Principles I - Exam Ii - Blood Transfusion Reactions And Complications

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acute hemolytic blood transfusion reaction is caused by

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ABO incompatibility, (misidentification of patient, blood specimen, blood unit)

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how common is acute hemolytic blood transfusion reaction

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1:6000

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symptoms of acute hemolytic blood transfusion reaction if awake

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chills, nausea, fever, dyspnea, chest pain, flank pain, headache

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symptoms of acute hemolytic blood transfusion reaction if asleep under anesthesia

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increased temperature, unexplained tachycardia, hypotension, hemoglobinuria, oozing, DIC, shock, renal failure

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what symptom of acute hemolytic blood transfusion reaction if under general anesthesia is not likely to be explained by other causes

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hemoglobinuria

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if suspect an acute hemolytic blood transfusion reaction

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recheck blood, stop transfusion, notify blood bank, send unused blood and tubing back, draw CBC, coags, type and cross, check urine for hemoglobinuria, osmotic diuresis with mannitol and fluids (to flush out kidneys), low dose dopamine, replace blood loss, platelets, FFP, steroids possibly

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characteristics of a delayed hemolytic reaction after blood transfusion

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mild, less common antigen-antibody reaction, 1:1,500 transfusions, 2 - 21 days after transfusion

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symptoms of delayed hemolytic reaction

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malaise, jaundice, fever

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treatment for delayed hemolytic reaction

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supportive

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nonhemolytic immune reactions occur because

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recipient is sensitized to donors WBC, platelets, or plasma proteins

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most common symptom of nonhemolytic immune reaction to a blood transfusion

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fever (3-5% of all transfusions)

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treatment for nonhemolytic immune febrile reaction

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stop infusion, antipyretices
in future transfusions patient should only receive leukocyte poor transfusions

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types of nonhemolytic immune reactions

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febrile, uticarial reaction, anaphylactic reaction, TRALI

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symptoms of uticarial reaction

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erythema, hives, itching, no fever

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treatment for uticarial reaction to a blood transfusion

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Antihistamine blockers H1 and H2

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how common are uticarial reactions to blood transfusions

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1% of all transfusions

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possible cause of uticarial reactions

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sensitization to transfused plasma proteins

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how common are anaphylactic reactions to blood transfusions

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1:150,000

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anaphylactic reactions to blood transfusions caused by

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IgA antibodies

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treatment for anaphylactic reaction to blood transfusion

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epinephrine, corticosteroids, H1 and H2 blockers, cardiovascular support (in the future patient should only receive washed cells and IgA free blood)

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symptoms of anaphylactic reaction under anesthesia

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hives, elevation in airway pressures, wheezing, decreased pulse ox, tachycardia

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TRALI stands for

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transfusion related acute lung injury

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TRALI is how common

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1:10,000

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TRALI caused by

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white cells aggregating in pulmonary circulation causing alveolar capillary damage

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treatment and symptoms of TRALI

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same as ARDS

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TRALI resolves within

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12 - 48 hours

Front 27

what to check when checking blood

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right patient (all must have ID band)
right MRN
right unit
right blood type
expiration date
(read out loud, repeat out loud)

Front 28

graft-host disease occurs in what patient population

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immunocompromised patients

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graft-host disease in blood transfusions is caused by

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the lymphocytes of the donor blood attacking the host

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for immunocompromised people needing blood, you should give

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only irradiated blood products that have hopefully killed the lymphocytes since filters do not effectively remove all the lymphocytes

Front 31

how is the immune system is affected by blood transfusion

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the transfusion of leukocytes causes immunosuppression which is good in organ transplants but bad if it helps tumors grow

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infection risk of hepatitis A

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1:1,000,000

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infection risk of hepatitis B

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1:30,000 to 250,000

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infection risk of hepatitis C

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1:30,000 to 150,000 (most common infection from blood transfusion)

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infection risk of HIV

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1:200,000 to 2,000,000

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infection risk of human T-lymphocyte virus I/II (HTLV)

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1:250,000 to 2,000,000

Front 37

what % of the population has been exposed to CMV (cytomegalovirus)

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50% - 80% of the population - 50% of donors have an antibody presence

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symptoms of CMV are

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mono-like in healthy people

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CMV can cause severe infections in immunocompromised patients such as

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retinitis, pneumonitis, gastroenteritis, hepatosplenomegally, risk of death

Front 40

reduce incidence of CMV with blood transfusions by

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leukocyte filters

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risk of Parvovirus B-19 with blood transfusion is

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1:10,000

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parvovirus b-19 is a problem for

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pregnant patients - may cause hydrops fetalis, stillbirth

Front 43

other diseases possibly transmitted by blood transfusions (very rare)

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Epstein-Barr, Human herpes 4 and 6, Syphilis, West Nile (no proven cases), Creutzfeld Jakob (not sure either - but seems possible)

Front 44

what about syphilis and blood transfusions

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syphilis doesn't survive cold storage, but platelets are kept at room temperature so could be a risk

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Creutzfel Jakob disease is

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a fatal neurodegenerative disease transmitted by prion infected meat and dura mater grafts, corneal transplants, reuse of EKG electrodes, pituitary growth hormone injections, and potentially blood transfusions

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examples of prion caused diseases

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Scrapie (sheep), bovine spongiform encephalopathy (mad cow disease), chronic wasting disease (deer and elk), Kuru (New Guinea tribe that ate the brains)

Front 47

prions infect and propagate by

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folding themselves into protein structures in the cells

Front 48

why did the Red Cross have to pay 4.5 million $$$$

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did not ask blood donors if they had been to Europe and eaten beef

Front 49

What is the chance of receiving contaminated PRBCs

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1:500,000

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death rate if receive contaminated PRBCs

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50%

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chance of receiving contaminated platelets

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1:12,000 - high death rate

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contamination in PRBC or platelets is due to

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bacteria on the skin during the donation process

Front 53

changes in stored blood

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increased plasma potassium, ammonia, lactate levels, red cell lysis
decreased pH, 2,3 DPG, RBC ATP levels

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what is citrate intoxication

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the CPDA anticoagulant preservative solution in a unit of PRBCs contains citrate that binds ionized calcium - so large transfusions (more than 1 unit) can cause a reduction in serum ionized calcium

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signs and symptoms of citrate intoxication

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hypotension, narrow pulse pressure, prolonged Q-T, wide QRS, coagulopathy

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what to remember about Citrate

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it is metabolized by the liver to bicarb over a few days - so watch for alkalosis later on

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treatment for citrate intoxication

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0.2 - 0.25 ml/kg calcium chloride (10%) over 10 minutes and recheck ionized calcium

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CPDA binds calcium causing

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decreased heart contractility, decreased clotting, vasodilation because decreased smooth muscle contractility

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why don't we give LR with PRBCs

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LR contains calcium and citrate will bind to the calcium to cause microaggregate clot formation (may lead to TRALI). Also, LR is slightly hypoosmotic

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續出

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속출
successive[frequent] occurrence, a succession[series] (of events) [continue + appear]

Front 61

what is the cause of metabolic acidosis during blood transfusions

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usually due to an effect of hypoperfusion not the blood transfusion, the body is very effective at buffering several units of blood

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why and when do you see metabolic alkalosis related to blood transfusions

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citrate metabolism to bicarb in the liver so will see metabolic alkalosis several days after blood transfusions sometimes

Front 63

does the oxyhemoglobin dissociation curve shift left or right with blood transfusions

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overall left shift with banked blood because of reduced temperature and reduced 2,3 DPG even though the acidosis would want to shift it right

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why risk of hyperkalemia with blood transfusions (Gayles never seen this as a real problem)

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as H+ increase, K+ moves out of cells to maintain neutrality
red cell lysis if PRBCs transfused through small bore catheter
hypotonic infusion solution

Front 65

problems from hypothermia in RBC transfusion

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decreased CO, vasonconstriction, shift left on oxyhemoglobin dissociation curve, coagulopathy, shivering

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shivering increases O2 consumption by

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400%

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when transfusing cold blood

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WARM it (will help anesthesia work better as well as prevent other side effects of hypothermia)

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what lab values will you see with dilutional coagulopathy from RBC transfusions

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thrombocytopenia will develop before loss of coag factors so give platelets

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how to differentiate between dilutional coagulopathy and DIC

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platelets will be the issue with dilutional coagulopathy whereas DIC will see big increase in FSP (D-dimer)

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what is D-dimer

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one of the FSP

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risks associated with blood transfusions

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disease transmission, graft-host disease, immune suppression, citrate intoxication, left shift of dissociation curve, hyperkalemia, hypothermia, dilutional coagulopathy, acute hemolytic reactions, non-hemolytic reactions, TRALI

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What to know about Jehovah's witnesses and blood transfusions

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will not accept donated blood or blood that has left the circulation, closed systems are sometimes OK (CABG), sign blood refusal form, eliminate religious pressure by talking to patient alone, remember some other products are partial blood products, may give procrit, epogen for 2-6 weeks before seeing result

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conservation strategies for preventing too much blood loss

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autologous blood, discourage family donation of blood, cell saver, CT autotransfusions, tourniquets, acute normovolemic hemodilution

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What about cell saver?

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anticoagulate blood - spins out RBC's, washes the cells with saline, all platelets coags removed, Hct 45 - 50%,

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Secured Party versus Purchaser

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1. General rule = secured party prevails
2. Debtor has permission to sell = purchaser prevails
3. Secured party unperfected at time of purchase - purchaser wins if (1) buyer gives value, (2) receives delivery of item, and (3) has no knowledge of security interest at time of delivery; but if PMSI creditor perfects within 20 days after debtor receives collateral but after debtor sells collateral to purchaser, creditor will prevail over the "gap" purchaser
4. Buyers in the ordinary course of business can prevail even over a perfected creditor if (a) good faith, (b) without knowledge of security interest violation, (c) purchase of goods that are not farm goods, (d) ordinary purchase from person in the business of selling goods of the kind, (e) security interest created by seller, and (f) creditor not perfected by possession

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HCT of PRBC

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70%

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why not family donated blood

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sets up family for deception

Front 78

describe acute normovolemic hemodilution

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remove blood prior to surgery, replace with crystalloid so fewer RBCs are loss during surgery, return with own blood after surgery with none of the risks associated with storage of blood

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contraindications for acute normovolemic hemodilution

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anemia, decreased renal function, CAD, carotid disease, pulmonary disease, liver disease, inadequate vascular access

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2 complications of acute normovolemic hemodilution

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MI and cerebral hypoxia