Download Case Presentation - Dr Modupe Elebute

Blood Transfusion
tutorial
MBBS Curriculum
IOD II
Dr Dupe Elebute
Consultant
Department of Haematology
Case Presentation 1
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A patient with Aplastic Anaemia arrived for her twice
weekly infusion of platelets
On receiving the platelets from the blood bank and
checking the unit the product appeared to be
“greenish” in colour
The unit was checked and was correct for this
particular patient
15 minutes into the transfusion she collapsed and the
transfusion was stopped
What is the diagnosis?
What actions would you take?
Case 1: Actions taken
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Platelet transfusion stopped immediately
ABC
Given hydrocortisone 100mg IV and piriton
10mg IV
Started on IV broad-spectrum antibiotics
Platelets returned to the lab and cultured
Culture of platelets: Bacillus Cereus
Case 1: Actions taken
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Returned unit to NBS; unit re-cultured and
also grew Bacillus Cereus
NBS recalled the 3 donors of the platelet
pool and swabbed the donors’ arms
One of the swabs also grew Bacillus Cereus
NBS reviewed technique for swabbing of
arms of donors and implemented new national
guidelines
Acute transfusion reactions
Acute haemolytic transfusion reaction due to
ABO incompatible blood or bacterial contamination
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difficult to differentiate clinically
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causes:
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acute intravascular haemolysis
shock
acute renal failure
DIC
extremely serious, can be fatal
Management of AHTR
A medical emergency:
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Stop transfusion immediately
Keep line open with N/Saline using new giving set
Monitor pulse, BP, temp
Call member of medical staff
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Check identity of patient against blood bag
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Take urgent blood samples:
FBC, cross-match, U & Es, clotting screen, blood cultures
Save any urine
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Send blood unit back to the blood bank
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Febrile non-haemolytic
transfusion reactions
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‘Allergic’ reaction caused by white cells in
blood bag
Symptoms:
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Fever
Urticaria
Anaphylaxis (rarely)
Management: Hydrocortisone and Piriton
Very rare in UK now following universal leucodepletion of red cells (vCJD initiative)
Case Presentation 2
A
45 year old was admitted for hysterectomy
Normal
blood count preoperatively
Received
Pale
three units of blood perioperatively
and jaundiced on the 10 day postoperatively
•What is the diagnosis?
•What haematological tests would you request?
Delayed haemolytic transfusion
reactions
Due to secondary immune response following reexposure to a red cell antigen
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Patient previously sensitised to a red cell antigen by
transfusion or pregnancy
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Antibody not detected on routine screening for X-match
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Patient given transfusion with blood containing same
antigen
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Provokes an anamnestic (secondary immune) response
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Within days, antibody level rises and transfused red
cells removed from circulation
Delayed transfusion reactions: 2
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Occurs 24hr after transfusion (7-10 days)
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Causes extravascular haemolysis
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Red cells destroyed in liver, spleen; occurs slowly
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Few clinical signs: fever, anaemia, jaundice
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Investigations:
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Coomb’s test positive
Re-testing of patient’s serum will now detect antibody
In future, patient must be transfused with
antigen negative blood
Case Presentation 3
A woman is bleeding profusely post partum
 On examination, she is agitated, sweating and
cold to the touch
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•What would you do first ?
•What baseline haematological tests are indicated ?
•How should she be managed ?
Massive blood loss
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Medical emergency
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Loss of one blood volume within 24 hour
50% blood volume loss within 3 hours
Rate of blood loss  150ml/min
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Any blood loss >2L (SGH)
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Usually occurs in A&E, operating theatre or
obstetric department
High morbidity & mortality
Massive Blood Loss (2)
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Ensure adequate venous access
Attempt to maintain blood volume with saline,
plasma expanders
‘Flying squad’ blood (O Rh Neg, CMV neg) available
if blood required in 15 minutes
Complications of Massive Transfusion
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Hypothermia  acidosis
Hyperkalaemia: K+ leaks out of red cells during
storage
Citrate toxicity: red blood cells kept in citrate plus
additive solution (SAG-M)
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Hypocalcaemia: Ca2+ ions bound by citrate
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Depletion of platelets and coagulation factors
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Fluid overload  acute respiratory distress
syndrome (ARDS)
Case 3
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A health care assistant collected a unit of blood from
the blood bank fridge without taking any means of
identification
The checking of the unit was undertaken only with the
compatibility slip and the blood unit at the nurses station
The patient was blood group B
Within 15 minutes of the transfusion the patient had
received 50 mls of Group A blood
Within 30 minutes the patient became unwell
What errors have occurred in the transfusion process?
Case 3: errors that occurred
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HCA took no means of formal identification
to collect the unit of blood
No other means of identification was taken
for checking the unit of blood
No bedside check took place
(must be done by 2 trained staff)
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No checking of the wrist band
Errors in transfusion
Wrong blood to wrong patient
1:3 ABO incompatible
1:10 fatal
B blood 
O:
†
Fatal errors in approx 1: 600 000 (UK, USA)
Non-fatal 1:12000
Further reading
•Essential Haematology
•ABC of Transfusion (BMJ books)
•HMSO Handbook of Transfusion
Medicine
•SGH handbook of blood transfusion
policies and procedures