Critically discuss the hazards associated with transfusion of plasma products. In your answer refer to the role of SHOT for monitoring such hazards.
The use of plasma products during transfusion is not without hazards. Plasma transfusions can be prescribed during an emergency situation like in trauma, surgery, excess bleeding, or even liver disease.
Plasma is a fluid compartment of blood and is made of 90% water, 7% colloids/proteins and 3% nutrients and vitamins. Plasma can be manufactured from whole blood after centrifugation and RBC removal. Clotting factors are the constituents for which transfusion of plasma is most often required. (1)
Plasma products- Fresh frozen plasma FFP- plasma frozen within 24 hours after phlebotomy, cryoprecipiate reduced plasma and thawed plasma are plasma based products used in hospitals and during emergency situations. (1)
Plasma transfusion is associated with a number of infectious and non-infectious adverse events. Transfusion transmitted diseases traditioinally include HIV, hepatitis B and C which are currently rare. Non infectious risks include allergic reactions, TRALI, TACO and haemolytic reactions.
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Some examples of risks associated with plasma transfusion include transfusion related acute lung injury (TRALI), transfusion associated circulatory overload (TACO) and acute transfusion reactions which include allergic and hypotensive reactions.(2)
Studies have shown that fresh frozen plasma is commonly requested for non-bleeding patients with abnormal coagulation studies.(2) FFP contains approximately 1 IU per ml (international units) of each clotting factor. (1) Multiple studies have shown that quite a large proportion of fresh frozen plasma transfusions do not follow any guidelines. (2) TRALI is known to be as one of the leading causes of transfusion-related mortality. TRALI is characterised by acute hypoxemia and non-cardiogenic pulmonary oedema within 6 hours of a completed transfusion. The primary mechanism of TRALI is the accumulation and activation of neutrophils within the pulmonary endothelium. (2) There are multiple strategies that have taken to reduce the risk of TRALI from plasma like donors implicated in prior TRALI reactions are deferred from further blood donation, female donors are now tested for HLA and HNA antibodies, and blood products with high volume plasma are not made from those with high-titre antibodies. Also plasma supplied to hospitals for transfusion can be only from male donors while the female plasma is diverted for fractionation (separating various components of blood plasma). An assessment of data collected from 1996-2006 thorough SHOT suggests a significant decrease in TRALI flowing institution of these policies. (BETH). TACO is similar to TRALI since ..???
Allergic transfusions can take place when pre-formed recipient antibodies bind to transfused allergens (BETH). Allergic transfusions take place in approximately 1-3% of plasma transfusions but most of them are mild reactions (BETH). Patients that have severe allergic reactions should be tested for IgA deficiency and the presence of anti-IgA. If anti IGA is present the patient should receive plasma products from IgA deficient donors or washed RBC and platelets products. ...... (BETH).
Transfusion associated circulatory overload is a result of infusion of blood product volume that exceeds the recipient’s circulatory capacity. This could be due to high volume or excessive infusion rate (beth). TACO is found to be more common in young or elderly patients with impaired cardiac function or positive fluid balance. Some of the symptoms of TACO could be dyspnea, tachycardia, and increased blood pressure within six hours of a completed transfusion. Additional known risk factors for TACO include larger volumes of transfusion, greater plasma transfusion volume and faster transfusion rate. TACO can be prevented by avoiding rapid transfusion unless clinically indicated.
Pg 384 chptr 58
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Marked to Standard
In patients with haemophilia A or B, recombinant factors VIII and IX may be used instead of plasma derived concentrates. In case of Factor VII deficiency, recombinant factor VIIa can be used for the treatment of patients.
According to the annual SHOT report 2013, the total issues related to plasma transfusion in the UK have been approximately 266,332.
ATR’s can be classified into different types of reactions namely, febrile, allergic and hypotensive. Anaphylactic is one of the most severe forms of an allergic transfusion reaction. They can be rare, but are life-threatening emergencies. Thiry three reactions were consistent with anaphylaxis or severe allergy according to the SHOT report 2013. Nausea, abdominal cramps, vomiting, diarrhoea, hypotension and shock are some of its symptoms which can occur after the transfusion of only a few millilitres of plasma has taken place. They are associated with antibodies to IgA. Some patients with IgA deficiency develop anti-IgA antibodies, which may then cause anaphylactic transfusion reactions when an IgA containing component is transfused (4). In 2013, out of the 120 anaphylaxis/hypersensitivity reactions, 21 occurred during plasma transfusion. Sometimes these reactions can be detected by routine observations. According to SHOT report, stopping the transfusion reaction in this case is very important and check for obvious contamination. In case of severe reactions, the plasma component should be taken down and further investigation should be carried out.
Some significant errors identified by SHOT involved the hospital and laboratory information technology system. The report states that the main issue with patient administration systems is that the hospitals do not have secure systems in place which therefore is leading to the misidentification of the patient and thereby the incompatible product being given. Storage error, which includes the temperature and proper management of the freezers or storage units, could be one of the reasons. Refrigerator mapping records were also found to be out of date in some cases. Training of the staff had also not been completed appropriately.
Another possible hazard could be the transfusion of an incorrect component i.e. when a patient gets transfused with an incompatible blood component or other than what was prescribed for the patient. 19 such cases were reported to SHOT in 2013 involving the fresh frozen plasma where confusion between platelets and FFP is regarded as the most common mistake. ABO antibodies in donor plasma can cause problems when transfused to a different group. Procedural and testing errors during the transfusion process can be one of the reasons for it. Lack of the component knowledge can also lead to the incorrect component being transfused to the patient. Wrong blood in tube (WBIT) can also be one of the reasons, meaning that the blood was taken from the wrong patient and labelled with the intended patient’s details and vice versa. There can be a high potential risk under such a situation, since the error cannot be detected easily
In terms of contamination, only a few reports have concluded that plasma products get contaminated during water bath with Pseudomonas species, otherwise plasma products are not known to be contaminated also the reactions to plasma do not need unit cultures to be carried out. (JOE)
Haemolytic transfusion reactions
Transfusion is a multidisciplinary activity with both the clinical and laboratory staff working in partnership as one integrated team. In an emergency, or if the group is unclear, the safe group of fresh frozen plasma (FFP) to give is group AB or group A (because AB is often in short supply), but not group O. Group O FFP should be reserved for patients confirmed to be group O and is not suitable for use in the emergency setting where the blood group is unknown. Laboratory protocols for emergencies should clearly state this.
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