Acute Transfusion Reactions

Clinical Symptoms and Laboratory

Investigation

Types of Transfusion Reactions

Acute Allergic Febrile Hemolytic Anaphylactic Bacterial Contamination

(Sepsis) Circulatory Overload Transfusion Related Acute

Lung Injury (TRALI)

Delayed Alloimmunization Hemolytic Transmissible Diseases Graft vs Host Disease Iron Overload Post Transfusion Purpura

Definition

Acute Transfusion Reaction: Reactions occurring at any time up to 24 hours

following a transfusion of blood or components.

The Most Common Cause of Acute Immediate Intravascular Hemolysis

Failure to identify the patient with the donor unit at the time of administration

Collecting pre-transfusion specimen from the wrong patient Incorrectly labelled specimens Unlabelled specimens that are labelled after leaving

the bedside (in the lab or at the nursing station)

Administration Guidelines (Preparation)

1. Have physician obtain informed consent and document the indications for the transfusion in the chart

2. Assess the patient’s understanding of the procedure3. Describe the procedure, component, length of

transfusion and expected outcome to the patient4. Instruct patient to report ANY unusual symptoms

immediately

Administration Guidelines (con’t)

5. Obtain and record baseline vital signs6. Assess for any pre-transfusion symptoms

which could be confused with a transfusion reaction

7. Premedicate patient with prophylactic medication as per physician’s orders

8. Use appropriate equipment9. Obtain the component from the lab

Administration Guidelines (con’t)

10. Inspect the component for leaks, abnormal cloudiness, color, clots, excessive air. Check that the component is not expired. Mix well

11. Check the physicians order for transfusion. Ensure component type is correct.

12. Do not underestimate the importance of patient and product identification that MUST occur at the bedside If the patient is not wearing a ID bracelet DO NOT proceed Contact the lab if there are ANY discrepancies

Administration Guidelines (con’t)

13. Start the infusion slowly (5 mL/minute or less for first 15 minutes) Symptoms of a severe transfusion reaction are usually manifested

during the first 50 mL or less of blood infusion If possible, remain with the patient the first 10-15 minutes of the

transfusion14. Document the identifying individuals, date and time

transfusion initiated in the chart The chart must also contain the unit identifying number, ABO/Rh

15. Keep all identification attached to the blood container until the transfusion is completed

Administration Guidelines (con’t)

16. Before leaving the bedside, remind the patient to notify you immediately if they feel anything unusual

17. Monitor and record vital signs as defined in nursing policy

18. At the end of the transfusion, record end times, volume transfused and immediate response (i.e. no reaction noted, reaction noted…)

When a Reaction is Suspected…

Signs & Symptoms GENERAL

Fever Chills Muscle ache,pain Back pain Chest pain Headache Heat at the site of infusion

or along vein

Nervous System Apprehension, impending

sense of doom Tingling, numbness

Respiratory Tachypnea Apnea Dyspnea Cough wheezing

Signs & Symptoms Gastrointestinal

Nausea Vomiting Pain, abdominal cramping Diarrhea (may be bloody)

Renal Changes in urine volume Changes in urine color

Cardiovascular Heart rate Blood Pressure Circulatory Bleeding

Cutaneous Rashes, Hives(urticaria) Itching

Signs in an Unconscious Patient

Weak Pulse Fever Hypotension Visible hemoglobinuria Increased operative bleeding Vasomotor instability

Tachycardia, brachycardia, hypotension Oliguria/anuria

Remember

Reactions from different causes can exhibit similar manifestations; therefore, every symptom should be considered potentially serious and transfusion should be discontinued until the cause is determined

Immediate Actions to Take1. Stop the Transfusion2. Notify the attending physician and the laboratory

immediately3. Do clerical check at bedside of identifying tags and numbers4. If symptoms are urticaria and pruritis only, consider

administering antihistimine If symptoms disappear continue transfusion

5. If additional symptoms or hives and itching do not disappear discontinue transfusion

6. Collect blood specimen and first voided urine

Immediate Actions to Take

7. Treat patient symptoms as per physician instructions Take vitals

Pulse Temperature Blood Pressure

8. Document thoroughly Complete reaction form Send form, bag, tubing and set to laboratory

What Happens in the Lab…

Laboratory Actions when Notified of Suspected

Reaction

Quarantine all other crossmatched units When Reaction form, unit, set, tubing, urine

received Centrifuge specimen Clerical Check Review Symptoms

To determine extent of investigation required

Clerical Check

Check test results vs. interpretation Check tag information with bag information

(unit number, ABO/Rh) Check Pre-transfusion specimen information

with tag information (name, number) Check that information on pre-transfusion

specimen is identical to post-transfusion

Visual Inspection

Compare plasma color of pre-transfusion and post-transfusion specimens

Is post-transfusion specimen hemolyzed? If yes, ensure that hemolysis is not due to difficult

collection (recollect if necessary) If still yes, notify physician immediately

Check contents of unit for hemolysis Check blood in tubing for hemolysis

Direct Antiglobulin Test (DAT)

To determine if there is in vivo sensitization May be negative if intravascular hemolysis has

occurred If positive, perform monospecific DAT to

determine if it is IgG, C3 or both

Extended Testing

ABO/Rh on pre and post transfusion specimens ABO/Rh on donor unit Antibody screen on pre and post transfusion

specimens Antibody Investigation, positive

DAT on pre transfusion specimen and donor unit

Reporting Classified as to type of reaction given

symptoms and investigation outcome Should be signed off by laboratory physician or

designate Reference for follow up for any attending physician

questions regarding future transfusions given the patient’s clinical need

Patient should be informed of reaction and outcome

Reporting

Should include future pre medication or special requirements, if applicable Examples

Antihistamines Anti pyretics Washed blood (when anaphylactic reactions are under

investigation and results are not back yet) Antigen negative blood if a clinically significant antibody is

identified

Reporting

Hospitals should report all severe and fatal reactions to the blood supplier Health Canada requires that CBS Head Office

advise them within 24 hours of a fatal reactions and as soon as possible (within 15 calendar days), of a life-threatening or permanently disabling reaction. To comply with this requirement, hospitals should report these types of adverse reactions immediately to their local CBS.

Future Transfusions

Patient should be notified if special requirements are necessary Antibody card

Transfusion reaction investigations and reports should be retained indefinitely by the laboratory

Risk of Suffering a Transfusion Reaction

RBC Alloimmunization: 1-2% Febrile Non-Hemolytic

to Platelets: 20-30% to RBC: 1%

Allergic (mild): 1-3% Circulatory Overload: 1% Acute Hemolytic: 1:12,500

Fatal: 1/600,000 Anaphylaxis: 1/25, 000

The Message

The risk of a severe transfusion reaction is low but health care professionals must have documented procedures for recognition and identification of the adverse effects of transfusion

The outcome Better informed patients, nurses, physicians and

laboratory personnel resulting in quality patient care