Blood Bank Exam 3: Adverse Events of Transfusion

what does the blood collection process look like for donors?

they answer a bunch of screening questions

what do the screening questions pertain to

risk behavior

medical history

what risk behaviors are asked about?

use of IV drugs

exposure to hepatitis

what medical history is a concern for blood donors (3)

previous cancer

mad cow disease

previous donation or transfusion

why are donor screening questions so important?

because it can be the only way that we can detect certain diseases that we don't have good tests for.

what are some diseases that cant be tested for that we ask about in the screening questions (3)

malaria

ebola

CJD

what are the two kinds of tests we do for donor testing

antibody tests

nucleic acid testing

what are the diseases we look for in antibody donor testing (4)

HIV

Hep C

HTLV

Hep B

what are the diseases we look for in nucleic acid donor testing (5)

Hep B virus

HCV

HIV-1

West nile virus

zika virus

what are the two things every unit is tested for

hep B surface antigen

serologic testing for syphilis

what are other optional tests for donor units

trypanosoma cruzi

babesia in endemic states

what needs to be done when blood is going into the patient

look for transfusion reaction symptoms

patient pretransfusion testing

two step verification when released from blood bank

two step verification at the bedside prior to infusion

what is the only thing that can be transfused with blood

normal saline

how quickly should blood be transfused

SLOWLY

what are the most common causes of death from blood transfusion (3)

TRALI

TACO

ABO incompatability

what are the four categories of transfusion events

acute reaction with fever

acute reaction without fever

delayed reaction with fever

delayed reaction without fever

what are the acute reactions with fever (4)

acute hemolytic reaction (HTR)

febrile nonhemolytic (FNHTR)

transfusion related sepsis

TRALI

what are the acute reactions without fever (3)

Allergic response

hypotensive

TACO

what are the delayed reactions with fever (3)

delayed hemolytic reaction (HTR)

delayed serologic

TA-GVHD

what are the delayed reactions without fever (3)

delayed serologic

post transfusion purpura

iron overload

what is the cause of an acute hemolytic transfusion reaction (usually)

transfusing ABO incompatible blood

usually due to a clerical error

define an acute hemolytic transfusion reaction

immediate and severe interaction between antibodies and RBCs

what are the major signs and symptoms of acute hemolytic reaction

chills

fever

hemoglobinuria

renal failure (back pain)

DIC

pain at infusion site

anxiety

what is the usual cause of death when someone dies from an acute hemolytic reaction

renal failure

what is a common symptom that is asked about on tests regarding acute hemolytic transfusion reactions

anxiety

what is the first thing we should we do when someone is experiencing an acute hemolytic transfusion reaction?

STOP THE TRANSFUSION

what needs to be done before the workup when someone has had a acute hemolytic transfusion reaction

check for clerical errors

draw new blood sample

visually inspect the sample for hemolysis

send urine

what values are altered in acute hemolytic transfusion reaction

hemoglobin increased

haptoglobin decreased

LDH increased

bilirubin increased

what should we do in the lab for a acute hemolytic transfusion reaction

repeat ABO

DAT test

run urine for hemoglobinuria

test haptoglobin, hemoglobin, LDH, and bilirubin

how common is is a febrile nonhemolytic reaction

most common acute reaction which results in fever

1:200 transfusions

what is the cause of febrile nonhemolytic reactions

HLA antibody in the donor

accumulated cytokines in the bag

in which populations are febrile nonhemolytic reactions more common

young

old

what are the signs and symptoms of febrile nonhemolytic reaction

chils

fever

headache

may see BP or HR changes

how can we prevent febrile nonhemolytic reactions (2)

leukocyte reduction of blood products

antipyretic premedication (controversial)

what lab testing do we do for febrile nonhemolytic reactions

ABO/Rh

DAT

rule out hemolysis

how does bacterial contamination of blood products happen?

contamination from phlebotomy site

silent bacteremia in the donor

which blood products are more susceptible to bacterial contamination and why?

platelets since they are stored at room temp

some bacterial contamination of blood products happens in the refrigerator. which bacteria like the cold?

pseudomonas

citrobacter

yersinia enterocolitica (loves iron)

how can we prevent bacterial contamination of blood products

careful donor prep

diversion pouch

bacterial testing of PLTs

pathogen inactivation

how does pathogen inactivation work?

psoralen and UV light "handcuffs" DNA in the product

how effective is pathogen inactivation

99.99%

what does TRALI stand for

transfusion related acute lung injury

what are the signs and symptoms of TRALI

respiratory distress

chills

fever

hypotension

what blood products have higher instances of TRALI

plasma

PLTs

what are the two hypothesis for why TRALI happens

donor antibody hypothesis

two hit hypothesis

what is the donor antibody hypothesis

HLA antibody in donor product

binds to patients neutrophils

aggregates in the lungs

what is the two hit hypothesis

sometnins causes neutrophils to aggregate in the lungs

transfusion of stored blood accumulates lipids which activates antibody to neutrophils

what do we see on the x ray for TRALI

bilateral "fog" look. the infiltrate is all over

what is the management for TRALI

STOP TRANSFUSION

aggressive respiratory support

report to blood supplier

how long does it take patients to recover from TRALI

2-4 days

what is the mortality rate from TRALI

<10%

is TRALI common?

no

what are the delayed reactions with fever

delayed hemolytic reaction (HTR)

delayed serologic

TA-GVHD

what causes delayed hemolytic reactions

antibody in the blood that was missed during the antibody detection test

how soon do delayed hemolytic reactions take place

5-7 days after the transfusion

what are the signs and symptoms of delayed hemolytic reactions (5)

fever

decreasing hemoglobin

new positive antibody detection test

positive DAT is likely

mild jaundice

what is the treatment for delayed hemolytic reactions

ID the antibody and transfuse accordingly

look at patient history

when does the lab usually end up detecting delayed hemolytic reactions

1-2 months after the transfusion

how does graft vs host disease work

white blood cells from the donor blood attack the recipient

how do we prevent graft vs host disease

irradiate the blood to inactivate WBCs

how fatal is graft vs host disease

90%

which population is more likely to get graft vs host disease

immune compromised patients

what are the acute reactions without fever

Allergic response

hypotensive

TACO

what is the most common cause of transfusion reaction

allergic reaction

when do we suspect an allergic transfusion reaction

when hives are the only symptom

what should we do when there is an allergic transfusion reaction

document, but no need to do follow up testing

what is another word for a allergic transfusion reaction which is not that serious

urticarial reaction

what is an anaphylactic transfusion reaction

severe but rare allergic reaction to a blood product

when does anaphylactic transfusion reaction happen

when a patient has very little IgA and produces an Ab to IgA

what does the patient need to receive to prevent anaphylactic transfusion reaction when it is suspected it might happen

give IgA deficient blood products

what is the treatment for anaphylactic transfusion reaction

epinephrine

antihistamine

beta-2 agonists

what are the signs and symptoms of anaphylactic transfusion reaction

bronchospasm

hypotension

urticaria

local edema

anxiety

what is a hypotensive reaction

>30 mmHg

drop in systolic pressure within 1 hour of transfusion

what is the only symptom in a hypotensive reaction (usually)

hypotension

what are the other possible symptoms in a hypotensive reaction (3)

facial flushing

dyspnea

abdominal cramping

what does TACO stand for

transfusion associated circulatory overload

what is the cause of TACO

giving too much blood volume, going too fast with the transfusion

what is the treatment for TACO

STOP TRANSFUSION

seat patient upright

diuretics/oxygen

phlebotomy in severe cases

what symptoms do we see with TACO (4)

dyspnea

cyanosis

severe headache

hypertension

what two transfusion reactions are commonly confused for eachother

TRALI and TACO

TRALI vs TACO

which is more common?

TACO

TRALI vs TACO

which has an elevated BNP

TACO

TRALI vs TACO

which has a normal BNP

TRALI

TRALI vs TACO

which is associated with HYPOtension

TRALI

TRALI vs TACO

which is associated with HYPERtension

TACO

TRALI vs TACO

which is associated with diffuse fluid in the lungs. does not move when the patient is moved/sat upright

TRALI

TRALI vs TACO

which is associated with fluid in the lungs which goes away when the patient is sat up

TACO

TRALI vs TACO

which is more severe

TRALI

TRALI vs TACO

which is associated with fever

TRALI

what are the delayed reactions without fever

delayed serologic

post transfusion purpura

iron overload

how common is post transfusion purpura?

not common

what is post transfusion purpura

PLT antibody destroys a patients PLTs leading to severe thrombocytopenia 5-10 days after transfusion

what is the treatment for post transfusion purpura (2)

usually self limiting

can use IVIg or plasma exchange

how does iron overload happen?

when someone is chronically transfused

what is the treatment for iron overload? (2)

chelation therapy

RBC exchange

what conditions may require regular transfusion

congenital anemias

what mechanical events can cause a transfusion reaction

hemolysis due to heat/cold

air embolism/microembolism

why would hemolysis due to heat/cold happen?

improper storage/handling of the product

why might air embolism/microembolism happen?

transfusing too fast, not using the right equipment

what is a massive transfusion?

replacement of a patients entire blood volume