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Adverse Affects of TXLecture  0 .   #|x<6X9`(CourierXx6X@`7X@sH2 ($. $      (9 Z 6Times New Roman Regular7#137=CIQYag1.a.i.(1)(a)(i)1)a)(@3z$ . !        i)  z*     _A" ) xdtEW AXRXXXXXR X MGMLAB2431  127  0 0 T$ T$0< T$ T$0<T$<T$0T$T$0DT$T$0DT$DT$XII.AdverseEffectsofBloodTransfusion#MG#(@3z$ . !       ,hAZ*Helvetica Regulara1{AZ"Arial Regularhp LaserJet 1300 PCL 5e,,,,0U(C Z(Times New Roman  A, B,Level 1Level 2Level 3Level 4Level 54#-2Quick A.  .0    z)     _9A" ) xdtEW!A X XRXXXXXRMGXII.AdverseEffectsofBloodTransfusion?$MLAB2431  127  #MG#,hAZ*Helvetica Regular(9 Z 6Times New Roman Regular3#37=CIQYag1.a.i.(1)(a)(i)1)a)i)H(;3$2#  0  .3  0   d . !       _XXHHXXXX   XRXXXXII.AdverseEffectsofBloodTransfusion#XXXXR# X  &%XX&%%&A.0  Introduction0$$ -X X XX-0  1.0$$Transfusionofbloodandcomponentsisordinarilyasafeandeffectivewaytocorrecthematologic  deficits,butuntowardresultsmayoccur.`$$ 0  2.0$$Manyoftheseadverseeffectsarecommonlycalled"transfusionreactions",butthedeleteriousresults h ofadministeringbloodincludearangeofeventsandproblemsbroaderthanthisterm.@ $$ 0  3.0$$Someadverseeffectscanbeprevented;otherscannot.  $$ 0  4.0$$Healthcareprovidersshouldknowtherisksofbloodtransfusionandevaluatethemagainstpotential  H  therapeuticbenefitsinlightoftheserisks.x $$ 0  5.0$$Transfusionreactionsarebrokendownintotwocategories.( $$ <X XX XX X X<0  0$$a.0 $$Immediateadverseeffectsoccurduringorshortlyafterthetransfusionofbloodorblood  components.X $ $ 0  0$$b.0 $$Delayedadverseaffectsoccurweeksormonthsaftertransfusionofbloodorbloodcomponents.` $ $ ?X X, XX XX X?B.0  EvaluationofSuspectedHemolyticTransfusionReactions$$ EX X XX X, XE  1.0  Thetimebetweensuspicionofatransfusionreactionandtheinvestigationandinitiationofappropriate h therapy shouldbeasshortaspossible. @$$   2.0  Responsibilityforrecognizingareactionrestswiththetransfusionist,whomaybeanurse,physicianor L othermemberoftheclinicalteam.$$$   3.0  Thefollowinglistsdetailswhatthetransfusionistshouldlookforasanadverseeffectthatwouldbecause | forimmediateaction.Thepresentingoffeverandchillsmaybethesameforlifethreateninghemolytic T transfusionreactionsandlessseriousfebrilereactions., $$  0    a.0$$fever\!$$ 0    b.0$$chills4"$$ 0    c.0$$chestpain #$$ 0    d.0$$_hypotension_ $$$ 0    e.0$$nausea!d%$$ 0    f.0$$flushing"< &$$ 0    g.0$$dyspneal#!'$$ 0    h.0$$_hemoglobinuria_D$!($$ 0    I.0$$shock%")$$ 0    j.0$$generalizedbleeding(_DIC_)%#*$$ 0    k.0$$_oliguria_Ԁoranuria&t$+$$ 0    l.0$$backpain'L%,$$ 0    m.0$$painorburningatinfusionsite|($&-$$   4.0  Anyadversesymptomorphysicalsignoccurringduringtransfusionofbloodoritscomponentsshouldbe ,*'/ consideredasapotentiallylifethreateningreaction.+(0$$ ̀ d. ,4   5.0  Nursingpersonnel musttakethefollowingactions:X$$ 0    a.0$$ Stopthetransfusionimmediately tolimittheamountofbloodinfused and notifyaresponsible   physician.$$ 0    b.0$$KeeptheIVlineopenwithinfusionofnormalsaline.@$$ 0    c.0$$ Atthepatient'sbedsidecheckalllabels,formsandpatientidentification todetermineifthe H patientreceivedtheintendedcomponent.$ $$ 0    d.0$$Reportthesuspectedtransfusionreactiontobloodbankpersonnel immediately. | $$  0    e.0$$ Sendrequiredbloodsamples ,carefullydrawntoavoidmechanicalhemolysis,tothebloodbank as  0  soonaspossible ,togetherwithdiscontinuedbagofblood,theadministrationset without theIV d  needle,attachedIVsolutionsandalltherelatedformsandlabels.@ $$ 0    f.0$$Sendotherbloodsamplesforevaluationofacutehemolysisasdirectedbythebloodbankdirectoror   patient'sphysician.p$$   6.0  Laboratoryinvestigation ofasuspectedhemolytictransfusionreactionshouldincludethefollowing:x $$ 0    a.0$$Checkidentificationofpatientbloodsampleanddonorblood.,$$ K"X X  XX X XK0  0$$0$$1)0 $$Ifthereisadiscrepancy, immediately notifythepatient'sphysicianorotherresponsiblehealth  careprofessionalandsearchappropriaterecordstofindif otherpatientsamplesordonor ` unitshavebeenmisidentifiedorincorrectlyissued .< $ $ 0  0$$0$$2)0 $$Afterascertainingifotherpatientsareatrisk,andafterperformingappropriatediagnostic H procedures,traceeachstepofthetransfusionprocesstofindtheerror.  $ $ 0  0$$b.0$$ Comparethepatient's_pretransfusion_Ԁand_postransfusion_Ԁspecimenforcolorofserumor x plasma. T$$ 0  0$$0$$1)0 $$Pinkorreddiscolorationpresentinthe_postransfusion_Ԁspecimenbutnotinthe_pretransfusion_ \! specimenmayindicatethepresenceoffreehemoglobinfromdestructionofdonorredcells.4" $ $ 0  0$$0$$2)0 $$_Intravascular_Ԁhemolysisofaslittleas5mLof_RBCs_Ԁcanproduce visible _hemoglobinemia_. $ $ $ 0  0$$0$$3)0 $$Mechanicalhemolysisoccurringduringbloodsamplecollectioncanalsoproducepinkorred "@ & tingedserum.p#!' $ $ 0  0$$0$$4)0 $$Iffaultysamplingissuspected,asecondspecimenshouldberequestedbutaslightly_hemolyzed_  %") sampleisacceptablefortheDAT.%#* $ $ 0  0$$0$$5)0 $$Yelloworbrowndiscolorationfromhemoglobinbreakdownproductssuchasbilirubinmay 'P%, indicaterecenthemolysisinsamplesdrawn57hoursaftertransfusion.((&- $ $     c.0  PerformaDATonthe_postransfusion_Ԁspecimen. 0*'/$$ 0  0$$0$$1)0 $$Ifincompatibletransfusedcellsarenotimmediatelydestroyed,theDATfromthe_postransfusion_ +)1 specimenwillbepositive,withamixedfieldappearance.,d*2 $ $   -<+3 _0  0$$0$$2)0 $$Sincecirculatingantibodyorcomplementcoatedcellsmaybeveryrapidlydestroyed,theDAT X  maybenegativeifthespecimenwasdrawnseveralhoursafterthesuspectedreaction.0 $ $ 0  0$$0$$3)0 $$Nonimmunehemolysis,e.g.,fromthermaldamageormechanicaltrauma,asfromtheroller  pumpsusedincardiacbypasssystems,canproduce_hemoglobinemia_Ԁ without apositiveDAT.` $ $ 0  7.0$$Iftheclericalcheckrevealsnoerrorsinpatientidentification,iftheplasmahasnohemolysisandtheDAT l isnegative nothingfurtherneedstobedone. D$$ C.0  InvestigationforPossible_Alloantibodies_  $$   1.0  IftheDATispositiveorhemolysisisevidentorifthephysiciantrulysuspectsahemolytictransfusion  P  reactionadditionaltestingisrequired. ( $$   2.0  RepeatABOandDonthepreand_postransfusion_Ԁspecimensaswellasthesprigsusedinthe_crossmatch_ 0  procedure. $$ 0    a.0$$AmixedfieldpatternwithmicroscopicreadingoftheDATsuggeststhepresenceofincompatible ` donorcells.8$$ 0    b.0$$IfABOandDtypingonthe patient's twosamplesdonotagree,therehasbeenanerrorineither @ patientidentification,typingorblooddrawing. Anotherpatient'sbloodmayhavebeendrawnat  thesametimeandmayhavebeenincorrectlylabeled,makingitespeciallyimportanttocheck  recordsofallspecimensreceivedatapproximatelythesametime. x$$ 0  0$$c.0$$IfthedonorbloodspecimenisnotoftheABOgroupnotedonthebaglabel,therehasbeenanerror ( inlabelingand,almostcertainly,anerrorinthe_crossmatch_Ԁaswell.X$$ 0  3.0$$Repeattheantibodydetectiontestsonthepreand_postransfusion_Ԁsamplesandonthedonorblood.Ifany  testsarepositive,identifytheantibody.$$ 0    a.0$$Testdonorunitsforthepresenceofthecorrespondingantigen.8$$ 0    b.0$$Ifthepatient's_pretransfusion_Ԁsampleorthedonorbloodhasanunexpectedantibodynotpreviously @! reported,checkrecordstoseehowthediscrepancyoccurred."$$ 0    c.0$$Ifthedonorbloodhasapreviouslyoverlookedantibody,doaminor_crossmatch_Ԁagainstthepatient's  p$ _pretransfusion_Ԁsampleortypethepatientforthesuspectedantigen.!H%$$ 0    d.0$$Ifthe_postransfusion_Ԁspecimenhasanantibodynotpresentbeforetransfusion,suspectananamnestic P# ' reactionorpassiveadministrationofantibodyinatransfusioncomponentrecentlyinfused.($!($$ 0    e.0$$Ifantibodyisidentified,phenotypethepatient's_pretransfusion_Ԁ_RBCs_Ԁtobesurethatthepatientlacks %#* thecorrespondingantigen.Checkthepatient'srecordstomakesurethatthepatienthasnotbeen &X$+ recentlytransfused.'0%,$$   4.0  Repeatthe_crossmatch_Ԁincludingan_AHG_Ԁphase,testingboththepreand_postransfusion_Ԁsampleagainst 8)&. the_RBCs_Ԁfromthedonorunit*'/$$ 0  0$$a.0$$Ifresultsareincompatiblewithboththepreand_postransfusion_Ԁspecimens,anerrorwasmadeduring +h)1 _pretransfusion_Ԁtesting.Thedonorspecimenusedforthe_crossmatch_Ԁmayhavebeentakenfroma ,@*2 differentunitorthepatientantibodyscreenwasincorrectlyreadasnegative.p-+3$$  H.+4 0  0$$b.0$$The_crossmatch_Ԁshouldberepeatedagainstcellsfromthesegmentactuallyusedintheinitial X _crossmatch_Ԁ(originalsegment).0$$ 0    c.0$$Ifthe_crossmatch_Ԁisincompatiblewiththe_postransfusion_Ԁspecimenbutcompatiblewiththe  _pretransfusion_Ԁsample,suspectananamnesticantibodyresponse.`$$ 0  0$$0$$1)0 $$Thisismostlikelyifthereactionhasoccurred,orifthe_postransfusion_Ԁsamplewasdrawn, 8 severaldaysaftertransfusion.h $ $ 0  0$$0$$2)0 $$Ifonlyashorttimehaselapsedsincetransfusion,checkthepatient'sprevioustransfusion @ history.Itispossiblethatanantibodyhasdevelopedto_RBCs_Ԁtransfusedintheprecedingfew   days.   $ $ 0  0$$0$$3)0 $$Lesslikely,anantibodymighthavebeenpresentinatransfusedbloodcomponent. p  $ $ 0  0$$d.0$$Ifboth_crossmatches_Ԁarecompatibleandthereisstrongclinicalreasontobelieveanacuteimmune x  hemolyticreactionhasoccurred,furthertestingisnecessary.P $$ D.0  InvestigationforNonimmuneHemolysis $$ 0  1.  Considerbacterialcontaminationofthedonorunitif:X$$ 0  0$$a.0$$Thecellsorplasmahavebrownishorpurplediscoloration.0$$ 0    b.0$$Thereareclotsorabnormalmassesintheliquidbloodorsegmentsclosesttoprimarybagappear ` _hemolyzed_.8$$   0    c.0$$Theplasmaisopaqueormuddy.$$ 0    d.0$$Thereisapeculiarodor.$$ 0    e.0$$Ifanyoftheseare_notated_Ԁsetupculturesat4C,2024Cand3537Candperformagramstainon h theunit.@$$ 0  2.0$$Examinethesupernatant plasma fromthe donorblood containerforpresenceof freehemoglobin .H$$ 0  0$$a.0$$Theunitmayhavebeendamagedbyimpropertemperaturesinshippingorstorageoratthetimeof " administration.$$ 0  0$$b.0$$Drugsorhypotonicsolutionsmayhavebeenaddedtotheblood.z$$ 0  0$$c.0$$Bacterialcontaminationmaybepresent.R$$ 0  3.0$$Examinethebloodremainingintheadministrationtubingforpresenceoffreehemoglobin.Z $$ 0  0$$a.0$$Iftheadministrationsethadpreviouslybeenusedforhypotonicsolutionsordextrosesolutions, 2! therecouldbehemolysisinthe tubing butnotinthebag. "$$ 0  0$$b.0$$Excessiveheatfromafaultyinlinebloodwarmercouldalsodamagetheinfusedbloodwithout  f$ causingabnormalitieswithinthebloodcontainer.!>%$$ 0  4.0$$ConsiderthepossibilitythatthepatientordonorhasanintrinsicRBCdefect.F# '$$ 0    a.0$$Patientswithglucose6phosphate_dehydrogenase_Ԁ(G6_PD_)deficiencyorsicklecellanemiamay $") experience _intravascular_ hemolysisbecauseofmedicalproblemsnotnecessarilyrelatedtothe %v#* transfusion.&R$+$$ 0  0$$b.0$$Paroxysmalnocturnal_hemoglobinuria_Ԁ(_PNH_)isarareproblembut,whenpresent,mayproduce Z(&- severe_hemoglobinemia_Ԁand_hemoglobinuria_.2)&.$$ 0  5.0$$Considerthepossibilityofmechanicalhemolysis.MechanicalRBClysiscanoccurwiththeuseof *(0 rollerpumpssuchasthoseusedincardiacbypasssurgery,pressureinfusionpumps,pressurecuffsor +b)1 smallboreneedles.,:*2$$   j-+3 0  6.0$$Considerosmotichemolysisduetoinadvertententryintothecirculationofhypotonicfluids,suchas X  distilledwaterusedforpostprostatectomybladderirrigation.0$$ E.0  Clinicalevaluationoncehemolysisisprovenorstronglysuspectedincludesthefollowing:$$ 0   $$   1.0  Examine_postransfusion_urinespecimensforthepresenceoffree hemoglobin .8$$ 0  2.0$$Test_postransfusion_Ԁserumsamplesfor_unconjugated_Ԁ bilirubin ,carefullyrecordingthetimingof D samplecollection.Peaklevelsoccurat57hoursanddisappearwithin24hours. $$ 0  3.0$$Measureserum _haptoglobin_ inpreand_postransfusion_specimens._Haptoglobin_Ԁisaproteinthat  x  bindstohemoglobin,decreasedlevelsareseeninconjunctionwithhemolysis. T $$ F.0  Specialteststodiagnoseredcellincompatibilitywhenroutinetestsareuninformativeandifimmune \   hemolysiscontinuestobestronglysuspected.4 $$ 0  1.0$$Performantibodydetectiontestsandcompatibilitytestswithmoresensitivetechniques. $$ 0  2.0$$PerformDATand_IAT_Ԁonseveral_postransfusion_Ԁspecimensatdailyorotherfrequentintervals.<$$ 0  3.0$$Measure_hematocrit_Ԁorhemoglobinatfrequentintervals_postransfusion_Ԁtodocumentwhetherthe D transfusedcellshaveorhavenotproducedtheexpectedtherapeuticrise,ortodemonstratethatadrop  in_hematocrit_Ԁhasoccurredafteraninitialrise.$$ 0  4.0$$Typethecellsoftherecipientandofthedonorunitundersuspiciontofindantigenspresentinthe L donorandabsentintherecipient.|$$$ 0  5.0$$Inpatientswitha_hemoglobinopathy_Ԁsuchassicklecellanemia,hemoglobinelectrophoresiscanbe , usedtodetermineiftransfusedcellscontaininghemoglobinAhavesurvived.$$ 0  6.0$$Rarecaseshavedocumentedtheoccurrenceofhemolytictransfusionreactionintheabsenceofany \ detectable_alloantibody_.4$$ G.0  AcuteHemolyticTransfusionReaction<!$$   1.0  Triggeredbyanantigenantibodyreaction,whichactivatesthecomplementandcoagulationsystems # andendocrineresponses. l$$$   2.0   Catastrophic clinicaleventsthatmayoccurincludeshock,disseminated_intravascular_Ԁcoagulation t" & (_DIC_),andacutere_nal_Ԁfailure.N# '$$   3.0  Lifethreatening_HTRs_Ԁare almostalwaysduetoABOmismatchattributabletoanidentification $") errorthatresultsintherecipientreceivingthewrongbloodgroup. %#*$$   4.0  Incompatibilityinotherbloodgroupsmayalsocauseacutehemolysisinarecipientwith_alloantibodies_ '6%, stimulatedbyprevioustransfusionsorpregnancies.Thesereactionsarerarelyassevereasthose f(&- involvingABOincompatibility.>)&.$$   5.0  Diagnosis*(0$$ 0    a.0$$Themostcommoninitialsignnotedinrecipientsis fever ,frequentlyaccompaniedbysymptomatic ,F*2 chills.x- +3$$  P.+4 0    b.0$$Reactionsmayoccurwhenaslittleas1015mLofincompatiblebloodhavebeeninfused.X$$   0  c.0$$Theonsetofsymptomsmaybemisleadinglymild,suchasvagueuneasinessoranachingback.$$ 0    d.0$$Thefirstsignthepatientobservesis redurine ,whichmaybeaccompaniedby backpain ormay ` becompletelypainless.<$$ 0    e.0$$Theseverityofinitialsymptomsis oftenrelatedtotheamountofbloodtransfused andmay D presagetheseverityoftheensuingclinicalproblems. $$ 0    f.0$$Intheunconsciousoranesthetizedrecipientstheonlymanifestationsofanacute_HTR_Ԁmaybe  x  bleedingatthesurgicalsite(dueto_DIC_),_hypotension_Ԁorthepresenceof_hemoglobinuria_. P $$ 0    g.0$$Wheneveran_HTR_Ԁissuspected,the transfusionmustbestoppedimmediately ,keepingtheIV X  lineopenfortherapeuticinterventionsthatmayberequired.4 $$ 0    h.0$$Followtheguidelinesforworkingupatransfusionreaction,startingwiththeclericalcheckatthe   bedside,sinceidentificationerrorscouldmeanantherpatientcouldbeindangeralso.d$$   6.0  Therapyinvolvesvigoroustreatmentof_hypotension_Ԁandpromotionofadequaterenalbloodflow.l$$ 0  0$$a.0$$Fluidtherapyshouldbedirectedatmaintainingurineflowratesabove100m/L/hourinadultsfor  atleast1824hours.Diureticsarealsohelpful.$$ 0  0$$b.0$$_DIC_Ԁwithresultantbleedingisthepredominantclinicalprobleminsome_HTRs_Ԁandmaybethe L initialpresentingfindinginanesthetizedpatients.Itislargelydueto_hypotension_Ԁandshock.|$$$ 0  0$$c.0$$Aphysicianexperiencedinintensivecaremedicineshouldbeinvolvedinthetreatmentofpatients , withrenalfailureorshocksincethemedicalmanagementmaybeverycomplicatedandrequire  aggressiveinterventiontopreventseriousmorbidityormortality.$$ 0  7.0$$Totalpreventionof_HTRs_Ԁisimpossiblebecausehemolysismayoccurevenwhenthe_crossmatch_Ԁis 4 compatible.d  $$ 0  0$$a.0$$Errorsinidentifyingsamples,donorunitsorrecipientsarethemostcommoncausesofsevere, " acute_HTRs_.#$$ 0  0$$b.0$$Humanerrorofthissortisdifficulttoprevent,butopportunitiesforerrorcanbemin_imized_ !D% throughcarefuldelineationofeverystepintransfusionprocedureinareadilyavailableSOP t" & manual,andcarefuladherencetodetailby everymember ofthetransfusionserviceandclinical L# ' team,fromphlebotomisttomedicaltechnicians/technologiststo_transfusionist_.($!($$ 0  8.0$$ Fatalities resultingdirectlyfromtransfusioncomplications(_eg_,hemolyticreactionsorviralhepatitis) %#* mustbereportedtotheDirector,OfficeofCompliance,Centerfor_Biologics_ԀEvaluationandResearch, &Z$+ FoodandDrugAdministration,within24hours.'2%,$$ -  -rH  .0    Other Immediate AdverseEffects-rrی:)&.$$ Ќ  0  1.0$$FebrileNonhemolyticReactions(_FNH_) arethemostcommontypeoftransfusionreaction. *(0$$ 0    a.0$$Definedasatemperatureriseof1C(2F)ormoreoccurringinassociationwithtransfusionand ,J*2 withoutanyotherexplanation.z-"+3$$  R.+4 0    b.0$$Duetocytotoxicoragglutinatingantibodiesdirectedagainsttransfusedlymphocytes,_granulocytes_ X orplatelets.0$$ 0    c.0$$_FNH_Ԁreactionstendtooccurinrecipientswhohavebeenrepeatedlytransfusedorwhohavehad  multiplepregnancies.`$$ 0    d.0$$Fevermaybetheinitialmanifestationofseveraltypesoftransfusionreactions,someofwhichare h potentiallyfatal.@$$ 0    e.0$$ Thetransfusionmustbestoppedandtheworkupinitiated.   $$ 0    f.0$$Ifapatienthas2ormorefebriletransfusionreactionsitisbesttogiveleukocytepoorproductsand  L  premedicatethepatientwithantipyretics(notaspirin).| $ $$ 0  2.0$$BacterialContamination, $$ 0  0$$a.0$$Bacteriamayenterthebloodorcomponentcontainersorcontaminatetheportofthebagduring   phlebotomyorcomponentpreparation.Withsteriledisposableequipment,bacterial \ contaminationofrefrigeratedbloodandcomponentsisveryrare.4$$ 0  0$$b.0$$Althoughfortunatelyveryrare,bacteriapresentinbloodorbloodcomponentscancausea < devastatingseptictransfusionreactioncharacterizedbyhighfever,shock,_hemoglobinuria_,_DIC_  andrenalfailure.$$ 0  0$$c.0$$Apurplecolor,clotsinthebagorhemolysissuggestcontamination,buttheappearanceofthe D bloodbagisoftenunremarkable.t$$ 0  0$$d.0$$Thepatient'sblood,thesuspectcomponentandallIVsolutionsusedshouldbeculturedforaerobic $ andanaerobicorganismsat4C,22Cand37C.$$ 0  0$$e.0$$Bacterialcontaminationisveryrare butsuchreactionsmaybefatal. T$$ 0  0$$f.0$$_Yersinia_Ԁ_entercolitica_hasrecentlybeeninvolved,healthypersondonates,laterbecomesillwitha `  selflimitingdiarrhealillness.8!$$ 0  0$$f.0$$ Thetransfusionmustbestoppedandaworkupordered. #$$ 0  3.0$$AnaphylacticReactions.!D%$$ 0    a.0$$Featuresthatdistinguishanaphylacticreactionsfromotherimmediateadversereactionsarethat L# ' they occuraftertheinfusionofonlyafewmillilitersofbloodorplasmaandtheabsenceof $$!( fever .$")$$ 0    b.0$$Theonsetmaybecharacterizedbythefollowingsymptoms:coughing,bronchospasm,respiratory &X$+ distress,vascularinstability,nausea,abdominalcramps,v_omiting_,diarrhea,shockandlossof '0%, consciousness.`(&-$$ 0    c.0$$Someofthesereactionsoccurin _IgA_Ԁdeficientpatientswhohavedevelopedanti_IgA_ *'/ antibodies afterimmunizationbyprevioustransfusionorpregnancy.*(0$$ 0    d.0$$ Thetransfusionmustbestopped and,onceanaphylaxisisdiagnosed,immediatetreatmentwith ,H*2 epinephrine.Aworkupmustbeordered.|-$+3$$  T.+4 0    e.0$$ Sensitized_IgA_Ԅdeficientpatientsmustbetransfusedwithbloodandbloodcomponentsthat X lack_IgA_ .Washedordeglycerolized_RBCs_Ԁcanbeusedforreplacementof_RBCs_.The_AABB_ 4 RareDonorFilewouldneedtobecontactedaboutcomponents(plasma,platelets)forthepatient.  Approximately1in700individualsis_IgA_Ԁdeficient.$$ 0  4.0$$Urticaria(CutaneousHypersensitivityReaction)@$$ 0    a.0$$Thisisacommonlyencounteredtransfusionreaction, secondonlytofebrile_nonhemolytic_ H reactions. $ $$ 0    b.0$$Characterizedbylocalerythema,hivesanditching,usuallywithoutfeverorotheradverseeffects. | $$ 0    c.0$$ Iflocalizedurticariaistheonlymanifestation,itisusuallynotnecessarytodiscontinuethe  ,  transfusion. `  $$ 0    d.0$$Etiologyisunknownbutthoughttobeanallergytoasolubleproductindonorplasma.   Transfusionofwashedordeglycerolized_RBCs_Ԁprevents_urticarial_Ԁreactionsbutisrarelynecessary   unlessthepatienthasrepeated,severe_urticarial_Ԁreactions.h$$ 0    e.0$$Recipientswithfrequent_urticarial_Ԁreactionsmaybepretreatedwithantihistamine.p$$ 0  5.0$$CirculatoryOverload $$ 0    a.0$$ _Hypervolemia_Ԁ mustbeconsideredifdyspnea,severeheadache,peripheraledemaorothersignsof x congestiveheartfailureoccurduringorsoonaftertransfusion.R$$ 0    b.0$$Rapidincreasesinbloodvolumearepoorlytoleratedbypatientswithcompromisedcardiacor Z pulmonarystatusand/orchronicanemiawithexpandedplasmavolume.Elderlyandpediatric 2 patientsathighestrisk. Transfusionmustbestoppedandaworkupordered.  $$ 0    c.0$$Symptomsincludecoughing,_cyanosis_,_orthopnea_Ԁanddifficultyinbreathing.f$$ 0    d.0$$Patientssusceptibletocirculatoryoverloadshouldreceive_RBCs_,notWBin small volumes , n  infusedslowly.J!$$ 0  6.0$$TransfusionRelatedAcuteLungInjury_TRALI_Ԁ(_Noncardiogenic_ԀPulmonaryReactions)#$$ 0    a.0$$Transfusionrecipientsrarelyexperienceclinicallyapparentpulmonaryedemawithoutconcurrent !R% changesincardiacpressures.Chestxrayistypicalofacutepulmonaryedema,andthereisacute "* & respiratoryinsufficiencybutnoevidenceofheartfailure.Z#!'$$ 0    b.0$$Symptomsofrespiratorydistressoccurafterinfusionofvolumestosmalltoproduce  %") _hypervolemia_,andmaybeaccompaniedbychills,fever,_cyanosis_Ԁand_hypotension_.%#*$$ 0    c.0$$Twomechanismspostulated.':%,$$ 0  0$$0$$1)0 $$Reactionbetween donor leukocyte antibodies and recipient leukocytes,whichproduces B)&. whitecellaggregatesthataretrappedinthepulmonarymicrocirculationwherethey *'/ producechangesinvascularpermeability.Fluidentersthealveolarairspacescausing *(0 problemswithadequategasexchange.+v)1 $ $ 0  0$$0$$2)0 $$Duringthetransfusionofgranulocyteconcentratesthereverseispossible,leukocyte ,N*2 antibodiesintherecipientaggregatethetransfused_granulocytes_.~-&+3 $ $  V.+4 0  0$$d.0$$ Thetransfusionshouldbestopped immediatelyandaworkupordered.X$$ 0  0$$e.0$$TreatmentincludesIVsteroidsandrespiratorysupportasrequired. $$   0  0$$f.0$$Washed_RBCs_Ԁmaypreventsuchreactions.d$$   7.0  MetabolicReactionsl$$ 0    a Citratetoxicity $$ 0    b.0 $$Hypothermia   $ $ 0    c.0 $$_Hyperkalemia_Ԁand_hypokalemia_ t  $ $ 0    d0 $$Airembolism L  $ $ I.0  DelayedAdverseEffectsT $$   1.DelayedHemolyticTransfusionReactions PrimaryImmuneResponse.    0    a.0$$Thefirstofdelayedhemolytictransfusionreactionismild,occurs severalweeks aftertransfusion ` andistheresultofprimary_alloimmunization_.Antibodyproductionafterthestimulating < transfusionbegins noearlierthan710daysaftertransfusionandusuallyseveralweeksor l monthslater .H$$   0  b.0$$Astheantibodyincreasesintiterandavidity,itcanreactwithantigenpositivetransfused_RBCs_  thatarestillcirculating.|$$ 0    c.0$$Thedegreeofhemolysisdependsonthe quantity ofantibodyproducedandthequantityof , transfusedcellremaining. `$$ 0    d.0$$Primaryimmunizationrarelycauseshemolysisoftransfused_RBCs_,andsuchdelayedhemolysisis  usually unsuspectedclinically. $$ 0    e.0$$DiagnosismightbesuggestedbyanunexplainedfallinhemoglobincoupledwithapositiveDAT D and/ortheappearanceintheserumonanewRBC_alloantibody_.t $$ 0    f.0$$Thebloodbankwillmakethediagnosisifadditional_crossmatches_Ԁareorderedwithinthe $" appropriatetimeframe(_ie_,whenantibodyisdetectableinpatientserum).#$$   2.0  Delayedhemolytictransfusionreaction Secondary(anamnestic)ImmuneResponse. !T%$$ 0    a.0$$Thesecondtypeofdelayed_HTR_Ԁoccursina previouslyimmunizedrecipient whoexperiences `#!' ananamnestic,orsecondary,responsetotransfusedredcellantigens.<$!($$ 0    b.0$$some_alloantibodies_Ԁformedafterprimaryimmunizationmaydiminishtolevelsundetectablein %#* serum.Antibodiesinthe_Kidd_Ԁsystem(anti_Jka_andanti_Jkb_)typicallybehaveinthismanner.&l$+$$ 0  0$$c.0$$_Pretransfusion_Ԁtesting revealsnounexpectedantibodies andnoserologicincompatibility. t(&-$$ 0  0$$d.0$$ Within37days aftertransfusion ,ananamnesticresponseleadstoincreasinglevelsof IgG (*'/ antibodies thatreactwiththetransfusedcells.+(0$$ 0  0$$e.0$$ Thecombinationofhighantibodylevelsandlargenumbersoftransfusedcellsinthe ,`*2 circulationmayproducereadilyapparentmanifestations. -<+3$$  l.,4 0  0$$f.0$$The mostcommonpresentingsignsarefever,anunexplainedfallinthepatient'shemoglobin X andmildjaundice, butassociatedclinicalproblemsareinfrequent.4$$ 0  0$$g.0$$_Hemoglobinuria_Ԁmayoccur;acuterenalfailureisararecomplication.Treatmentisrarely  necessary,butthepatient'surineoutputandrenalfunctionshouldbefollowed.h$$ 0  3.0$$Detectionofdelayedtransfusionreactions.p$$ 0    a.0$$ThebloodbankmaydetectaDTR,throughserologicfindingsinpatientswithnoclinical   symptomsifmoretransfusionsareordered.  $$ 0    b.0$$Thecurrentbloodspecimen mayhaveapositiveDAT.  P $$ 0    c.0$$Positiveantibodydetectiontestsand_crossmatch_Ԁincompatibilitiesmightbenotediftheantibody \   hasrisentolevelswhicharenowdetectableintheserum.4 $$ 0    d.0$$Thespecimenusedforcompatibilitytesting mustbenomorethan72hoursoldatthetimeof   transfusionifthepatienthasbeentransfusedorpregnantwithinthepast3months. This h practicewilldetectrapidlydevelopingantibodiesthat,ifmissed,mightcause acute_HTR_ upon D subsequenttransfusion.x $$ 0    e.0$$IfaDATisperformedatthistime,orispartofaroutinelyperformedautologouscontrol,the ( presenceofantibodycoatedtransfusedcellsmaybedetectedeventhoughantibodyintheserumis  notyetdetectable.$$ 0    f.0$$ElutionandidentificationoftheantibodyiscriticalwhentheDATbecomespositiveinapatient 0 whohasbeentransfusedwithintheprevious23weeks.`$$ 0    g. 0$$ IncaseswheretheDATispositivebutresultsontestingthepatient'sserumarenegativeor  equivocal,_crossmatching_ԀwiththeRBCeluatemaybeuseful.$$   -  -J  .0    DelayedAdverseAffects InfectiousComplicationsofBloodTransfusions .-ŷ ی@$$ Ќ  0  1.0$$ViralHepatitisL!$$ 0  0$$a.0$$Transfusionassociatedhepatitisremainsthemostfrequentseriousinfectiouscomplicationof # bloodtransfusion. |$$$ 0  0$$b.0$$TransmissionofhepatitisAvirusbytransfusionis extremelyrare .", &$$ 0  0$$c.0$$HepatitisBtransmissionhasbeenmarkedlyreducedbymandatorytestingforHepatitisBsurface 8$!( antigen(_HBsAg_)indonorbloodandbyeliminatingtheuseofpaidblooddonors.%")$$ 0  0$$d.0$$Foratleast90%ofthecasesof_postransfusion_Ԁhepatitis,noknownviruscanbeidentifiedasthe &h$+ etiologicagentandthesecaseshavebeentermednonA,,nonB,nonC(_NANBNC_)hepatitis.'@%,$$ 0  0$$e.0$$Manypatientwillhaveamildcaseofthediseaseandrecover,but50%mayhaveabnormalliver H)&. functiontestsfor612monthsaftertransfusion. *'/$$ 0  0$$f.0$$Theseliverabnormalitiesarethoughttoindicatechronicpersistenthepatitisorchronicactive +x)1 hepatitis,whichinsomecasesmayprogresstocirrhosisanddeath.,P*2$$   -(+3 0  0$$g.0$$Sincethereisnoreliabletesttodetect_NANBNC_Ԁhepatitis,preventiondependsuponcareful X  screeningofdonorsand carefulfollowupofrecipientswhobecomeinfectedwithhepatitisdue 0 tobloodtransfusion . $$ 0  0$$h.0$$Thebloodbankshouldbegiventhenamesofallpatientswhodevelopviralhepatitis h _postransfusion_, lookback.@$$ 0  0$$0$$1)0 $$Thebloodbankrecordsalldonorstransfusedtothepatientandsendsthisinformationtothe H bloodsupplier.  $ $ 0  0$$0$$2)0 $$Thebloodsupplierdocumentsalldonorsashavingbeeninvolvedinacaseof_postransfusion_  x  hepatitisandwillpermanentlydeferdonorsifitisstatisticallyproventhattheyarecarriers. P  $ $ 0  2.0$$_Cytomegalovirus_X $$ 0  0$$a.0$$_Immunosuppressed_Ԁpatientshavebeenrecognizedtobeathighriskformoresevereformsof   transfusioninduced_CMV_Ԁinfections. $$ 0  0$$b.0$$Patientswhohaveundergonebonemarrowtransplantationmaydevelopfatal_CMV_Ԁinterstitial 8 pneumonia.h$$ 0  0$$c.0$$_CMV_Ԁisknowntobe transmissiblebyviableleukocytes intheperipheralblood.$$ 0  0$$d.0$$Significantmorbidityandmortalityattributableto_CMV_Ԁinfectionmayoccurinlowbirthweight t prematureinfantsbornof_CMV_Ԅ_seronegative_Ԁmothers.L$$ 0  0$$e.0$$Manybloodcentershavedevelopedprogramstoprovide_CMV_Ԅ_seronegative_Ԁunitstopatientsat T highriskfor_CMV_Ԁinfectionbybloodtransfusion.,$$ 0  3.0$$Malaria$$ 0  0$$a.0$$Therearenopracticallaboratoryscreeningtestsformalaria.4$$ 0  0$$b.0$$Althoughstillveryrare,thenumberofcasesoftransfusionassociatedmalariahasincreasedtothe <! highestlevelinthepast25years."$$ 0  0$$c.0$$Travelandimmigrationareamongthefactorsresponsibleforthisincrease. l$$$ 0  0$$d.0$$Exclusionofdonorsathighriskofharboringparasitesistheonlyeffectivepreventivemeasure.t" &$$ 0  0$$e.0$$Allcasesof_postransfusion_Ԁmalariamustbereportedtothebloodbankandbloodprovider.$$!($$   4.0  _Babesiosis_%|#*$$ 0  0$$a.0$$CausedbyBabesiaspecies,ticksarethedefinitivehosts,andoccasionaltickbornehuman ',%, infectionshavebeenreported.\(&-$$ 0  0$$b.0$$Inhumans,theorganismsmultiplyin_RBCs_.Clinicalsignsfollowingthebiteofaninfectedtick  *'/ resemblesymptomsofmalaria.Onexaminationofbloodsmearsonemustbecarefulnotto *(0 confusethemorphologywithmalaria.+d)1$$ 0  0$$c.0$$Donorsarepermanentlydeferred.l-+3$$  D.+4   5.0  SyphilisX$$ 0  0$$a.0$$Transmissionbytransfusionispossiblebutrequiresbloodbedrawnduringthebriefperiodof  _spirochetemia_Ԁ and thatorganismsareviableatthetimeoftransfusion.$$ 0  0$$b.0$$_Treponemes_Ԁmaysurvivefor72hoursat4C,sotransmissioncanbethroughcomponentsstoredat < RTortransfusedshortlyaftercollection.l$$ 0  0$$c.0$$Performanceofthe_STS_Ԁdoesnotpreventtransmissionbecausethetestischaracteristically   negativeinprimarysyphilisandmostpositive_STS_Ԁareduetobiologicfalsepositive.  $$ 0  0$$d.0$$_AABB_ԀStandardsrequires_STS_Ԁofdonorssinceapositivetestmayreflecthighrisklifestyle  L  activities.| $ $$   6.0  Chagas'Disease, $$ 0  0$$a.0$$Causedby_Trypanosoma_Ԁ_cruzi_. $$ 0  0$$b.0$$Transmittedbythebiteofthereduviidbug.Theparasiteusesthebloodstreaminlifecycletoget 4 tothetissues.d $$ 0  0$$c.0$$DiseasefoundprimarilyinMexico,CentralandSouthAmerica.Itisthecauseof30%ofadult  deathsinBrazil.therehavebeenafewcasesreportedinTexasandCalifornia.$$   7.0  _Toxoplasmosis_D$$ 0  0$$a.0$$Hasbeenreportedasanunusualtransfusioncomplicationof_immunosuppressed_Ԁpatients.L$$ 0  0$$b.0$$Clinicalillnessreportedingranulocyterecipients,butisnotaprobleminroutinetransfusion  practice.|$$   8.0  LymeDisease,$$ 0  0$$a.0$$CausedbythespirocheteBorreliaburgdorferi,transmittedbyticks.4!$$ 0  0$$b.0$$Maybeapotentialtransfusionproblem,transfusionrelatedcaseshavenotbeenreported.#$$ 0  0$$c.0$$DonorswithahistoryofLymediseaseshouldbeasymptomaticandhavecompletedafullcourse !<% ofantibiotictherapypriortodonatingblood.l" &$$   9.0  HumanImmunodeficiencyVirus(HIV)$!($$ 0  0$$a.0$$Initiallyrecognizedinlate1979.Mostcaseshavebeenassociatedwithsexualcontactamonggay %t#* males,IVdrugabuseorheterosexualcontactwithhighrickgroups.&L$+$$ 0  0$$b.0$$InitiallyitwasfeltthatHIVcouldnotbetransmittedbybloodtransfusion,unfortunatelythiswas T(%- notthecase.ThelargestpopulationhitbytransfusiontransmittedHIVhasbeenthehemophiliacs ,)&. whocontracteditthroughcommerciallypreparedFactorVIIIconcentrates.*'/$$   d- +3 0  0$$c.0$$AttemptstopreventtransfusiontransmittedHIVbythebloodprovidersisbasedona fourpoint X  program:2$$  0  0$$0$$1)0 $$voluntaryblooddonation $ $ 0  0$$0$$2)0 $$carefulmedicalhistoryandphysicalexaminationtoeliminatehighriskdonors. $ $ 0  0$$0$$3)0 $$asensitivetestforantiHIV` $ $ 0  0$$0$$4)0 $$aconfidentialselfexclusion8 $ $ 0  0$$d.0$$RecommendationstoreducethepotentialspreadofHIVthroughbloodtransfusionincludethe @ following: $$ 0  0$$0$$1)0 $$transfusionofbloodandbloodcomponentsshouldbegiven onlyforclearmedical  p  indications. L  $ $ 0  0$$0$$ 2)0 $$blooddonorsshouldbecarefullyscreenedandindividualsinhighriskgroupsshouldbe | $  educatedtoabstainfromdonation.T  $ $ 0  0$$0$$3)0 $$autologoustransfusionshouldbeemployedaswidelyaspossible.,  $ $ -  -K  .0    OtherDelayedAdverseEffectsofTransfusion- ی $$ Ќ  0  1.0$$TransfusionAssociatedGraftvsHostDisease(TA_GVHD_)4$$ 0    a.0$$TA_GVHD_Ԁisarare,usuallyfatal,complicationfollowingtransfusiontopatientswhoareseverely < _immunosuppressed_,suchasthosebeingintensivelytreatedwithchemotherapyandirradiation.$$ 0    b.0$$TA_GVHD_Ԁoccursif_immunocompetent_Ԁdonorlymphocytesengraftandmultiplyinthebone l marrowofaseverely_immunodeficient_Ԁrecipient.Theseengrafteddonorcellsreactagainstthe D "foreign"tissuesofthehostrecipient.t$$ 0    c.0$$Theclinicalsyndrome_ofTA_Ԅ_GVHD_Ԁmayincludefever,skinrash,hepatitis,diarrhea,bone $ marrowsuppressionandinfectionusuallyprogressingtoafataloutcome.$$ 0    d.0$$_ Pretransfusion_ԀirradiationofallbloodcomponentscontaininglymphocyteswillpreventTA T _GVHD_. Thefunctionof_RBCs_,_granulocytes_Ԁandplateletsisnotaffectedbysuchirradiation. . Situationsinclude:` $$   0  ^^1)0 $$cellularcomponentsforintrauterinetransfusions8! $ $   0  ^^2)0 $$patientsidentifiedasbeingatriskforTA_GVHD_" $ $   0  ^^3)0 $$cellulardirecteddonationsfromrelatives# $ $   0  ^^4) transfusionof_HLA_Ԁselectedproducts h$$$   2.0  _Postransfusion_Ԁ_Purpura_p" &$$ 0    a.0$$_Postransfusion_Ԁ_thrombocytopenic_Ԁ_purpura_Ԁ(_PTP_)isarareevent,occurringalmostexclusivelyin  $!( multiparouswomen.$")$$   0  b.0$$Aprecipitousfallinplateletcountproducesgeneralized_purpura_Ԁaboutaweekafterablood &P$+ transfusion.'(%,$$ 0    c.0$$Somepatientshavebeenshowntohavedevelopedaplateletspecific_alloantibody_, anti_HPA_Ԅ1a  0)&.  ( formerly antiPla1) .thisantigenhasaprevalenceof98.3%inthepopulation,soonly1.7%of  *'/ recipientsareatriskofdevelopingthe_alloantibody_.*(0$$ 0  0$$d.0$$Theantibodydestroysnotonlythetransfused_HPA_Ԅlaplateletsbutalsothepatient's_HPA_Ԅla ,@*2 negativeplatelets.themechanismforthedestructionofautologousplateletsremainsthesubject p-+3 ofintenseinvestigation.H.+4$$ Ї0  0$$e.0$$The_thrombocytopenia_Ԁisusuallysevere,andiftreatmentisneededexchange_plasmapheresis_Ԁhas X beensuggestedaspossibletherapy.0$$ 0  0$$f.0$$The_thrombocytopenia_Ԁisusuallyselflimitingandplatelettransfusionsare usuallynotbeneficial. $$ 0  3.0$$IronOverload(Transfusion_Hemosiderosis_)<$$ 0    a.0$$Everyunitof_RBCs_Ԁcontainsapproximately200mgofiron.Forchronicallytransfusedpatients, D suchas_thalassemics_Ԁwithpersistenthemolysis,progressiveandcontinualaccumulationofironin   themitochondriaofcellscanbedangerous.  $$ 0    b.0$$Whenpatientshavereceivedmorethan100transfusion,irondepositionmayinterferewith  L  functionoftheheart,liverorendocrineglands.| $ $$ 0    c.0$$Treatmentisdirectedatremovingironwithoutundulyreducingthepatient'scirculating ,  hemoglobin. $$ 0    d.0$$Useof_neocytes_Ԁisbeinginvestigated,theseyoung_RBCs_Ԁshouldremainlongerinthecirculation \ andtherebydecreasethenumberoftransfusionsneeded.4$$ 0  4.0$$_Immunomodulation_ԀbyTransfusion<$$ 0    a.0$$Transfusionhasbeenknowntomodulateimmunesystemresponsesandhavebeenimplicatedin  otherclinicalsettings,including:l$$ 0  0$$0$$1)0 $$Improvedrenal_allograft_Ԁsurvivalintransfusedpatients.D $ $ 0  0$$0$$2)0 $$increasedratesofsolidtumorrecurrencest $ $ 0  0$$0$$3)0 $$andincreasedratesofpostoperativebacterialinfections.L $ $ 0    b.0$$Effectsaresomewhatcontroversialandhavenotbeenconfirmed,butsuggeststhattherelationship  betweentransfusionandtheimmunesystemismorecomplexthanpreviouslyconsidered.|$$ L.0  RecordsofTransfusionComplications,$$   1.0  Recordsmustbekeptofallreportsoftransfusioncomplications.4!$$   2.0  Patientrecordsshouldindicatetheneedfor specialcomponentssuchas_leukopoor_,irradiated,_CMV_ # negative,antigennegative,etc.. d$$$   3.0  Casesoftransfusionassociateddisease(includingbutnotconfinedtohepatitisB,_NANB_Ԁhepatitisand l" & transfusionassociatedAIDS)mustbereportedtothecenterthatdrewtheblood.D# '$$   4.0   Fatalities resultingdirectlyfromtransfusioncomplications(_eg_,hemolyticreactionsorviralhepatitis) $") mustbereportedtotheFDAwithin24hoursfollowedbywrittenreportwithin7days.%