, anemia, etc. Treatment: Infusion of deferoxamine - an iron chelating agent has been useful.

64. Infectious Complications of Blood Transfusion (Viral is rare)

65. Infectious Complication of Blood Transfusion Bacterial Contamination Etiology: At time of collection: either from the donor or the venipuncture site. During component preparation, etc . Usually involves endotoxins Staph, Pseudomonas, E.coli, Yersinia

66. Bacterial Contamination Components: Most often from platelet components (room temp). Red cell units will look dark. Symptoms: Rapid onset Fever, hypotension, shaking chills, muscle pain Vomiting, abdominal cramps, bloody diarrhea, hemoglobinuria, shock, renal failure, & DIC.

67. Transfusion must be stopped immediately Gram stain & blood cultures should be done on the unit, patient and all infusion sets . Broad-spectrum antibiotics should be given immediately intravenously Prevention: Maintain standards of donor selection, blood collection and proper maintenance of collected blood components. Bacterial Contamination

68. Transfusion Reaction Follow-up Clinical Information Needed: Recipient diagnosis Medical history of pregnancy &/or transfusion Current medications Signs & symptoms during transfusion reaction How many mL’s of RBC’s or plasma were transfused?

69. Clinical Information Needed Were rbc’s cold or warm when transfused? Were red cells infused under pressure? What was the size of the needle used? Were other solutions given through the IV line at the same time? If so what? Were any other drugs given at the time of transfusion? If so, what? What were pre- & post- transfusion vital signs?

70. Transfusion Reaction Follow-up Post Transfusion Reaction blood samples to be collected from the recipient: Clotted specimen EDTA specimen Clotted specimen 1st voided urine specimen post-tx’n Repeat ABO, Rh, IAT and Crossmatch. Visual check for hemolysis and compare with pre transfusion sample. DAT (Direct Antiglobulin Test) Collect 5-7 hours post transfusion to check for bilirubin Free hemoglobin determination

71. Transfusion Reaction Workup CLERICAL CHECKS Correct identification of patient, specimen, and transfused unit. Agreement of records and history with current results Correct labeling of transfused unit SPECIMEN CHECKS Visual inspection of post-transfusion specimen Visual inspection of blood bag and lines

72. Post Transfusion Lab Testing Direct Antiglobulin Test (DAT) Recipient post-tx’n spec. Positive: Perform eluate and identify antibody if the pre-TX spec negative. ABO Grouping and Rh Typing Recipient pre transfusion and post transfusion specimen Donor bag.

73. Post Transfusion Lab Testing Indirect Antiglobulin Test (IAT) Recipient Pre- & post-transfusion reaction specimens Pre neg and post pos: Identify antibody and compare results of serum panel with eluate panel.