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monitoring patients being transfused
Upon completion of this exercise, participants should be able to do the following:
This case is a composite derived from 2 cases:
Special thanks to the following who kindly provided advice, information, and ideas for the case. The discussion benefits from their valuable input. (Any errors or misstatements are entirely those of the author.)
Thanks to the following hematopathologist for advice on the clinical uses of FFP and investigation of adverse events, including the differential diagnosis of TACO.
Thanks to the following Canadian nurses for advice on aspects of administering and investigating transfusions:
This case also benefits from discussions on the Canadian TSO mailing list "transfusion" regarding transfusion practices in Canada.
*revised from the originals
A 59 year old unemployed, unmarried, diabetic male (HL) with poor personal hygiene and a 3-year history of mild renal failure (thought to be diabetes-related) was admitted to the hospital because of chronic hemorrhoidal bleeding, inability to get out of bed, poor energy and dyspnea with very little exertion.
Past medical history includes
HL lives alone and has refused to see a physician in the past year. His main diet consists of prepared dinners and junk food such as popcorn, potato chips, and diet cola. He likes his cola in big glasses of ice and chews the ice in bed while watching TV most of the day.
He has gradually become more and more fatigued and bedridden, experiences dyspnea on exertion, spends most days sitting in bed propped up by pillows, and makes numerous trips to the bathroom.HL says that he cannot lie flat in bed, and that every time he does he feels like he cannot get enough air and feels "panicky". Upon further questioning the patient admits that he drinks beer daily.
Medications:HL takes insulin but no medications for heart or kidney disease.
Table 1. Admission blood tests (Patient HL)
|Value (SI units - see conversion table)
|65 g/L (130-180 g/L)|
28 pg (25-35 pg)
69 fl (78-100 fl)
|320 g/L (310-370 g/L)|
356 x109/L (130-400 x109/L)
White Cell Count
8.2 x109/L (4.5-11x109/L)
20 seconds (10-13 s)
|Activated Partial Thromboplastin Time||32 seconds (25-35 s)|
|Blood Urea Nitrogen||25 mmol/L (2.9-8.9 mmol/L)|
|Creatinine||221 µmol/L (70-120 µmol/L)|
*A reminder that reference ranges vary depending on the age, sex, ethnicity and race of the test population, as well as the laboratory methods and instruments used to do the tests. By definition 5% of the population will fall outside the reference range.
The following process was used to diagnose and treat patient HL.
The peripheral smear showed microcytes, hypochromic red cells, normal lymphocyte, and ample platelets. This smear with the low MCV, combined with pagophagia-a form of pica associated with iron deficiency-and blood loss strongly suggested iron deficiency.
To confirm iron deficiency, the following tests were ordered (reference range):
That evening the attending physician saw HL and scheduled an examination and possible minor hemorrhoid surgery for the next day. After reviewing the liver tests, the physician concluded that HL had alcoholic liver disease and its associated coagulopathy.
Due to the prolonged prothrombin time (20 s) and current mild bleeding, the physician decided to give HL plasma transfusions to correct his coagulopathy prior to surgery and ordered 5 units of FFP.
HL had been tested once (5 years ago) and was on record as group A Rh positive with a negative antibody screen. The laboratory policy was to require an ABO/Rh typing on each new admission. Accordingly, the lab requested a blood specimen to confirm HL's ABO group before thawing and issuing the FFP. HL's new sample typed as group A Rh positive.
At 18:30 h the first unit of thawed FFP was brought to the ward by a porter. HL's vital signs had been taken prior to transfusion (20 minutes earlier) and were taken again at the start of the transfusion.
Two nurses verified patient identification information on the FFP unit with the information on HL's wristband and asked HL to state his first and last name. Because the hospital used a Typenex bracelet, they also confirmed that the Typenex number on the bracelet matched the one on the FFP. They verified that the donor unit information on the bag (blood supplier donor number and component type) matched the information on the hospital blood bank label.
Immediately after starting the transfusion, the date and start time were recorded on the Transfusion Record form and both nurses signed the form. One of the nurses stayed with HL for 5 minutes after the transfusion was started.
HL was told to call the nurses if he experienced possible symptoms of a transfusion reaction such as itchiness, feeling warm with a fever, chills, rash or hives, muscle aches, back pain, chest pain, headache, cough, or difficulty breathing.
One of the nurses returned about 15 minutes post-transfusion to take HL's vital signs, which were similar to those at the start of transfusion, and entered them on the Transfusion Record. Vital signs were taken and recorded hourly and upon completion of transfusion, as specified in the facility's transfusion protocol.
The second of the FFP transfusions was started about 15 minutes after completion of the first one at 21:50. Vital signs were not taken, but the nurse planned to take them one hour into the start of the second transfusion.
Approximately 15 minutes after infusion of FFP #2 began, HL began to develop these symptoms:
HL did not have any chills, fever, rash, hives, red urine, or hypotension. HL felt disoriented and confused but finally called for a nurse about 45 minutes into the transfusion after the chest pain started.
Upon discovering HL in extreme respiratory distress, the nurse quickly
The resident, who was nearing the end of an extended 30-hr. shift, asked the nurse for a portable chest x-ray and ECG STAT, ordered nasal oxygen, and ran from the on-call room to the bedside.
Physical examination revealed
The resident concluded that HL was most likely suffering from transfusion-associated circulatory overload (TACO) secondary to the plasma transfusions and may be going into cardiac arrest.
Despite treatment, HL's condition deteriorated. He was intubated for desaturation, tachypnea, and rhonchi and died from myocardial infarction after a failed resuscitation attempt at 04:30 h.
To test your knowledge and as an advance organizer for the discussion section, read and consider these questions:
Proceed to Discussion (includes interactive questions with feedback):
This case study presented a scenario of transfusion-associated circulatory overload that led to death. A possible contributing factor was that the nurse incorrectly considered the monitoring of vital signs to apply to the entire transfusion event, as opposed to each unit transfused. Some of the key learning points include:
Goldy D. Emergency! Circulatory overload secondary to blood transfusion. Am J Nurs 1998 Jul;98(7):33.
Abdel-Wahab OI, Healy B, Dzik WH. Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities. Transfusion. 2006 Aug;46(8):1279-85.
Andrzejewski C. Transfusion-associated adverse pulmonary sequelae: widening our perspective (editorial). Transfusion 2005 July;45: 1048-50.
Atkinson S. An audit of fresh frozen plasma transfusion use in the Royal Hospitals Trust (RGHT) (poster P12). Transfus Med 2006 Oct;16(s1):30.
BCSH Guidelines: Guidelines for the use of Fresh Frozen Plasma, Cryoprecipitate and Cryosupernatant Br J Haematol 2004; 126, 11-28.
Brunskill S, Doree C, A. Blest A, J. Murdock J, M. Roberts M, and D. Watson D. Bedside practice of blood transfusion - Where is the evidence? (poster P17) Transfus Med October 2006 Oct;16(s1):32.
CSA. Blood and blood components (Z902-04). Mississauga, Ontario Canadian Standards Association, 2004.
Gajic O, Dzik WH, Toy P. Fresh frozen plasma and platelet transfusion for nonbleeding patients in the intensive care unit: benefit or harm? Crit Care Med. 2006 May;34(5 Suppl):S170?3.
Gajic O, Gropper MA, Hubmayr RD. Pulmonary edema after transfusion: how to differentiate transfusion-associated circulatory overload from transfusion-related acute lung injury. Crit Care Med 2006 May;34(5 Suppl):S109?13.
Holland LL, Brooks JP. Toward rational fresh frozen plasma transfusion: The effect of plasma transfusion on coagulation test results. Am J Clin Pathol. 2006 Jul;126(1):133?9.
Holland LL, Foster TM, Marlar RA, Brooks JP. Fresh frozen plasma is ineffective for correcting minimally elevated international normalized ratios. Transfusion 2005 Jul;45(7):1234?5.
Knippen MA. Transfusion-Related Acute Lung Injury: A rare but potentially lethal result of allogeneic blood transfusion, TRALI resembles acute respiratory distress syndrome. Early intervention can save lives. Am J Nurs 2006 Jun;106(6):61?4.
Luk C, Eckert KM,Barr RM,Chin-Yee IH. Prospective audit of the use of fresh-frozen plasma, based on Canadian Medical Association transfusion guidelines. CMAJ 2002 Jun 11; 166(12): 1539?40.
Lumadue JA, Boyd JS, Ness PM. Adherence to a strict specimen-labeling policy decreases the incidence of erroneous blood grouping of blood bank specimens. Transfusion. 1997 Nov-Dec;37(11-12):1169-72.
Pierce RN, Reich LM, Mayer K. Hemolysis following platelet transfusions from ABO-incompatible donors. Transfusion. 1985 Jan-Feb;25(1):60?2.
Popovsky MA, Audet AM, Andrzejewski C Jr. Transfusion-associated circulatory overload in orthopedic surgery patients: a multi-institutional study. Immunohematol 1996;12(2):87?9.
Shulman IA, Saxena S, Ramer L. Assessing blood administering practices. Arch Pathol Lab Med 1999;123(7):595?8.
Wallis JP, Dzik S. Is fresh frozen plasma overtransfused in the United States? Transfusion. 2004 Nov;44(11):1674?5.
Williamson LM, Lowe S, Love EM, Cohen H, Soldan K, McClelland DB, et al. Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports. Br Med J 1999;319:16?9.
Zhou L, Giacherio D, Cooling L, Davenport RD. Use of B-natriuretic peptide as a diagnostic marker in the differential diagnosis of transfusion-associated circulatory overload. Transfusion 2005 Jul;45(7):1056-63.
(also see individual discussion sections)
AABB: Composition and use of plasma components - presentation and speaker notes (AABB members only) (May 2006)
ASH and AABB Educational Session (2004): Silliman CC. TRALI
Bloody Easy Online Course (Sunnybrook & Women's College HSC, Toronto, Ontario, Canada)Canadian Blood Services:
Case 108 - Transfusion reaction (University of Pittsburgh)
CBBS e-Network Forum
EU directive and haemovigilance (Angela Robinson, UK NBS medical director)
Iron deficiency anaemia (emedicine.com)
TraQ: Informed Consent (Resource Library)