Welcome to Tuesday. POTD.
Question: Why do nurses use red pens? ---- answer at the bottom of this e-mail.
Have you ever been sickle to your stomach about consenting patients about the risks of transfusions? Well today we're going to iron out all the details about transfusion reactions
Facts about transfusions
~20,000,000 units of pRBC's are transfused in the US per year
In 2011, 8,000,000 people in America received a transfusion
There were 51,000 reported transfusion reactions (0.64% of transfusions)
317 of them required pressor support, intubation, or ICU care
While screening techniques have reduced the risk of viral transmission, they still exist. in 2010, the risks of viral transmission were estimated:
HIV: 1:1,467,000 units
Hep C: 1:1,149,00 units
Hep B: 1:357,000 units
The initial therapy for ALL transfusion reactions is to STOP THE TRANSFUSION
Types of transfusion reactions and therapies:
Acute Hemolytic Reaction
most severe, easiest to prevent
due to ABO compatibility 2/2 human/lab error ---> patient antibodies attack donor blood
presentation:
within minutes of transfusion initiation
fever, agitation, tachycardia, hypotension, diffuse pain
can progress to jaundice and bleeding 2/2 coagulopathy and DIC
intervention
STOP the TRANSFUSION
IVF to maintain renal perfusion, loop diuretics to maintain urine output, pressors for refractory hypotension
work up
notify blood bank, send a type and screen from the patient AND the bag of donor blood to the blood bank
send labs
peripheral smear, LDH, haptoglobin, bilirubin, direct coombs to assess for hemolysis
repeat CBC, BMP, UA
fibrinogen, D-dimer, coags if concerned for DIC
Febrile non-hemolytic transfusion reaction (FNHTR)
most common, usually due to recipient antibodies against donor leukocytes
STOP the TRANSFUSION
while FNHTR is a benign process, more severe reactions must be ruled out
assess the patient to ensure a more severe reaction isn't occurring (monitor vital signs, assess for pain indicative of acute hemolytic reaction)
Tylenol is the mainstay of treatment
patient's with a history of this can receive leuko-reduced or washed cells for future transfusions
Allergic reactions/anaphylaxis
within minutes the patient will have symptoms of a typical allergic reaction: rash, urticarial, itching. Can progress to an anaphylactic reaction with hypotension, angioedema, and respiratory distress
Treat as an allergic reaction with H1-blockers, adding epinephrine if signs of anaphylaxis are present
If no signs of anaphylaxis, can continue the transfusion
Transfusion-associated Circulatory Overload (TACO)
typically within 6 hours of transfusion initiation, due to fluid overload
may show signs similar to a CHF exacerbation: crackles, peripheral edema, B-lines on US, infiltrate on CXR, hypoxia
obtain an EKG to assess for ACS
positioning (sit upright), diuresis, nitrates, respiratory support as needed
BNP can be helpful if a pre-transfusion BNP was drawn
prevent this by transfusions SLOWLY in at risk patients (Heart failure, renal failure patients)
Transfusion Related Acute Lung Injury (TRALI)
Similar presentation to TACO, within the same 6 hour timeframe
both present with dyspnea, crackles, hypoxia, bilateral infiltrates on CXR
TRALI is non-cardiogenic pulmonary edema due to donor antibodies attacking recipient leukocytes causing cytokine release --> increased permeability in pulmonary capillary membranes -- > ARDS
so will not have signs of cardiogenic fluid overload = NO peripheral edema, normal cardiac function
STOP the transfusion
manage as an ARDS patient
respiratory support
if intubation is required, use lung protective ventilation strategies
diuretics are NOT helpful. but if there is concern for an underlying cardiac problem you may administer them
Sepsis
due to bacterial contamination of donor blood
will show signs of septic shock.
can be confused with early stages of acute hemolytic reaction --> send the appropriate labs to rule that our
send cultures from patient and from donor blood
manage sepsis as per usual, broad antibiotic coverage
IVF, sepsis protocols, get your eyes on that lactate measuring and re-measuring
There are also several delayed reactions
Graft Versus Host Disease (GVHD)
7-10 days after transfusion
due to donor lymphocytes attacking an immunocompromised patient’s cells or when immunologically similar lymphocytes are transfused and not recognized as donor/foreign cells by the patient’s immune system
fever, jaundice, pancytopenia, transaminitis
prevented by using irradiated blood products in high-risk populations (immunocompromised
supportive treatment, though nearly 100% fatality rate
immunosuppressants, steroids, cytotoxic agents, and stem cell transplantation rescue have been used, though with questionable efficacy
Delayed hemolysis
5-10 days after transfusion
less severe form of acute hemolytic reaction due to antibodies against minor RBC antigens
typically minor hemolysis and progressive anemia
supportive care, transfuse as necessary; discuss with blood bank
And a brief word on effects of massive transfusion
Coagulopathy can occur from dilutional effect of administering pRBC alone without clotting factors. prevent by using MTP
Hypothermia can result form using cold blood products. Prevent by warming products
hypocalcemia can result from citrate binding. Can administer empiric calcium gluconate
hyperkalemia can result. monitor potassium levels and treat accordingly
Acidosis can result from large amounts of lactic acid in stored blood
Why do nurses use red pens?
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Because they draw blood!!!!
Thank you Ankit and Rebecca of our pharmacy department for your insight into today's Pearl.
-Elly