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醫療安全暨品質討論會血品使用與急性反應處理

朱芳業臨床病理科主任 品質管理中心主任

(14:10~14:35 台大醫院第七講堂 )

精神 誠勤樸慎 創新宗旨 持續提升醫療品質 善盡社會醫療責任願景 成為民眾首選的醫學中心

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大綱什麼時後該輸血急性輸血反應之處置結語

案例 病患因疑似輸血過敏呼吸喘 0:00AM ，停止輸血，通知值班醫師，予藥物 Solucortef 100mg IV → Brircayl 1Amp IH → Solu-medrol 40mg IV → Bosmin 3mg SC → Bricanyl IH 仍未改善，喘、 wheezing 重， ABG 呈酸中毒，經醫師評估予家屬解釋，預 on endo 緩解，並聯絡轉床

ICU 表示先於病房中 on 上 endo 後再轉，所以先 on endo （ 1AM 左右）。於 on endo 中， on 上時發現病人心搏變緩且至停止（ 1AM30）故 call 9595 並予 2Am 轉床

病人血品（ PRBC 2U ）只輸約 150ml ，已請值醫 key 過敏通報，詢問血庫人員是否須將剩餘血品退回血庫檢驗，血庫人員表示應是白血球過敏，直接將剩餘血品丟掉即可

• 輸血 150 ml 呼吸喘，要懷疑什麼輸血反應，進行那些評估• Solucortef, Bricanyl, and Bosmin 是適當的處置嗎 ?• ABG 呈酸中毒， Ventilatory support 適當嗎 ?• 直接將剩餘血品丟掉恰當嗎 ?• 什麼是輸血過敏 ?

(TPR 通報案例 )

案例 A 81 year-old female 2012/08/02 14:45 Transfused 2U PRBC (CPD-SAGM) 2012/08/02 16:40 SOB, room air SPO2 79~86%, rales (+) developed

after transfusion of 320 ml of PRBC◦ Gave O2 mask 10 L/min, Furosemide 40 mg IV stat, Atrovent + Bricanyl

inhalation◦ CXR : Cardiomegaly

2012/08/03 14:45 ~ 16:27◦ Transfused 1U of LPR 2U and discarded the remaining 1U◦ Diphenylhydramine 30 mg IV stat before transfusion

2012/08/04 12:00 ~ 15:15◦ Transfused 1U of LPR 2U and discarded the remaining 1U◦ Furosemide 40 mg IV stat after transfusion

2012/08/04 23:11 SOB, four limbs edema I/O +700ml

• 血品的選用恰當嗎 ?• 輸血前給予 Diphenylhydramine 30 mg IV stat 是恰當的嗎 ?• 丟棄 1U LPR 是必要的嗎 ?

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No TransfusionNo Transfusion

Reaction

Safe Transfusion : Processes Not Just Product

A+

Recruit

Screen donor

Collect & Process

TTD test

Product

Process

Pre-transfusion testing

Reason for Tx

Patient sample

Issue

AdministerMonitor

&Evaluate

(Adapted from Dzik, W. H. Hematology 2005;2005:476-482)

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Reason for Transfusion

General Recommendations for Appropriate Hemoglobin Transfusion Thresholds

American Society of Anesthesiologists task force, 1996 British Committee for Standards in Haematology, 2001 Australian and New Zealand Society of Blood

Transfusion, 2001

Why transfusedIt Depends…Why not transfused

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None of these guidelines recommended a specific transfusion trigger

7 8 g/dL

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Red Blood Cell TransfusionA Clinical Practice Guideline From the AABB

Recommendation 1:The AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients(Grade: strong recommendation; high-quality evidence)

(Ann Intern Med. 2012;157:49-58.)

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Red Blood Cell TransfusionA Clinical Practice Guideline From the AABB Recommendation 2:

The AABB suggests adhering to a restrictive strategy in hospitalized patients with preexisting cardiovascular disease and considering transfusion for patients with symptoms or a hemoglobin level of 8 g/dL or less(Grade: weak recommendation; moderate-quality evidence)

(Ann Intern Med. 2012;157:49-58.)

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Red Blood Cell TransfusionA Clinical Practice Guideline From the AABB

Recommendation 3:The AABB cannot recommend for or against a liberal or restrictive transfusion threshold for hospitalized, hemodynamically stable patients with the acute coronary syndrome(Grade: uncertain recommendation; very low-quality evidence)

(Ann Intern Med. 2012;157:49-58.)

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Red Blood Cell TransfusionA Clinical Practice Guideline From the AABB

Recommendation 4:The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration(Grade: weak recommendation; low-quality evidence)

(Ann Intern Med. 2012;157:49-58.)

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Comment Recent guidelines recommended a restrictive

strategy (transfusion when the hemoglobin level is less than 7 g/dL) for adult trauma and critical care patients, with the exception of those with acute myocardial ischemia

Avoiding transfusion based only on a hemoglobin trigger. Instead, the decision should be guided by such individual factors as bleeding, cardiopulmonary status, and intravascular volume

European Society of Cardiology has recommended : Withholding transfusion in patients with the ACS unless the hemoglobin concentration decreases to below 8 g/dL

Current Prophylactic Platelet Transfusion Thresholds (AABB)Patient Category Platelet Count

All patients 10,000/L

- or-

Stable patient 5,000/L

Patient with fever or recent hemorrhage (now stopped)

10,000/L

Patient with coagulopathy, on heparin, or with anatomic lesion likely to bleed

20,000/L

Note : These levels are most commonly applied to inpatient. Adjustment of the transfusion threshold may be necessitated by unusual clinical situations.

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Although platelet source, ABO compatibility, and duration of storage exert a modest impact on both absolute and corrected posttransfusion platelet increments, they have no measurable impact on prevention of clinical bleeding.

(BLOOD 2012;119(23):5553-62)

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What’s The Point? Current studies favor a restrictive

transfusion strategy More RCT for some clinical situations

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急性輸血反應之處置

Adverse Effects of RBC Transfusion Contrasted with Other Risks

(Ann Intern Med 2012;157: 49-58. )18

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Acute Complications Of Transfusion

Occur during or shortly after (within 24 hours) the transfusion

Broadly classified into three categories according to their severity and the appropriate clinical response

Guidelines for the Recognition & Management

of Acute Transfusion ReactionsCATEGORY SIGNS SYMPTOMS POSSIBLE CAUSE

CATEGORY 1 :

MILD REACTIONS

Localized cutaneous

reactions:

-Urticaria

-Rash

Pruritus (itching) Hypersensitivity (mild)

CATEGORY 2 :

MODERATELY SEVERE REACTIONS

Flushing

Urticaria

Rigors

Fever

Restlessness

Tachycardia

Anxiety

Pruritus (itching)

Palpitations

Mild dyspnea

Headache

Hypersensitivity (moderate-severe)

FNHTR:

Ab to WBC, PLT

Ab to proteins, including IgA

Possible contamination with pyrogens and/or bacteria

CATEGORY 3 :

LIFE-THREATENING REACTIONS

Rigors

Fever

Restlessness

Hypotension (fall of

≥20% in systolic BP)

Tachycardia (rise of

≥20% in heart rate)

Hemoglobinuria

(red urine)

Unexplained

bleeding (DIC)

Anxiety

Chest pain

Pain near infusion

site

Respiratory

distress/shortness

of breath

Loin/back pain

Headache

Dyspnoea

Acute intravascular hemolysis

Bacterial contamination and septic shock

Fluid overload (TACO)

Anaphylaxis

Transfusion-associated lung injury (TRALI)

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Drugs that may be required in the management of acute transfusion reactionsTYPE OF DRUG RELEVANT

EFFECTEXAMPLES NOTES

Name Route and dosage

Intravenous replacement fluid

Expand blood volume

Normal saline If patient hypotensive, 20-30 ml/Kg over 5 minutes

Avoid colloid solutions

Antipyretic Reduce fever and inflammatory response

paracetamol Oral or rectal

10 mg/Kg

Avoid aspirin containing products if patient has low platelet count

Antihistamine Inhibit histamine mediated responses

Chlorpheniramine IM or IV

0.1 mg/Kg

Bronchodilator Inhibits immune mediated bronchospasm

Adrenaline

Consider salbutamol

Aminophylline

0.01 mg/Kg by slow IM injection

By nebulizer

5 mg/Kg

Dose may be repeated every 10 minutes according to blood pressure and pulse until improvement occurs

Inotrope Increases myocardial contractility

Dopamine

Dobutamine

IV infusion 1 g/kg/min

IVinfusion 1-10 g/kg/min

Dopamin in low doses induces vasodilation and improves renal perfusionDoes above 5 ug/kg/min cause vaso-constriction and worsen heart failure

Diuretics Inhibit fluid reabsorption from ascending loop of Henle

Frusemide Slow IV injection

1 mg/Kg

Platelets, Cryoprecipitate, Fresh frozen plasma

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Key Recommendation Initial treatment of ATR is not

dependent on classification but should be directed by symptoms and signs. Treatment of severe reactions should not be delayed until the results of investigations are available. (1C)

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Category 3 Life-threatening Reactions

Acute intravascular hemolysis Bacterial contamination and septic

shock Transfusion-associated circulatory

overload (TACO) Anaphylactic shock Transfusion-associated acute lung

injury (TRALI)

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Category 3Life-threatening Reactions

Signs Rigors Fever Restlessness Shock Tachycardia Hemoglobinuria (red

urine) Unexplained

bleeding (DIC)

Symptoms Anxiety Chest pain Respiratory

distress/shortness of breath

Loin/back pain Headache Dyspnea

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Transfusion-associated Circulatory Overload (TACO)

When too much fluid is transfused, the transfusion is too rapid or renal function is impaired, fluid overload can occur resulting in heart failure and pulmonary edema

Patients with chronic severe anemia, underlying cardiovascular disease, and infants are particularly at risk, especially during rapid transfusion

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Transfusion-associated Circulatory Overload (TACO)

Management◦Stop the transfusion◦Administer O2 and diuretics as required

Prevention◦Avoid unnecessary fluids◦Use appropriate infusion rates◦Give diuretic before transfusion may be

required

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Transfusion-associated Acute Lung Injury

TRALI is usually caused by donor plasma that contains antibodies against the patient’s leucocytes

Donors are almost always multiparous women

Usually presents within 1 to 4 hours of starting transfusion

Rapid failure of pulmonary function with diffuse opacity on the chest X-ray

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Transfusion-associated Acute Lung Injury

Incidence◦In North America

Quebec 1/100,000-1/10,000 transfusions United States 1/5,000-1/1,323 transfusions

◦In Europe (rarer) 1.3/1,000,000-1/7,900 transfusions

◦True incidence remains unknown

Blood Reviews (2006) 20, 139–159

Definition of TRALI TRALI

◦ Acute onset◦ PaO2/FiO2 ≤ 300 or SpO2 < 90% on room air◦ Bilateral lung infiltrates on chest X ray◦ No evidence of left atrial hypertension◦ Occurrence during or within 6 hours of transfusion◦ No preexisting ALI before transfusion or temporal

relationship to an alternative ALI risk factor

Possible TRALI◦ In cases of TRALI occurring in the setting of transfusion

and an alternative risk factor for ALI◦ These alternative risk factors included a variety of

conditions that may directly or indirectly induce lung injury, such as pneumonia, pulmonary contusion, and sepsis.

 (Canadian Consensus Conference Panel on TRALI, 2004 )29

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Transfusion-associated Acute Lung Injury

Management◦No specific therapy - Intensive respiratory

and general support in an ICU is required◦Symptoms generally resolve over 24 - 48

hours Prevention

◦Diverting plasma units from multiparous women from the blood supply

Comparison of TRALI and TACOTRALI TACO

Patient characteristics More frequently reported in hematology and surgical patients

May occur at any age, but characteristically age > 70

Type of component Usually plasma or platelets Any

Speed of onset During or within 6 hours of transfusion, usually within 2 hours.

Defined as occurring within 6 hours of Transfusion

Oxygen saturation Reduced Reduced

Blood pressure Often reduced Often raised

JVP Normal Raised

Temperature Often raised Usually unchanged

CXR findings Often suggestive of pulmonary edema with normal heart size: may be a whiteout

Cardiomegaly, signs of pulmonary edema

Echo findings Normal Abnormal

Pulmonary wedge pressure

Low Raised

Full blood count May be fall in neutrophils and monocytes followed by neutrophil leucocytosis

No specific changes

Response to fluid load Improves Worsens

Response to diuretics Worsens Improves

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Summary No transfusion no transfusion reaction Current studies favor a restrictive

transfusion strategy, though more RCT for some clinical situations

TACO and TRALI should be considered and treated as in patients developing respiratory distress during or shortly after transfusion

Management of ATRs is not dependent on classification but should be guided by symptoms and signs

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Thanks for Your Attention !

jacpha@mail/femh.org.tw