Washed RBCs prevent recurrent acute hypotensive transfusion reactions

Biological investigations of transfusion reactions: contribution of symptom-based decisional algorithms

OBJECTIVES

While transfusion is a common and safe therapeutic procedure in health care facilities, transfusion reactions can occur, whether acute or delayed, mild or life-threatening. In face of these reactions, the biological analysis laboratory plays a central role in their diagnosis. The objective of this article is to develop decisional algorithms for laboratory tests to be performed according to the clinical symptoms developed by the patient during or after transfusion.

METHODS

Based on the information collected by reviewing the literature and the procedures used in our hospital, we then developed biological investigation algorithms according to the symptoms presented by the patient, rather than the presumed reaction.

RESULTS AND CONCLUSION

We have developed symptom-based algorithms for acute transfusion reactions management that streamline laboratory testing and simplify the differential diagnosis.

Association of Veterinary Hematology and Transfusion Medicine (AVHTM) Transfusion Reaction Small Animal Consensus Statement (TRACS). Part 1: Definitions and clinical signs

OBJECTIVE

To use a systematic, evidence-based consensus process to develop definitions for transfusion reactions in dogs and cats.

DESIGN

Evidence evaluation of the literature was carried out for identified transfusion reaction types in dogs and cats. Reaction definitions were generated based on synthesis of human and veterinary literature. Consensus on the definitions was achieved through Delphi-style surveys. Draft recommendations were made available through industry specialty listservs and comments were incorporated.

RESULTS

Definitions with imputability criteria were developed for 14 types of transfusion reactions.

CONCLUSIONS

The evidence review and consensus process resulted in definitions that can be used to facilitate future veterinary transfusion reaction research.

Profound Intraoperative Hypotension Associated With Transfusion via the Belmont Fluid Management System

This retrospective observational case series conducted at 2 large academic centers over a 4-year period consists of 15 cases of profound hypotension in surgical patients immediately after initiation of the Belmont Fluid Management System for rapid transfusion of blood products. Halting the infusion and administering vasoactive agents led to resolution of hypotension. Repeat transfusion with the Belmont system resulted in repeat hypotension unless counteracted with vasopressors. No etiology was elucidated. This represents the largest documented association of acute hypotensive transfusion reaction with any rapid infusion system in surgical patients.

[Cell salvage : Scientific evidence, clinical practice and legal framework]

Cell salvage is an efficient method to reduce the transfusion of homologous banked blood, as documented by several meta-analyses detected in a systematic literature search. Cell salvage is widely used in orthopedics, trauma surgery, cardiovascular and abdominal transplantation surgery. The retransfusion of unwashed shed blood from wounds or drainage is not permitted according to German regulations. Following irradiation of wound blood, salvaged blood can also be used in tumor surgery. Cell salvage makes a valuable contribution to providing sufficient compatible blood for transfusions in cases of massive blood loss. Certain surgical procedures for Jehovah's Witnesses are only possible with the use of cell salvage. Another possible use is the washing of homologous banked blood, e. g. to prevent potassium-induced arrhythmia or sequestration of autologous platelets. Other advantages besides a good compatibility are the high vitality and functionality of the unstored autologous red blood cells. These have been declared a pharmaceutical product by the German transfusion task force in 2014, so that the autologous red blood cells are now under the control of the Pharmaceutical Products Act (AMG). The new hemotherapy guidelines, however, tolerate cell salvage only under strict rules, whereby the production of autologous blood during or after surgery is still possible without additional special permits. The new guidelines now require the introduction of a quality management system for cell salvage and regular quality controls. These quality controls include a control of the product hematocrit for every application, monthly controls of the protein and albumin elimination rates and the erythrocyte recovery rate for each cell salvage device. Testing for infection markers is not required. The application of cell salvage has to be reported to the appropriate authorities.

Intraoperative Diagnosis and Management of Acute Hypotensive Blood Transfusion Reaction (AHTR): A Report of Two Cases

Case series

Patients: Female, 68 • Male, 86

Final Diagnosis: Acute hypotensive transfusion reaction

Symptoms: Hypotension

Medication: —

Clinical Procedure: —

Specialty: Anesthesiology

Hypotensive Transfusion Reaction Treated With Vasopressin in a Patient Taking an Angiotensin-Converting Enzyme Inhibitor: A Case Report

Hypotensive transfusion reactions, which account for almost 3% of all transfusion reactions, are associated with patients treated with angiotensin-converting enzyme inhibitors. The current hypothesis suggests that they are caused by bradykinin-induced vasodilation in the absence of allergic, hemolytic, or septic mechanisms. The hypotension observed frequently is unresponsive to conventional therapy with catecholamines. The suggested intraoperative management includes cessation of transfusion and washing red blood cells before blood replacement. We present a patient experiencing a severe intraoperative hypotensive transfusion reaction, unresponsive to epinephrine and norepinephrine, in whom we were able to restore blood pressure and continue the transfusion of blood and plasma by infusing vasopressin.

Clinical Pattern in Hypotensive Transfusion Reactions

BACKGROUND

Hypotensive transfusion reactions (HyTRs) may be underreported and have been associated with patients taking angiotensin-converting enzyme inhibitors (ACEIs) receiving poststorage leukoreduced blood products through negatively charged filters. Although bedside leukoreduction is no longer commonplace, HyTRs still occur and are insufficiently characterized in the prestorage leukoreduction era. We describe recently reported cases at our institution.

METHODS

We reviewed transfusion reaction records at Stanford Healthcare from January 2014 to April 2015. HyTRs were defined by National Health Safety Network Hemovigilance Module classification.

RESULTS

Eleven HyTRs occurred in 10 patients. All were adults (mean age 71.7 years; range 45-92 years), 7 were male, and all underwent major surgery 0 to 2 days before the reaction. Nine patients underwent cardiac or vascular surgery, and all 10 were taking ACEIs with the last dose taken within 48 hours of the transfusion reaction in 9 patients. Nine patients were on extracorporeal circuits within 24 hours before the reaction (median duration 180 minutes; range 87-474 minutes). In 5 reactions, the implicated unit was restarted with resultant recurrent hypotension. Implicated units included 9 packed red blood cells, 1 apheresis platelet, and 1 plasma frozen within 24 hours.

CONCLUSIONS

Contrary to what has been previously reported in the era of prestorage leukoreduction, HyTRs at our institution showed consistent patterns in patients at risk. Patients scheduled to undergo major surgery with cardiopulmonary bypass may benefit from earlier preoperative cessation of ACEIs or temporarily switching to an alternative drug class.

Modifications to Blood Components: When to Use them and What is the Evidence?

Blood component modifications can be performed by the hospital blood bank for select clinical indications. In general, modification of blood components increases costs and may delay availability of the blood component because of the additional time required for some modification steps. However, the benefit of blood product modification may outweigh these concerns. Common modifications include leukoreduction, irradiation, volume reduction, splitting, and washing. Modification availability and selection practice may vary from hospital to hospital. In this article, available blood component modifications are described along with the benefits, drawbacks, and specific clinical indications supporting their use.

Blood Products

Perioperative hemorrhage, anemia, thrombocytopenia, and coagulopathy are common in the surgical intensive care unit. As a result, blood product transfusion occurs frequently. While red blood cell, plasma, and platelet transfusions have a lifesaving role in the resuscitation of patients with trauma and hemorrhagic shock, their application in other settings is under scrutiny. Current data would suggest a conservative approach be taken, thus avoiding unnecessary transfusion and associated potential adverse events. New and developmental products such as prothrombin complex concentrates offer appealing alternatives to traditional transfusion practice—potentially with fewer risks—however, further investigation into their safety and efficacy is required before practice change can take place.

Incidence of hypotension and acute hypotensive transfusion reactions following platelet concentrate transfusions

BACKGROUND AND OBJECTIVES

Platelet concentrates (PCs) are associated with transfusion reactions involving hypotension, particularly bradykinin-mediated acute hypotensive transfusion reactions. This study aims to determine the incidence of hypotensive events and more specifically acute hypotensive transfusion reaction associated with PC transfusions. We also sought to ascertain whether these reactions are associated with elevated bradykinin levels.

MATERIALS AND METHODS

This is a prospective descriptive study of PCs administered at Sainte-Justine Hospital over 28 months. All PCs administered during this period were screened for hypotension through review of all transfusion-associated reaction reports (TARRs) sent to the blood bank. All residual PC bags were returned to the blood bank. TARRs associated with hypotension were reviewed by adjudicators that established the imputability of the PC transfusion to the reaction. Bradykinin levels were sampled in the first 168 PC bags returned to the blood bank. Levels were compared between PCs associated with hypotension and control PCs not associated with hypotension.

RESULTS

A total of 3672 PC bags were returned to the blood bank; 25 PCs were associated with hypotension. Adjudicators ascertained that five hypotensive events were imputable to PCs of which one was an acute hypotensive transfusion reaction (incidence: 0·03%). Bradykinin level in the latter PC was 10 pg/ml, whereas levels were 226·2 ± 1252 pg/ml in the 143 control PCs.

CONCLUSION

Our results show a low incidence of hypotension after PC transfusion. We identified only one acute hypotensive transfusion reaction. No correlation between bradykinin level and the occurrence of acute hypotensive reactions could be observed given that only one event was identified.