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Suspected Transfusion Reactions

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We have a set of pre-defined classes of suspected transfusion reactions that the nurses can pick from.  I met with our residents and interns and went over transfusion reactions and what the nurses are supposed to do when one is suspected and that the Doctor cannot cancel one even if they don't think the signs/symptoms are related to a transfusion reaction.  They asked for a some standard guidelines as to what the nurses were calling reactions.  For example:  we have a hyper/hypo tension symptom.  They would like to know what is the standard change (systolic up 30mm, etc).  They also didn't like the pain symptom because some people are chronic complainers and I tried to explain a new onset of pain.   Anyway......does anyone have set parameters that the nurses use to call a suspected transfusion reaction?  I've looked on AABB's website and can't find exactly what I'm looking for.

 

Natalie

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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.

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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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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.

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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

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6 hours ago, SMILLER said:

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.

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14 hours ago, SMILLER said:

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

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.

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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. 

 

 

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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. 

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On 10/5/2018 at 9:34 AM, seraph44 said:

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

 

 

Thanks for the heads up on this. We have a JC inspection coming up next year. Gives us time to get this problem fixed.

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We use the CDC guidelines for the pathologist to interpret the reaction workup, not for nurses to determine whether it is a suspected reaction needing workup--not that they shouldn't have such information available.  We also quote the JC standard in our procedures that says the workup should be performed if it meets our criteria "regardless of whether the physician deems it necessary".

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