Transfusion Reactions Past Paper 2024-2025

Transfusion Science Transfusion Reactions Dr Ross Pallett HCPC Biomedical Scientist: BS71638 [email protected]  Preparation For this lecture you’ll need… Listened to the Coffee! NHSBT lecture ...

Transfusion Science Transfusion Reactions Dr Ross Pallett HCPC Biomedical Scientist: BS71638 [email protected]  Preparation For this lecture you’ll need… Listened to the Coffee! NHSBT lecture  Aim and Objectives Aim To discuss compatibility testing in the blood transfusion laboratory and introduce the various types of transfusion reactions Following this lecture, you should be able to: 1. Describe the purpose of cross-matching 2. Understand the range of transfusion reactions that can occur 3. Understand how the blood bank laboratory investigates transfusion reactions  Blood Grouping 9 important blood group systems in humans System System Number Number of System Name Major Antigens Symbol Antigens ABO ABO 001 4 A, A1, B MNS MN 002 49 M, N, S, s, U P P 003 3 P1 Rh (Rhesus) Rh 004 55 C, Cw, c, D, E, e Lutheran Lu 005 27 Lua Kell K 006 36 K, k, Kpa Lewis Le 007 6 Lea, Leb Duffy Fy 008 5 Fya, Fyb Kidd Jk 009 3 Jka, Jkb Blood grouping is based upon the presence or absence of antigens upon the red cell surface  ABO antigens and Landsteiner’s Law Genes for the ABO antigens are located upon chromosome 9 Inherited in an autosomal dominant fashion Landsteiner’s Law - whenever an antigen is present, the corresponding antibody is absent The ABO system is the only system where the antibodies are predictably present Glu = Glucose Gal = Galactose GlcNac = N-Actyl glucosamine GalNac = N-Actyl galactosamine Fuc = Fucose  Acceptance Criteria Samples and request forms must be labelled immediately (handwritten) Minimum identifiers: 1. Correct forename and surname 2. DOB 3. Hospital Number 4. Sample date 5. Collection time Request form must be signed Zero Tolerance Policy to Errors!  Cross-Matching The transfusion of red cells is varied but generally occurs due to blood loss, surgery, sickle cell disease, thalassaemia, cancer treatment and anaemia with symptomatic problems Compatibility testing is determined through Group and Antibody Screen: 1. Determining the patient’s ABO and Rh D blood group 2. Screening the patient’s serum for the presence of clinically significant antibodies  Cross-Matching Ensure compatibility between a unit of blood and the patient Patient’s location, type, amount, date and time required Special requirements e.g. CMV negative or irradiated Signature and name of person requesting the blood Usually takes 35-40 minutes  Cross-Matching – Electronic Issue 1. Electronic cross-matching Cross-matching is performed using LIMS (non- serological issue of red cells) Criteria: 1. ABO and Rh D group on the current sample and antibody screen matches historical record 2. Group and antibody screen are complete, fully automated and no manual amendments have been made to the record 3. Historic and current negative antibody screen  Immediate Spin Cross-Matching 2. Cross-matching 1. Donor red cells are arranged in order they will be tested 2. The gel card is labelled 3. Centrifuge donor red cells (~30 s) and make a 0.8% red cell suspension 4. 50 µl of donor red cell suspension are added to the appropriate wells in the gel card 5. 25µl of the patient’s plasma is added to the wells 6. The sample is incubated at 37 °C for 15 minutes 7. If the patient has an Ab against the donor, it binds 8. Card is centrifuged and antibodies are trapped within the anti-human globulin microcolumn gel  Cross-Matching 2. Cross-matching 9. Ensure the patient and unit details are printed correctly on the compatibility labels and this is attached to the blood being issued 10. The unit is then placed into the issue fridge Cross-Matching  Transfusion Reactions Many different types of transfusion reactions: 1. Acute Haemolytic Reaction 2. Delayed Haemolytic Transfusion Reaction 3. Unit contamination with bacteria 4. Severe Allergic Reaction 5. Transfusion Associated Acute Lung Injury (TRALI) 6. Transfusion Associated Circulatory Overload (TACO) 7. Post-transfusion purpura (PTP) 8. Non-haemolytic Febrile Transfusion Reaction (NHFTR)  Acute Transfusion Reaction Occur within 30-60 minutes following a transfusion Transfusion of red cell units to which the patient has antibodies Rapid destruction of donor cells – release of cytokines Fever, chills, rigors, pain, vomiting, tachycardia and hypotension DIC and shock Transfusion should be immediately stopped and laboratory contacted! Often occurs due to clerical errors when taking or labelling blood  Delayed Transfusion Reaction 12-36 hours post-transfusion (also weeks later) Antibody against an erythrocyte antigen that has fallen to an undetectable level or rare blood group antigens Patient’s haemoglobin level will decrease, jaundice, may experience malaise and may develop a mild fever Increase in the antibody level and haemolysis up to 2 weeks following transfusion  Bacterial Infections Collection through to processing Screening and correct storage Most commonly occurs with platelets (22-24 °C) and short expiry date May appear cloudy, have an abnormal colour or exhibit aggregates  Allergic Reaction Acute urticaria or anaphylaxis Patients who are IgA deficient IgE mediated immune response Type I hypersensitivity Minimised by using red cell and platelet products from IgA deficient donors or by washing plasma  Transfusion Related Acute Lung Injury (TRALI) Occurs within ~6 hours of a transfusion Characterised by sudden acute respiratory distress, hypoxia and a fever anti-HLA class I and class II antibodies in the donor blood reacts with the patients neutrophils Damage to the capillaries – extravasation of protein rich fluid into the alveolar spaces Diagnosis through exclusion – ruling out an acute transfusion reaction, myocardial infarction etc. Associated with ~10% mortality  Transfusion Associated Circulatory Overload Condition that occurs following a rapid transfusion of a large volume of blood products in a short period of time Often unrecognised by clinicians and confused with TRALI The risk increases in children, those over the age of 60 and patients with cardiac or pulmonary disease Whilst hypotension is seen with TRALI, hypertension is seen with TACO Patients develop tachycardia, respiratory distress and pulmonary oedema TACO is easily prevented by closely monitoring patients receiving transfusions and transfusing smaller volumes of blood at a slower rate Provide diuretics  Role of the Blood Transfusion Laboratory STOP the transfusion! Laboratory is contacted immediately! Transfusion reaction paperwork is completed with the patient’s details and their symptoms Transfused and unused units are sent back to the laboratory Pre-transfusion sample will be re-tested Post-transfusion sample will be tested  Role of the Blood Transfusion Laboratory Pre-transfusion sample – Re-group, antibody re-screen and DAT – confirm results Post-transfusion sample - Blood group and antibody screen and DAT – check the patient’s blood group and Ab status – was the original sample taken from the correct patient? Are antibodies coating red cells? Transfused unit and unused units - returned to the laboratory – check for correct labelling, grouping, antigen type and send for microbiology testing Haptoglobin – binds to free haemoglobin (reduced) Post-transfusion urine – haemoglobinuria Blood film FBC, Clotting Screen, U&E, LFT, Bilirubin and LDH  Role of the Blood Transfusion Laboratory Investigation 1. Serious Adverse Blood Reactions and Events (SABRE) MHRA Reporting system 2. Serious Hazards Of Transfusion (SHOT) Collect data and make recommendations to improve patient safety SABRE SHOT  Role of the Blood Transfusion Laboratory Reporting: Transfusion Reaction Acute Transfusion Reaction Delayed Transfusion Reaction Transfusion Associated Circulatory Overload (TACO) Transfusion Related Acute Lung Injury (TRALI) Adverse Events Requirements not met Incorrect component transfused Handling errors Storage errors  Case Study 1 60 year old female was admitted to hospital following a road traffic accident Urgent blood transfusion was prescribed Within a minute of the transfusion it was noted that the name on the erythrocyte pack did not match the patient. The transfusion was immediately stopped and the laboratory informed What was the error? Nurse collecting the blood from the satellite refrigerator did not follow the correct procedure and did not complete the pre-administration checks  Case Study 2 Erythrocytes collected from the laboratory at 01:32 and returned to the laboratory at 03:03 unused. Units were entered into quarantine to be checked by a senior BMS – Senior BMS unsure of the appropriate times out of controlled temperature of the unit Units were deemed to be cold chain compliant and returned to stock and reissued What was the error? No/poor communication with other colleagues Units would not be appropriate for transfusion and should have consequently been discarded Fortunately, patient did not come to any harm  Case Study 3 Two patients on the same ward, A and B Patients incorrectly transfused Patient Patients group Unit transfused A A RhD pos O RhD pos B O RhD pos A RhD pos What was the error? Patient A was unaffected – O RhD positive unit is compatible with the patient’s A RhD Pos blood group Patient B developed an acute haemolytic reaction – Patient is O RhD positive and therefore has anti-A antibodies  Summary Incorrect blood transfusions cause a high morbidity rate and can be fatal! Zero tolerance policy Leading cause of transfusion related incidents are ‘human error’ Year-on-year increase in errors Investigate any transfusion reactions or near misses to SABRE and SHOT Adverse reactions remain underreported