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Reaction Protocol


KKidd

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Does anyone have a reaction protocol specific for plasma or platelets? We had a patient over the weekend and a workup was requested for a plasma transfusion. I was away(of course) and would like to provide more speicifc guidance in the protocol.

:juggle:

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KKID,

I have posed this same question on this forum in the past with zero response! I am very interested in how Transfusion Services are handling minor reactions to FFP and PLP. Obviously you would not retype the patient and or unit, say for PLP when you haven't even given type specific product in the first place - so what do people do routinely for possible reaction workups. We have a policy due to the age of our population, that we consider all symptoms significant and stop the transfusion and call a possible reaction. Do they routinely perform a DAT on the post sample as you would with packed cells?

I have read every textbook I can get my hands on and they all infer that the possible hemolytic reaction work-up is with red cell products.

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We have very, very few Transfusion Reactions reported to us, particularly since we switched to all leukocyte-reduced red cell and platelet products many years ago. (Also, we service a large oncology practice, and I'm under the impression that the oncologists premedicate almost all of their multiply-transfused patients with Tylenol & sometimes Benedryl.)

Back to your question......If a patient experiences symptoms of a transfusion reaction involving platelets or plasma, we have the nursing unit report the incident the same way they would if it involved a red cell transfusion. (Fill out the paperwork to document the symptoms, return the product or empty bag to Blood Bank, etc.) Our techs do what testing and documentation that they can. (ie: ABO/Rh & DAT on patient, reverse ABO Group on the product, document the paperwork check to make sure we gave the correct donor unit to the correct patient, possibly do a gram stain, etc.)

I know that some of this is not warranted if it involved plasma or platelets, but our staff rotates through all Lab areas (so they are not Blood Bank experts.) Therefore, they do not have to evaluate what to do and what not to do and we don't have to worry about an important part being omitted. (Again, we receive so few that I really is not much work.)

Yes, most of us know that it is unlikely that we are going to find anything from this testing, but I think it is important to document that the patient experienced something unfavorable during the transfusion. If a patient does it repeatedly, he/she might need a special product or medication during future transfusions. (Also, if there is every any claim about the problem later down the road, we have a record that we investigated and found no indication of incompatibility.)

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I think one has to be a little careful here, because there is always the chance of HLA and platelet specific antibodies, but most serious of all, Transfusion-related Acute Lung Injury (TRALI).

I've got a lecture on this KKidd (written by my Consultant, Dr, Nay Win - not by me - I'm not that intelligent), but it is too big to post on this website. If you email me on malcolm.needs@blueyonder.co.uk I'll do my best to compress it and send it to you (I say I will do my best, because I am far from an expert in IT!!!!!!!!!!).

:)

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We have a separate policy for adverse reactions in platelet and fresh frozen plasma transfusions, which basicly states that only the nursing section of our transfusion reaction from is completed before pathologist review. Our policy then contains notes on FNH, allergic and TRALI reactions and what tubes to collect if TRALI is suspected and how to order. I think it's a good idea to state what testing the lab does, or in this case does not do, for staff reference.

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To Nancy C - would it be possible to share your policy for plasma products?

We do as L106's hospital does - we essentially work up plasma exactly the same as RBCs. Since going to to all Leukocyte reduced RBCs and plasma products, we see more "reactions" to plasma products than we do to RBCs anyway - and we see very few reactions either way. Last CAP inspection, I was told to make sure the DAT was done with Polyspecific AHG and told to add backtyping to my pt ABORH testing (pre and post) because so many of our platelet transfusions are not type specific and are even type incompatible. We also had one suspected TRALI case - the adverse reaction paperwork for the report to United Blood Services of Phoenix AZ was extensive!! You might be able to pick it up from the document portion of their website under the hospital/physician area. I have also felt that doing only one kind of workup is better for team members that maybe only see a workup once every 2-3 years (!) now.

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The most common reasons for a reaction to these products are 1. A high titer of Anti-A or more commonly Anti-B; and 2. A deficiency of IgA in the Patient with or without a concomitant Anti-IgA and a normal or elevated amount of IgA in the unit.

Since platelets are frequently and sometimes purposely given out-of-type, do a DAT on the Patient, and if positive then do an elution, preferably by a Lui (freeze/thaw) elution.

For plasma reactions request a quantitative IgA. If value is low and Patient needs more plasma, select IgA deficient or at least low level IgA units - these will be from healthy older donors (>60 yrs old).

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I am new to this group - lots of good information here. Thanks eveyone.

Our protocol for Transfusion Reactions on non red cell products is essentially the same as others have posted. We do routinely do a culture on the unit in case of contamination. With the new TRALI regs, if it is suspected then we would follow UBS protocol. Haven't seen a case of that yet..

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Does anyone have a reaction protocol specific for plasma or platelets? We had a patient over the weekend and a workup was requested for a plasma transfusion. I was away(of course) and would like to provide more speicifc guidance in the protocol.

:juggle:

We are a teaching hospital and Level 1 trauma center, and we do get multiple suspected transfusion reaction workup requests to FFP's and Plateles. We get the product back to Transfusion Services, after Suspected TR work up is initiated by the blood bank physician and bed site physician. Unless a blood culture is requested, we only perform clerical checks on the product in question, which includes a review of transfusion tags, product appearance and labeling. A blood sample is not collected unless requested by the blood bank.

If a TRALI or platelet antibody is suspected the blood bank medical director reviews the patient chart requests a platelet antibody screen which is done inhouse. Rest of the TRALI workup is done as per the blood center's protocol.

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This is to Mary, I don't think we have had a transfusion reaction involving both RBC and FFP. We would follow our RBC TX RX policy and note the FFP as part of the products received in the last 24 hours on the transfusion reaction form. The RBC TX RX is more complete with the pre and post ABO/Rh and DAT data. Hope this helps.

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Another consideration is that the donor has high-titered anti-A,B. Here is a report from my colleagues addressing this.

Significant numbers of apheresis-derived group O platelet units

have “high-titer†anti-A/A,B: implications for transfusion policy. Transfusion 2004; 44,805.

When customers report suspected reactions to our blood center, we perform titers if they have not already been done, and if the donor has high-titered atni-A,B will defer the donor from donating plasma or platelets.

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Harev, Why would you defer a donor from donating plasma if they have a "high-titer" anti-A/A,B. I would assume that only O patient's receive O plasma. So I don't see the harm in giving a patient that already has an anti-A/A,B a high titer of the same.

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Harev, I'm with PaulSunV, we do not give O Platelets to anyone who isn't an O unless it is an extreme emergency and that is all we have. We generally stock A Pos pheresis platelets for our emergency supply and then order group and type specific platelets for scheduled transfusions. If you are going to give O pheresis platelets to a non-O patient, you should plasma reduce first.

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Harev, Why would you defer a donor from donating plasma if they have a "high-titer" anti-A/A,B. I would assume that only O patient's receive O plasma. So I don't see the harm in giving a patient that already has an anti-A/A,B a high titer of the same.

If they are group O, I would agree, but even these are sometimes given to other groups (such as when HLA-matched platelets are required) so you would still have to be careful, and the donors should, at the very least, be flagged.

The other problem is that donors with high titres have usually been "boosted" by some form of sensitisation, very often an ABO incompatible pregnancy. These individuals are obviously "responders" and so they may have other antibodies (HLA, granulocyte and/or platelet specific antibodies), and so they may also be "dangerous" donors from the point of view of TRALI.

:fear:

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When I stated donating plasma I was referring to PHF and FFP, which here is being restricted to male donors as much as possible. My thought really was about deferring any person willing to donate products when it is becoming much more difficult to obtain willing donors.

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