Simulation Training Assessment Tool (STAT)– Acute Hemolytic Transfusion Reaction
SCENARIO ALGORITHM
SET UP
• Sim man & monitor; BP cuff & leads on
• Critical—Blood labeled with “Mrs.
Jones—A+”, foley w/ dark urine, IVF,
pressor gtt, O2 mask
• Additional—Crash cart incl intub equp
• Confederates—Resident plays signing out
doc, transitions to nurse
BACKGROUND
• “Mrs. Smith” is a stable sign-out,
admitted to medicine, leaving ED in 10’
• Dx– LGIB 2/2 colon CA; H/H 6/18
• Feels weak otherwise stable
• Blood is hanging (she’s O-)
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CURRENT SITUATION
HR 100, BP 100/60 (MAP 73)
Receiving A+ blood
Patient reports she feels chills
Nurse verifies T 101.5
SCENARIO PROGRESSION
BP drops to 80/40 w/ HR 110 at 5 mins
If low dose pressor started, then BP
stabilizes
If pressor not started, BP drops to 70/30
w/ HR 120 at 10 mins
If pressor not started, BP disappears and
patient goes asystolic at 13 mins
• Does not recover w/ ACLS
LABS & IMAGES NET 10 mins
• Coombs test +, plasma free Hb 35
• Hapto 0, LDH 1000
• H/H 20/6.5
END CASE NLT 15 mins
Dispo to ICU
Date: 27 MAR 13
Instructor(s):
Learner(s):
Learning Objectives:
1. Recognize acute hemolytic transfusion reaction (AHTR)
2. Manage AHTR appropriately
3. Respond appropriately to systemic error of wrong blood transfusion
CRITICAL ACTIONS
MS
ME
NI
SUSTAIN
IMPROVE
Pt greets new doctor, “I was feeling weak for several weeks. Now I’m feeling chills since transfusion started.”
Recognize AHTR—classic triad:
F, flank px, dark urine
PC12
Stop transfusion, check name
& type, return blood to lab and
order repeat T&C
PC52
BP drops to 80/40 at ~5 mins. Pt states, “I’m feeling kind of bad now, really dizzy”.
Vigorous supportive care—
Repeat VS, O2 mask, 2nd line,
pressure bag, lay pt flat
PC13
Hydrate with NS @ 100-200
mL/h. GOAL: UOP 100-200
PC52
Start low dose pressor for
hypotension (DA > NE?)
PC53
If pressor not started by ~10 mins, pt’s BP drops to 70/30. If not started by ~13 mins, pt goes asystolic arrest.
Order labs– Coombs, plasma
free Hb, haptoglobin, LDH, DIC
panel
PC32
Alert blood bank for second pt
at risk
SBP
2-2
Admit to ICU, Heme consult
PC73
TOTAL
Admission Labs
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WBC 6.5
Hb 6.0
Hct 18
Plt 270
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Na 139
K 5.0
Cl 102
HCO3 24
BUN 25
Cr 1.1
Glu 105
iSTAT
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Na 140
K 5.2
Cl 100
iCa 1.20
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TCO2 28
Glu 105
BUN 26
Cr 1.3
– Hct 20
– Hb 6.5
– AnGap 18
Hemolysis Labs
• Coombs test +
• Plasma free Hb 50
mg/dL
– Ref range 1-4 mg/dL
• Haptoglobin 0
– Ref range 5-20 mg/dL
• LDH 1000
– 50-150 U/L
• Urine hemoglobin +
Vasopressor
Mechanism
Indications
Dosing
Norepinephrine
(Levophed)
Action on alpha-1 and beta-1 receptors
produces potent vasoconstriction
Hypotension/Shock
Initial: 8-12 mcg/min; titrate to
effect. Usual maintenance range:
2-4 mcg/min.
Post cardiac arrest care
0.1-0.5 mcg/kg/min (7-35
mcg/min in 70 kg pt); titrate to
effect
Sepsis and septic shock
0.01-3 mcg/kg/min (0.7-210
mcg/min in 70 kg pt)– range from
clinical trials
Phenylephrine (NeoSynephrine)
Purely alpha-adrenergic agonist activity
results in vasoconstriction with minimal
cardiac inotropy or chronotropy
Hyperdynamic sepsis (low SVR +
high CI “warm sepsis”)
Neurologic disorders
Anesthesia-induced hypotension
100-500 mcg/dose Q10-15 mins
prn
Epinephrine (Adrenalin)
Potent beta-1 adrenergic receptor activity
and moderate beta-2 and alpha-1
adrenergic receptor effects
Most often used for anaphylaxis
Second line for septic shock
Hypotension s/p CABG
0.1-0.5 mcg/kg/min (7-35 mcg in
70 kg pt); titrate to effect
Dopamine (Intropin)
Activates dopamine-1 receptors in renal,
mesenteric, cerebral and coronary beds
No proven indication
1-2 mcg/kg/min
Stimulates beta-1 adrenergic receptors and
increases cardiac output w/ variable effects
on heart rate
5-10 mcg/kg/min
Stimulates alpha-adrenergic receptors and
produces vasoconstriction with increased
SVR
Second line to norepinephrine in
patients with absolute or relative
bradycardia
10-20 mcg/kg/min
Dobutamine (Dobutrex)
Predominant beta-1 adrenergic effect
increases inotropy and chronotropy and
reduces LV filling pressure
Severe, medically refractory heart
failure and cardiogenic shock
Should not be used in sepsis due
to vasodilatory effects
2.5-20 mcg/kg/min, max 40
mcg/kg/min; titrate to effect
Isoproterenol (Isuprel)
Primarily inotropic and chronotropic, acts
on beta-1 receptors
Bradyarrythmias, AV block,
refractory Torsades de Pointe
2-10 mcg/min; titrate to effect
Acute hemolytic transfusion reaction
• Results from infusion of incompatible RBCs
• Transfused RBCs are destroyed by pre-formed
antibodies
– Usually anti-A or –B, but also anti-Rh, anti-Jka that are
capable of fixing complement
• Signs and symptoms include fever, chills, flank
pain, hemoglobinuria, shortness of breath
• May progress to shock, DIC, respiratory failure,
ARF
• NB– Delayed hemolytic transfusion reaction is an
entity
Acute hemolytic transfusion reaction
Treatment
• Stop transfusion
• Brisk hydration to avoid
acute renal injury
– Goal= UOP 100-200 cc/h
• Vigorous supportive care
while labs pending
confirmation
Labs
• Free hemoglobinemia and
hemoglobinuria
• Haptoglobin is decreased
(binds to free hemoglobin)
• Coombs testing of pre- and
post-transfusion blood
– Test for globulin antibodies on
the surface of RBCs
Febrile nonhemolytic transfusion reaction
– Most common transfusion reaction
– Manifests with fever and chills
• May be hard to distinguish from early acute hemolytic
reaction
• Must stop transfusion and rule out hemolysis
– Treat with antipyretics & antihistamine while labs are
pending
• No evidence to support pre-treatment
– Caused by interleukin release from leukocytes
• Leukoreduction is an effective preventive therapy
– 40% of patients with one FNHTR will have another?
– 75% of PRBC in US are pre-reduced
Allergic Transfusion Reactions
– Range from minor to anaphylaxis
– Due to plasma protein incompatibilities
– Erythema, urticaria, pruritus, bronchospasm,
vasomotor instability
– Reaction severity is not dose-related
– Treat urticaria with antihistamines
– Discontinuation of transfusion is not always
required
Delayed Transfusion Reactions
• Delayed hemolytic
transfusion reaction
• Infections
– Severe bacterial infection
• Platelets 1:50,000
• PRBCs 1:500,000
– Risk of hepatitis B =
1:200,000
– Risk of hepatitis C or HIV =
1:2,000,000
– Risk of West Nile virus and
Creutzfeldt-Jakob disease
is unknown
• Transfusion Related Acute
Lung Injury (TRALI)
– Pulmonary edema due to
incompatibility of passively
transferred leukocyte
antibodies
– 50% of transfusion related
deaths
• Other transfusion-related
risks
– Volume overload
– Hypothermia