SRMC BB

Fantastic list - now all they need is TACO (Transfusion Related Circulatory Overload) and it's differential diagnosis from TRALI and they are set to go with current recommendations.  Seems like there is an increased interest in TACO with regulatory agencies lately.

At the end of the quoted policy above is this caveat:
"Increase in temperature alone should not always constitute justification for a transfusion reaction work up. Nursing judgment should be used in evaluating symptoms and notification of physician."
Here, we occasionally have problems with workups not being done, or direction from the blood bank to stop transfusions, against hospital policy.  This is because there is sometimes a tendency to excuse reactions, such as a temp increase, to something other than an acute reaction to the transfusion. 
Now, every facility has to go by their own policy, but I would rephrase this as:
"A significant increase in temperature, that may be attributable to some other cause, shall not constitute justification for ignoring what may be a life-threatening acute transfusion reaction.  Nursing judgment should be used in evaluating symptoms only after consultation with the Laboratory Blood Bank, and attending physician."
Scott

We have had similar problems with providers and nurses. The last statement is something we wrestled with when the policy was presented to us and my medical director is still not quite fully satisfied with it. Scott - I'm going to show him your suggestion to see what he thinks.

I like this as a rise in temperature can be due to the temperatures being taken by different methods or locations (oral, rectal or armpit). SMILLER's phrase ensures this is incorporated into the evaluation process.

So, we just got hit on this by JC and they recommended us to use guidelines established by the CDC on the hemovigilance program. This is located on the following website: https://www.cdc.gov/nhsn/acute-care-hospital/bio-hemo/index.html
There are over 10 different categories for an adverse reaction and they have 4 sections to it: Case Definition, Severity, Imputability, and Other. From what I gather, if the investigation falls under Doubtful or Ruled out (both options under Other), then it is not considered and adverse reaction or safety concern. 
The Case Definition gives physicians and pathologists a criteria they can  use to rule out that specific Adverse Reaction. For example, TACO would need to meet the following to be considered Definitive:
New onset or exacerbation of 3 or more of the following within 6 hours of cessation of transfusion:
 Acute respiratory distress (dyspnea, orthopnea, cough)
 Elevated brain natriuretic peptide (BNP)
 Elevated central venous pressure (CVP)
 Evidence of left heart failure
 Evidence of positive fluid balance
 Radiographic evidence of pulmonary edema
 
It is a great guide for physicians and pathologist to use once and adverse event is reported to them. The problem I struggle with here is that all of these with the exception of Acute respiratory distress are procedures that are ordered after you suspect an event. We want to make sure the nurse is calling it a transfusion adverse event under the right circumstance. For example, if a patient was hypotensive 90/40 and received ended with a BP of 125/75 while receiving a second unit. Does this require the physician to order those diagnostics tests to rule out TACO? I think this is where each facility has to come together and develop a policy to rule out adverse events before having to order all those diagnostic tests. For example, if the patient does jump in BP, but has no respiratory distress, pulse oxygen has not decrease greater than "X", and lungs sounds have not worsen or present crackles and rales; then no workup should be initiated. All this should be documented and the physician and blood bank pathologist should still be notified, since techs and nurses are not allowed to make that call. Transfusions can be stopped momentarily while the initial investigation is taken place and resumed if no adverse effect is determined. 

So, we just got hit on this by JC and they recommended us to use guidelines established by the CDC on the hemovigilance program. This is located on the following website: https://www.cdc.gov/nhsn/acute-care-hospital/bio-hemo/index.html
There are over 10 different categories for an adverse reaction and they have 4 sections to it: Case Definition, Severity, Imputability, and Other. From what I gather, if the investigation falls under Doubtful or Ruled out (both options under Other), then it is not considered and adverse reaction or safety concern. 
The Case Definition gives physicians and pathologists a criteria they can  use to rule out that specific Adverse Reaction. For example, TACO would need to meet the following to be considered Definitive:
New onset or exacerbation of 3 or more of the following within 6 hours of cessation of transfusion:
 Acute respiratory distress (dyspnea, orthopnea, cough)
 Elevated brain natriuretic peptide (BNP)
 Elevated central venous pressure (CVP)
 Evidence of left heart failure
 Evidence of positive fluid balance
 Radiographic evidence of pulmonary edema
 
It is a great guide for physicians and pathologist to use once and adverse event is reported to them. The problem I struggle with here is that all of these with the exception of Acute respiratory distress are procedures that are ordered after you suspect an event. We want to make sure the nurse is calling it a transfusion adverse event under the right circumstance. For example, if a patient was hypotensive 90/40 and received ended with a BP of 125/75 while receiving a second unit. Does this require the physician to order those diagnostics tests to rule out TACO? I think this is where each facility has to come together and develop a policy to rule out adverse events before having to order all those diagnostic tests. For example, if the patient does jump in BP, but has no respiratory distress, pulse oxygen has not decrease greater than "X", and lungs sounds have not worsen or present crackles and rales; then no workup should be initiated. All this should be documented and the physician and blood bank pathologist should still be notified, since techs and nurses are not allowed to make that call. Transfusions can be stopped momentarily while the initial investigation is taken place and resumed if no adverse effect is determined. 
 
 

I agree with new pain.  I find that the BP question is difficult because of patients being treated concomitantly for either hypo or hypertension, not to mention getting up to use the bathroom or getting riled by being visited by that annoying person who says they deserved to be sick because of something they have done. Or maybe they got the post-op cancer diagnosis during the transfusion.  I have heard 30 mm Hg suggested but I think it depends on how it is applied.  I look forward to someone having a clear cut answer for you.

The grocery list below is what is in nursing policy at my hospital, with my notes in italics. This is their reference cited in the policy:  Berman, A. & Snyder, S. (2012). Administering intravenous therapy. In Skills in Clinical Nursing (7th ed., 511-512, 516). Upper Saddle River, NJ: Pearson Education Inc.

A.     Recognize and report any of the following signs / symptoms of a transfusion reaction to the Physician and blood bank immediately for consideration of transfusion reaction work up:

1.     An immediate hemolytic transfusion reaction may contain any or all of the following clinical presentations: 
a)     Fever, chills, or both (specifically 1.5 F increase)

b)     Nausea or vomiting  (also sudden onset of diarrhea)

c)     Headache

d)     Pain – localized to the back (also flanks, abdomen, chest, head, and infusion site)

e)     Chest constriction (also sudden onset of cough)

f)       Dyspnea and cyanosis

g)     Subjective feelings of distress – sometimes reported as a “sense of impending doom” (anxiety, agitation)

h)     Hypotension, tachycardia or both (significant change in BP)

i)       Hemoglobinuria (dark urine, anuria in extreme cases)

j)       Unexpected degree of anemia due to hemolysis of transfused RBC’s

k)     Shock

l)       Rash

m)   Feeling of heat along the vein used for infusion

                                             2.     Delayed Hemolytic Transfusion Reaction (24 hours to 2 weeks post-transfusion) may contain any or all of the following clinical presentations:

a)     Fever, chills, or both

b)     Jaundice (sclera) (increase in bilirubin)

c)     Pain-localized to flanks, back, abdomen, chest, head, and infusion site

d)     Dyspnea

e)     Sudden unexplained fall in hemoglobin 7-14 days post transfusion

f)       Continued anemia despite transfusion therapy

g)     Hemoglobinemia and/or hemoglobinuria

                                             3.     Febrile Nonhemolytic Transfusion Reactions (occur at the end of the transfusion or up to 2 hours later) may contain any or all of the following clinical presentations:

a)     Fever – occasionally

b)     Chills, colds

c)     Discomfort

d)     Rigors – occasionally

e)     Headache

f)       Nausea – some patients may vomit

g)     Dyspnea

                                             4.     Allergic Reactions (occur usually seconds to minutes after initiation of transfusion) and may contain any or all of the following clinical presentations:

a)     Intensely pruritic, localized or disseminated urticarial eruption (well circumscribed, discrete wheals with erythematous, raised, serpiginous borders and blanched centers)

b)     Generalized pruritis may precede eruption or generalized erythema or flushing of the skin.

c)     Angioedema, a more severe form, consisting of localized, nonpitting, deep edema of the skin.

                                             5.     Anaphylactoid and Anaphylactic reactions (occur usually seconds to minutes after initiation of transfusion) and may contain any or all of the following clinical presentations:

a)     Upper or lower airway obstruction or both

b)     Upper – laryngeal edema causing hoarseness or stridor (lump in the throat)

c)     Lower – Bronchospasm generates audible wheezing, tightness in the chest or substernal pain. Other associated symptoms include dyspnea, cyanosis, feelings of anxiety (“a sense of impending doom”)

d)     Profound hypotension

e)     Tachycardia

f)       Severe G.I. symptoms present from onset-abdominal cramps, nausea, vomiting, diarrhea.

g)     Erythema and urticarial eruptions are prominent and typically involve confluent areas of the trunk, face, and neck.

                                             6.     Transfusion Reaction Acute Lung Injury (TRALI) (symptoms arise in setting of recent transfusion of plasma containing blood components [ Red Cells, Whole Blood, Fresh Frozen Plasma, Cryoprecipitate, Granulocytes], always within 1-6 hours and usually within 1-2 hours of infusion): 

a)     Acute respiratory distress which may first be manifested as dyspnea or cyanosis

b)     Severe bilateral pulmonary edema and severe hypoxemia

c)     Tachycardia

d)     Fever (1-2 C increase)

e)     Mild to moderate hypotension, usually unresponsive to IV fluid administration

f)       FDA regulations require all cases of TRALI to be reported.  If TRALI is mentioned and/or charted by a physician as a differential diagnosis, the Blood Bank must be notified.

Increase in temperature alone should not always constitute justification for a transfusion reaction work up. Nursing judgment should be used in evaluating symptoms and notification of physician.

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We are switching to Meditech 6.1 on May 1st.  It's been a stressful year and a half!!!
I had them specific for the EMR and the consultants told me to get them into more generic categories because the doctors wouldn't care what anticoagulant was in the bag.
I used packed cells, LP packed cells, LP-irr packed cells, FFP, LP Pheresis platelets, LP-irr Pheresis platelets.
 
Hope this helps
Natalie

Thanks Laurie and Tricore. Luckily for us FloSeal is considered acellular at the time of use so it's not considered a tissue according to TJC.

The only people who never make mistakes are the ones who never do any work......

We (Finally) got our microwave!  It has been on order since January and we got it late last month and the rep came and did the install/inservice on October 14.   The policies are going through med staff and med exec this month so hopefully we will be allowed to use it...soon!!!
 
I'm going to replicate your validation worksheet Terri!

Yes we have had a microwave plasma thawer for a few years and we LOVE IT. Thaws in about 6-7 minutes, depending on the size of the unit. Couple limitations:
Can't thaw cryo in it: not FDA approved for cryo
Can't thaw the long, folded FFP units in there, they don't fit in the holder.
It's expensive...but totally worth it in my opinion.
We have a Helmer water bath unit as well for the cryo and folded FFP units.

We have a microwave too.   We also convert our FFP to thawed plasma, so we keep several units (A's and O's) thawed and ready for use.

Hi - would have done it to begin with but am computer challenged most of the time - nice FAQ helped me out so here goes a try -
this is our SOP for responding to most of the lookbacks/recalls/withdrawals that our blood distributor sends our way -
92-Notification of Transfusion Recipients.doc