transfusion reactions - pa · call is coming from the blood bank. ... • transfusion related acute...
TRANSCRIPT
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Transfusion Reactions:
Melissa R. George, D.O., F.C.A.P.
Medical Director, Transfusion Medicine & Apheresis
Penn State Milton S. Hershey Medical Center
Office: HG069, Phone: 717-531-4627
E-mail: [email protected]
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Disclosures
• Novartis Medical Advisory Board Member, May 2013- May 2014.
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Overview
Serious
• Acute hemolytic
• Delayed hemolytic
• Anaphylactic
• Transfusion Associated Circulatory Overload (TACO)
• Transfusion Related Acute Lung Injury (TRALI)
• Bacterial contamination
Uncomfortable, not serious
• Allergic/anaphylactoid
• Febrile non-hemolytic
• Hypotensive
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Scenario
• Your pager goes off at 2 AM. You see that the call is coming from the blood bank.
• You return the call and are presented with the following information:
– Mr. Smith had a transfusion reaction, 150 mL into a platelet transfusion he developed a fever of 38.5°C and chills, no other S & S
• What should you do?
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The serious
• Acute hemolytic transfusion reactions (AHTR)
• Delayed hemolytic transfusion reactions (DHTR)
• Anaphylaxis
• Transfusion Associated Circulatory Overload (TACO)
• Transfusion Related Acute Lung Injury (TRALI)
• Bacterial Contamination
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Acute Hemolytic Transfusion Reactions (AHTR)
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Acute Hemolytic Transfusion Reactions (AHTR)
• Pathophysiology: Mostly ABO incompatibility: mislabeled blood sample or improper patient identification
– Intravascular hemolysis
– Naturally occurring IgM ABO antibodies
– RBC stroma activates cascades: bradykinin, inflammation, coagulation, etc.
• Incidence: ~1 in 100,000 transfusions
• Significance: Up to 60% fatal
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AHTR recognition
• Timing: Happens within 10-15 minutes
• S & S: fever, chills, nausea/vomiting, flank & abdominal pain, headache, dyspnea, hypotension, tachycardia
• Labs: DAT positive, urine hemosiderin later
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Delayed Hemolytic Transfusion Reaction (DHTR)
Image used with permission of Stephanie Griggs, Brand and Sales Coordinator, Mr Men Little Miss
LITTLE MISS LATE
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Delayed Hemolytic Transfusion Reactions (DHTR)
• Pathophysiology: – Antigens other than ABO
– Extravascular hemolysis
– Alloantibody (IgG) stimulated by prior exposure • Undetectable or missed pre-transfusion
• Anamnestic response
• Incidence: 1 in 7,000 transfusions
• Significance: Fatality rare
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Extravascular Hemolysis
Scanning electron micrograph - reaction
of phagocyte to antibody-coated red cell
1-Phase contrast photomicrograph - interaction
of antibody-coated red cell and phagocyte
3-Separation of internal and external portions of red
cell; the external portion of red cell circulates as spherocyte2-Further interaction of phagocyte and antibody-coated cell
resulting in internalization of portion of red cell
Images from Petz LD and Garratty G; Immune Hemolytic Anemias, second edition: 2004; 145
Scanning electron micrograph
Slide courtesy of Dr. Saleh Ayache
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DHTR Recognition
• Timing: Hours to days after transfusion
• S & S: Typically patient feels fine
• Labs: Positive DAT, drops in H & H
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Anaphylaxis
License agreement to use image through Condé Nast Cartoon Bank 3-6-14
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Anaphylaxis
• Pathophysiology: Anaphylatoxins produce secondary mediators, complement activation
• Incidence: Uncommon, 1:20-50,000 transfusions
• Significance: May be fatal
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Anaphylaxis Recognition
• Timing: Usually early onset, minutes
• S & S: Hypotension, edema, dyspnea, stridor, wheezing, cramping, diarrhea, shock, loss of consciousness
• No fever or chills
• Labs: Anti-IgA reported (uncommon), DAT negative
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Anaphylaxis Reaction Prevention
• IgA deficiency with anti-IgA: frozen, washed RBCs or blood from IgA deficient donor (only option for plasma based products)
• Steroid premedication unproven
• Recurrence not predictable
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No
TACO
¡No quiero TACO!
Microsoft clip art
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Transfusion Associated Circulatory Overload (TACO)
• Pathophysiology: Rapid intravascular volume expansion, depends on rate/volume of transfusion
• Common in infants and elderly
• Incidence: 1 in 350-5,000 reported
• Significance: Same as CHF, can be fatal
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TACO Recognition
• Timing: Variable, depending on other fluids given
• S & S: Dyspnea, orthopnea, cyanosis, cough, JVD, CHF, tachycardia, hypertension, headache, responds to diuresis
• Labs: Elevated BNP
• Treat like CHF, space transfusions over time
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Transfusion Related Acute Lung Injury (TRALI)
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TRALI
Donor factors: Anti-HLA antibodies in plasma
Chemokines released during product storage
Recipient’s underlying disease state
Chest x-ray image from Peter Maslak, ASH Image Bank 2011; 2011-3672
Recruitment of neutrophils in small vessels of lung infiltrates
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TRALI
• Incidence: ??? 1 in 1,300 to 190,000
• Significance: Usually resolves, but can be fatal
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TRALI Recognition
• Timing: Later in transfusion, usually high plasma content products rather than pRBC
• S & S: Dyspnea, pulmonary edema/ new infiltrates, cyanosis, tachycardia, chills, hypotension, does not respond to diuresis
• Labs: DAT negative, antibody testing of donor and antigen testing of recipient
• Diuretics worsen condition, supportive care
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TRALI Prevention
• Use of male-only plasma for transfusion
• Deferral of donors with anti-HLA/HNA antibodies
• New AABB guidance will close loopholes for AB plasma and impact inventory
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TACO TRALI
Clinical history Underlying cardiac dysfunction, + fluid balance
No underlying cardiac condition
Physical exam Sudden elevation of BP, JVP, wheezing
Hypotension
Chest x-ray B/L infiltrates/pulmonary edema Cardiomegaly with increased vascular pedical width
B/L infiltrates/pulmonary edema
ECHO Systolic or diastolic dysfunction (EF<45%)
Could be normal
Labs Increased BNP Pulmonary edema albumin / plasma albumin >0.55 Short-lived, sudden drop in neutrophil count
Response to diuretics
Rapid improvement No response
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Bacterial Contamination
Wikimedia Commons- General Permission to Use Image
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Bacterial Contamination
• Pathophysiology: Sepsis
– Platelet: skin flora, Salmonellae sp.
– RBC: psychrophilic, esp. Y. enterocolytica
• Incidence: Had been common in past with platelets (1 in 3,000 platelet transfusions)
• Significance:
– With platelet transfusion, 25% fatal
– Rare in RBC units, ~75% fatal
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Bacterial Contamination
• Older platelets ( >5 days) had log phase growth
• Asymptomatic donor bacteremia and skin plugs retrograde into product
• All platelets now screened/cultured
– Also, first blood in draw diverted
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Bacterial Contamination
• Timing: Late onset, may occur hours after transfusion
• S & S: Hypotension, fever, chills, headache, back/flank pain, dyspnea, abdominal pain, oliguria, coagulopathy, endotoxic shock
• Labs: Culture patient, Quarantine unit for possible culture
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Uncomfortable but not serious
• Febrile Non-Hemolytic Transfusion Reactions
• Allergic Reactions
• Acute Hypotensive Reactions
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Febrile Nonhemolytic Transfusion Reactions (FNHTR)
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Febrile Nonhemolytic Transfusion Reactions (FNHTR)
• Pathophysiology: Donor derived cytokines, non-recurrent (product dependent) OR patient WBC antibodies, recurrent (patient dependent)
• Incidence: Had been most common
– 1% of RBC transfusions
– 30% of platelet transfusions
– Decreasing with leukoreduction
• Significance: Uncomfortable but not fatal
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FNHTR Recognition
• Timing: Usually toward the end of transfusion or within short time of completion
• S & S: Rise in temperature > 1 °C*, other sx overlap with AHTR namely chills, rigors, headache, nausea, vomiting, hypertension, tachycardia, dyspnea
• Labs: DAT negative
* Can be masked by premedication
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Allergic Reactions
Permission to use this cartoon granted via e-mail by Aaron Schaff, Inkjot Comics
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Allergic Reactions
• Pathophysiology: Allergens mainly in plasma
• Incidence: Most common, 1-3 % of transfusions, serious recurrences uncommon
• Significance: Annoying but not usually serious
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Allergic Reaction Recognition
• Timing: Usually early in transfusion
• S & S: Pruritus, erythema, urticaria localized to IV site, may become systemic, bronchospasm
• Labs: DAT negative
* Can restart transfusion if symptoms are mild and resolve
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Acute Hypotensive Reactions
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Acute Hypotensive Reactions
• Pathophysiology: ACE inhibitors often associated
– Multiple factors create risk
• Genetic variability in BK metabolism
• Negatively charged filters
• Contact system activation in product
• BK receptor induction
• Incidence: ???
• Significance: Recovery generally rapid
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Acute Hypotensive Reactions
• Timing: Rapid onset (minutes)
• S & S: Hypotension, lightheadedness, anxiety
– Rarely nausea, dyspnea, flushing, hives
– No fever, chills, wheezing, edema
– Rapid recovery once transfusion stopped
• Labs: DAT negative
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Summary
• Signs and symptoms of TRs can overlap, so even simple, allergic reactions should be reported
• Most “transfusion reactions” are actually due to underlying disease