COMPLICATIONS OF BLOOD TRANSFUSION COMMON IN THE SUBSAHARAN AFRICA

COMPLICATIONS OF HAEMOTRANSFUSION CAN BE FETAL

1. COMPLICATIONS OF Blood transfusion DR LUDOVIC BANDANAA

2. Outline INTRODUCTION DONATION OF BLOOD TYPES OF BLOOD PRODUCT STORAGE OF BLOOD INDICATIONS FOR TRANSFUSION PRINCIPLES ADMINISTRATION OF BLOOD COMPLICATIONS AND MANAGEMENT OF BLOOD TRANSFUSION

3. INTRODUCTION Blood transfusion consists of the ‘safe’ transfer of blood and blood components from a donor to a recipient. Transfusion reactions are any undesirable occurrence in a patient associated with the transfusion of blood or blood products Despite the various advancement has been made in the field of transfusion, particularly to reduce the adverse events associated with blood-product infusion like; Improved donor screening and the reduction in transfusion-associated morbidity and mortality substantial risks associated with transfusion remains

4. EPIDEMIOLOGY In a study involving 372 recipients and 432 transfusions in a Ghanaian teaching hospital, the adverse events incidence was 21.3%(92/432), predominantly mild acute reactions (84%) In a study by the Department of Medical Laboratory Science of the University of Cape Coast involving 200 patients. Out of 200 patients, 169 were transfused with whole blood while 31 patients received packed red cells . The overall incidence of transfusion-related adverse reactions was 47.5%.O ut of the 169 patients who received whole blood, more than half (53.8%) experienced more than one of the transfusion-related adverse reactions that were monitored 87 per 1000 blood components resulted in transfusion-related adverse events in a tertiary Hospital in Nigeria ( Arewa , Akinola, & Salawu , 2009)

5. PHM BLOOD BANK SERVICES

6. Types of blood Products WHOLE BLOOD CONCENTRATED RED CELLS (CRC) PLATELET CONCENTRATE FRESH FROZEN PLASMA (FFP) CRYOPRECIPITATE FACTOR CONCENTRATES(e.g. FACTORS VIII,IX) PROTEIN SOLUTIONS(e.g. ALBUMIN CONCENTRATE, HUMAN PLASMAFRACTION) GRANULOCYTE CONCENTRATE

7. Blood Grouping System & Cross-Matching All transfusions are preceded by ABO and Rh typing of both donor and recipient blood to ensure compatibility. ABO system is based on presence of antigen A or B Rhesus system is based on presence of antigen D(Rh factor) Cross matching is done to detect the rare Ags present in the recipient such as Kell, Kidd, Lewis, Duffy, MNS, etc

8. STORAGE BLOOD PRODUCT STORAGE TEMPERATURE Whole Blood 2 -6 oC CRC 2-6 oC Platelets Room Temperature( being mechanically rotated) Fresh Frozen Plasma -18oC Cryoprecipitate -40oC

9. Principles Of Administration IT SHOULD ONLY BE DONE WHEN NECESSARY Counselling and consent Strict asepsis Double check details Pretransfusion vital signs Pre transfusion medication (if required) Warm blood when necessary

10. TIME LIMIT FOR TRANSFUSION START INFUSION COMPLETE INFUSION WHOLE BLOOD OR CRC Within 30mins of removing pack from refrigerator Within 4hours PLATELETS CONCENTRATE Immediately Within 20mins FRESH FROZEN PLASMA As soon as possible Within 20mins CRYOPRECIPITATES As soon as possible Within 20mins

11. BLOOD TRANSFUSION PROCESS Counsel patient Confirm correct patient identification Confirm ABO/Rh compatibility (GXM) Confirm Screening results Check Expiry date, haemolysis, clots, leakages Labels tally (check, check, and check again) Pre-transfusion vitals Administer pre-transfusion medications Start transfusion Monitor patient

12. TRANSFUSION NOTES BLOOD TRANSFUSION WITH A UNIT OF CRC OVER 3-4HRS PRODUCT DETAILS: DONOR NO - 2408903 BLOOD GROUP:O-POSITIVE DATE CROSSMATCHED- 28/ 06/ 24 EXPIRY DATE - 30/ 07/ 24: PRE TRANSFUSION VITALS SIGNS:T- 35.9C,BP- 122/95MMHG,P- 75BPM,RR- 23CPM,SPO2- 99% PRETRANSFUSION MEDICATION :IV FRUSEMIDE 40MG ST IN CASE OF TRANSFUSION REACTION STOP BLOOD TRANSFUSION BUT DO NT DISCARD REMAINING BLOOOD PRODUCT TAKE BLOOD SAMPLE IV HYDROCORTISONE 200MG STAT IV PROMETHAZINE 25MG STAT RUN  500ML OF IV N/SALINE STAT SEND THE REMAINING BLOOD AND BLOOD SAMPLE TO THE BLOOD BANK CALL THE NEAREST DOCTOR

13. Recording the transfusion The following information should be recorded in the patient’s notes. Type and volume of each product transfused. Batch number and Blood group of each unit transfused. Time at which the transfusion of each unit commenced. Time the transfusion is completed. Any adverse effect. Signature of the person administering the blood component.

14. Monitoring the transfused patient For each unit of blood or blood products transfused, monitor the patient. Before starting the transfusion. As soon as the transfusion is started. 15 minutes after starting the transfusion. At least every hour during transfusion. On completion of the transfusion. 4 hours after completing the transfusion

15. COMPLICATION Most are immune-related and range from mild (urticaria) to severe (haemolytic). Others may also be due to human error. Two main types; ACUTE/IMMEDIATE TRANSFUSION REACTIONS DELAYED TRANSFUSION REACTIONS

16. ACUTE/IMMEDIATE TRANSFUSION REACTIONS FEBRILE NON HAEMOLYTIC REACTION ACUTE HAEMOLYTIC REACTION TRANSFUSION RELATED ACUTE LUNG INJURY(TRALI) TRANSFUSION ASSOCIATED CIRCULATORY OVERLOAD(TACO) ALLERGIC REACTION BACTERIAL CONTAMINATION

17. FEBRILE NON HAEMOLYTIC REACTION Reactions result from donor leucocyte antigens reacting to antibodies present in the recipient’s plasma. More common with platelet transfusion than RBCs These antibodies react with the leucocytes to form a leucocyte antigen–antibody complex that binds complement and results in the release of endogenous pyrogens —IL-1, IL-6 and TNF a Symptoms of non- haemolytic febrile reactions include fever, chills, headache, myalgia and general malaise. Rarely, they may progress to hypotension, vomiting and respiratory distress.

18. Onset is during, or several hours after, transfusion and the severity of the reaction is dependent upon leucocyte-load and the rate of transfusion Discontinue transfusion, take samples to the lab (check labels, repeat GXM, Direct Coombs test) Treatment is symptomatic – IV Paracetamol Prevention:Leucodepletion

19. ACUTE HAEMOLYTIC REACTION A life threatening reaction Carries a mortality of 10-50% Haemolysis of donor cells due to antibodies in recipients plasma against donor red cell antigens. Usually due to wrong identification of blood and recipient, therefore resulting in ABO incompatibility or Rhesus incompatibility

20. Clinical Manifestations include Feeling of apprehension Fever, Chills Pain along IV line, back or chest Tingling sensation of all limbs Hypotension Cola like urine Uncontrolled bleeding due to DIC AKI

21. When AHTR is Suspected STOP transfusion Maintain BP and diuresis Maintain airway and give high flow oxygen via face mask Take new blood sample Return remainder of blood and new sample to blood ban Bedside clerical checks IV Corticosteroids and bronchodilators Alert blood bank immediately Others – FBC, BUE,Cr , Clotting profile, urine, blood C/S Diagnosis is confirmed by measuring urinary Hb, serum LDH, bilirubin, and haptoglobin. If DIC, give FFP and platelets Prolonged oliguria and shock are poor prognostic signs Dialysis may be needed

22. Prevention Correctly LABEL all blood sample bottles and request forms as well. Check, check, recheck blood labels and recipient’s details

23. ALLERGIC REACTION Allergic reactions are common and usually mild. The majority are because of the presence of foreign proteins in donor plasma and are IgE -mediated. This usually presents as Pruritus and urticaria, with or without fever. The transfusion should be stopped and anti-histamines administered. If symptoms resolve in less than 30 min and there is no cardiovascular instability, the transfusion may be restarted. However, If the symptoms recur then administration of that particular unit of blood should be abandoned

24. ANAPHYLACTIC REACTIONS Anaphylactic reactions are rare after transfusions. They occur most often in patients in whom a hereditary IgA deficiency, and pre-existing anti-IgA antibodies, predisposes to an antibody–antigen interaction and subsequent anaphylaxis. This reaction occurs immediately after commencement of transfusion and is not dose-related. Clinical features include urticaria, dyspnoea , bronchospasm, laryngeal oedema and cardiovascular collapse. Treatment: IVF resuscitation, epinephrine administration to reverse bronchospasm, antihistamines, corticosteroids and respiratory support Prevention: Patients with IgA deficiency require blood products from IgA deficient donors

25. TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI) TRALI is the most common cause of major morbidity and death after transfusion. It presents as an acute respiratory distress syndrome (ARDS) either during or within 6 hours of transfusion The highest incidence occurs with transfusion of fresh frozen plasma (FFP) followed by platelets. Occurs when antibodies present in transfused donor plasma interact with recipient leukocytes, resulting in leukocyte activation and adhesion to the pulmonary endothelium. This process results in the release of proteolytic enzymes and reactive oxygen species, causing endothelial injury and l eukocyte agglutination also occurs, leading to obstruction of pulmonary capillaries.

26. Characterized by : Acute dyspnoea , Tachypnoea, Fever, Hypotension Tachycardia Investigations: Chest radiograph will reveal bilateral patchy pulmonary infiltrates Fbc : Leucopenia Treatment: Immediate management of TRALI is to stop the transfusion. There are no specific treatment hence Supportive measures including oxygenation and mechanical ventilation

27. TRANSFUSION ASSOCIATED CIRCULATORY OVERLOAD(TACO) Commoner in elderly, debilitated, patients with chronic anaemia , CCF,pulmonary , renal or hepatic disease Leads to Pulmonary oedema Characterised by : Dyspnea, orthopnea, cough with pink, frothy sputum, cyanosis, Raised JVP, Bibasal fine crepitations Rapid, weak pulse

28. Management Stop transfusion Prop up in bed Give intravenous diuretic Prevention – Increase duration of transfusion in at-risk patients (4 hours), or Transfuse smaller volumes over days, or Pre-medication of Frusemide

29. BACTERIAL CONTAMINATION Important cause of transfusion-related morbidity and mortality. Commonly implicated organisms: CRC:Pseudomonas , Citrobacter, E. coli, and Yersinia enterocolitica PLATELETS: Staphylococcus epidermidis, Staphylococcus aureus and Bacillus species Sources: Donor skin, donor bacteraemia,Improper handling during blood processing and equipment used for the blood collection processing. Thawing FFP or cryoprecipitate in water-bath The bacteria can multiply during storage. May also occur during setting up of the transfusion or the insertion site Symptoms occur during or shortly after transfusion of the contaminated unit and include high fever, rigors, hypotension, nausea and/or diarrhea

30. Management S top transfusion Take donor and recipient samples for blood culture and Gram staining IV fluids Give IV broad-spectrum antibiotics Prevention Collection of blood under asepsis P roper storage and use within 2-3 hrs of removal from blood bank

31. Hypomagnesaemia and Hypocalcaemia Rapid administration of large quantities of stored blood may cause citrate (the anticoagulant used in blood products) to bind to those cations. Result in myocardial depression or coagulopathy as well as tetany, convulsions, and hypotension Patients most at risk are those with liver dysfunction and neonates with immature liver function Management Slowing or temporarily stopping the transfusion to allow citrate to be metabolized,

32. Hyperkalaemia Stored red cells leak Potassium proportionately throughout storage life. Also irradiation of red cells increases the rate of potassium leakage. Hyperkalemia can occur during rapid, large volume transfusion of older red cells. Characterised by: Palpitations,chest pains,paresthesias,shortness of breath,nausea,muscle weakness,cardiac arrhythmias Diagnosis :ECG, electrolytes Management- ECG monitoring, Calcium gluconate, insulin/glucose Prevention – use of blood < 7days old for rapid volume transfusion in small infants

33. Hypothermia Can occur in rapid transfusion of large volumes of stored blood. Manaement Maintain patient body temperature Prevention Blood warmers during massive or exchange transfusion

34. DELAYED TRANSFUSION REACTIONS DELAYED HAEMOLYTIC REACTION TRANSMISSION OF DISEASES POST TRANSFUSION THROMBOCYTOPENIC PURPURA THROMBIPHLEBITIS GRAFT VERSUS HOST DISEASE IRON OVERLOAD

35. DELAYED HAEMOLYTIC REACTION Develops 3 to 10 days on average post transfusion. Delayed hemolytic transfusion reactions (DHTRs) may result from 2 situations; R e-emergence of a non-ABO antibody occurs in the recipient Less commonly, development of a new antibody against a non-ABO blood group antigen in donor RBCs Clinical features Mild jaundice Drop in Hb Commoner in multiple transfusions

36. MANAGEMENT S upportive treatment However, close monitoring of the patient is recommended, including serial assessment of renal function and HCT.

37. TRANSMISSION OF DISEASES Viral Hepatitis A, B, C, D Malaria Syphilis HIV CMV Trypanosomiasis Toxoplasmosis Brucellosis Variant Creutzfeldt-Jacob Disease [ vCJD ] Parvovirus

38. IRON OVERLOAD A consequence of chronic RBC transfusion such as sickle cell patients Organ toxicity begins when reticuloendothelial sites of iron storage sites become saturated. Multiple organs will be affected including: -liver (liver cirrhosis) -pancreas (Diabetes) -heart (cardiomegaly and conduction disturbance) - joints ( arthralgia) -skin (hyperpigmentation/bronzing) Management: Monitor iron status and commence iron chelation therapy early in the course of chronic transfusion therapy

39. POST TRASFUSION PURPURA Rare Occurs 7-14 days post-transfusion Caused by Antigen-Antibody complexes which attach to platelets causing premature destruction Clinical features includes 1. Petechiae 2. Bleeding from mucous membranes Management Majority recover spontaneously In severe cases, Prednisolone,IV Immunoglobulin Recovery of platelets count after 2- 4 weeks is usual

40. BLOOD PRODUCT SUBSTITUTES RED CELL SUBSTITUTES Diaspirin cross-linked haemoglobin solution Perfluorocarbons Recombinant DNA derived haemoglobin PLATELET SUBSTITUTES: Pegylated Recombinant Human Megakaryocyte Growth and Development Factor(PEG- rHuMGDF )

41. PLASMA SUBSTITUTES 1. Plasma expanders are: Stable plasma protein solution Albumin Dextran Synthetic gelatin colloids ( Haemaccel , Gelofusine ) Hydroxyethyl starch preparations ( Hetastarch , Pentastarch 2. Electrolyte Solutions (Crystalloids): NS/RL 3. Hypertonic solutions:3 % NaCl, 7 .5 % NaCl

42. Alternatives to Donor Blood Pre-operative Autologous blood transfusion Acute normovolaemic haemodilution (ANH) Blood salvage (intra-operative/post-operative) Hypervolaemic haemodilution

43. CONCLUSION Transfusion reactions are relatively common in modern day practice and affect all systems to varying degrees. As such, as clinicians nurses ,midwives etc we must be able to first recognize when our patient is having one and be equipped with the knowledge and skills to manage adequately.

44. Thank you!!!

45. REFERENCES Diagnosis, Treatment, and Reporting of Adverse Effects of Transfusion Richard Torres, MD,1,2 Barton Kenney, MD,1,3 and Christopher A. Tormey , MD1,2* Transfusion-related Adverse Reactions: An update from a District Hospital in Ghana: Joseph Boachie et al Complications of blood transfusion: Melanie J Maxwell FRCA,Matthew J A Wilson MD MA BM ChB FRCA National Guidelines for the Clinical Use of Blood and Blood Products in Ghana Hoffbrand’s Essential Haematology,7 th edition