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Side Effects of Blood Donation by Apheresis Adverse Events Donor

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Side Effects of Blood Donation by Apheresis Adverse Events Donor Adverse events Side effects of blood donation by apheresis Adverse events of “blood collections” • Whole blood collections Hans Vrielink, MD, PhD • Apheresis collections Department of Transfusion Medicine • Donors • Adverse events c an be local and / or systemic or both • Events must be registered 2 Donor side effects after WB-donation Donor complications after WB-donation 1000 random donors interview ed 3 w eeks post donation (WB; 500 mL) Adverse Events Incidence % • 36% donors had one or more A E • Female : men = 2:1 (48 vs 23%) Local / Systemic • FD > RD (47 vs 36%) Bruis e / Hematoma 25 • Race affects bruising • Spontaneous reported < solic ited rates Arm pain 10 • Rates differ w ith interview er and used questions Burning Numbness Tingling 1 Fatigue 8 Vasovagal sy mptoms 5 Nausea vomiting 1 3 4 Newman B, et al. Transfusion 2003 Newman B, et al. Transfusion 2003 Effect Adverse Events on Return Rates (RR) Effect Adverse Events on Return Rates (RR) 1000 interview ed random WB-donors number return v isits (follow -up 9-21 Adverse Events % decrease months) Hematoma (inc idence 15%) 0 (n.s.) Estimated overall effect various A E on s ubsequent donation in general Pain in arm (7%) 2 (n.s.) blood donor population = 6% reduction Fatigue (5%) 20 •Greatest impact Vas ovagal sy mptoms Donor reaction (4%) 34 •Combinations: synergistic reducing effect (pain + fatigue: 65 instead 22) Donor reaction + pain arm 35 Pain arm + fatigue 65 Donor reaction + fatigue 66 Donor reaction + fatigue + pain arm 85 Estimated RR without AE: 1.32 visits / yr 5 6 Newman B, et al. Transfusion 2006 Newman B, et al. Transfusion 2006 1 “Donors who react may not come back” Adverse Events WB vs Apheresis (%) •Whole blood donors (n=89,587) A merican Red Cross Blood Serv ices WB Apheresis •Analyzed repeat donation vs. vasovagal reaction McLeod AE 11 - 21 2.18 • one-year follow -up: Despotis AE 0.81 moderate & severe vasovagal reaction: 50% overall reduction FD 1.09 RD 0.77 mild vasovagal reaction (97%): 20% reduction FD, 33% RD Winters Hematoma or pain 9 - 6 1.15 Citrate toxicity 0.4 Mild vas ovagal 2 - 5 0.05 Vasovagal + syncope 0.1 - 0.3 0.08 Vasov. + syncope + injury 0.013 7 8 France et al. TRASCI 2005 Vasovagal reaction Vasovagal reaction • A reflex of the parasy mpatic nervous system The body overreacts to certain triggers: • Affects the heart: bradycardia •Stress • Affects the nerves to the blood v essels in the legs dilatation. •Stress related to painful or unpleasant stimuli • As a result: hypotension • The brain is deprived of oxygen fainting • Trauma • Watc hing / experiencing medical procedures (e.g. venipuncture) • Hypocalcaemia • Anxiety •Extreme emotional distress •Lack of sleep •Dehydration •Hunger •etc 9 10 Vasovagal Reaction: symptoms Vasovagal Reaction: actions bradycardia • Trendelenburg’s position restoring the hypotension blood flow to the brain dizziness, pallor and sw eating • Stop donation / procedure naus ea, anxiousness • Control pulse and RR unconsciousness • Trust giv ing attitude 10-15% develop syncope after leaving the donation site 11 12 2 Strategies to decrease Vasovagal Reactions Hypotension a. Attention to donor & “keep their minds busy” Can be seen in donors (and patients) during apheres is. • Vasovagal reactions b. Effect of drinking w ater • Anaphy laxis w ithout: 8/22 presyncope, w ith: 1/22 presyncope mediated by increased peripheral vascular res istanc e Lu, Circulation 2003 RCT high school (+ FD) WB-donors 473 ml w ater (after medical acceptanc e for donation): 21% reduction Vasovagal reaction rate (men 27% vs w omen 15%) Newman Transfusion 2005 and 2007 Hanson Transfusion 2004 500 ml: 28% reduction Newman Transfusion 2006 13 14 Hypotension Hemodynamic changes in apheresis donors Can be seen in donors (and patients) during apheres is. • Hypovolemia • Vasovagal reactions • Plas mapheresis • Anaphy laxis • Cytapheresis • Hypovolemia • Plateletapheresis • WBC collections • RBC collections 15 16 Standards Guide (standards) In any combined collection of plas ma, platelets and/or red c ells in one apheresis procedure, the total volume of donated plas ma, platelets and red cells must not exceed 16% of total blood volume w ith a max imum of 750 mL (exclusive of anticoagulant) unless fluid replacement is undertaken. The total blood volume must be calculated on the bas is of gender, height and w eight. 3 Hypotension ACE-Inhibitors Can be seen in donors (and patients) during apheres is. Possible causes: • Decreased ability to inactivate bradykinin • Vasovagal reactions • Negatively charged plastic (disposables) or albumin • Anaphy laxis • flushing, hy potension, bradycardia, and dyspnea • Hypovolemia • Angiotensin c onverting enzy me (A CE) inhibitors 19 20 Hypotension Citrate Can be seen in donors (and patients) during apheres is. Possible causes: • Tris odiumcitrate • Vasovagal reactions • Flavoring and buffering agent in drinks / food • Anaphy laxis • Prevention of blood c lotting in dispos able / mac hine • Hypovolemia • Laxans • Angiotensin c onverting enzy me (A CE) inhibitors • WHO “oral rehydration solution” • Citrate toxicity 21 Citrate handling during apheresis procedures FXII FXIIa FXI FXIa Tissue factor • Tri-sodiumcitrate is added to w hole blood donor in procedure s pecific ratio 2+ • Citrate resolves completely in plas ma Ca FIX FIXa FVIIa FVII • Citrate chelates free Calc ium • Citrate returns to donor w ith plas ma containing components Ca2+ FIXa-FVIIIa Tissue factor-FVIIa Ca2+ FX FVIII FVIIIa Ca2+ Tissue factor FXa Ca2+ FV FVa FXa-FVa Ca2+ prothrombin thrombin 23 fibrinogen fibrin 4 Calcium metabolism Calcium metabolism • Active intake in intestines • Excretion via Kidney: • 250 mmol/day in pre-urine • Reabs orption of 245 mmol/day • Exc hange blood – bone parathyroid hormone (PTH) http://www.en.wikipedia.org Serum calcium & citrate infusion Serum PTH, iCa and citrate during plt apheresis McLeod BC, Szczepiorkowski ZM, Weinstein R, Winters JL, eds; Apheresis: Principles and Practice, KURZ 2001 3rd edition; Bethesda, MD: AABB Press, 2010 Function of Calcium Citrate Reactions • Structural function bones • Decrease in ioniz ed calcium results in • Signaling function messenger for some hormones increased excitability of neurons to the point of spontaneous depolarization. • Enzy matic function co-enzy me for clotting factors • Function in trans mission of nerve impulse • Function in the contraction of muscles 30 5 Symptoms of Citrate reactions Citrate → Hypomagnesemia 1. Minor: metallic taste and (peri-oral) tingling • Mg2+ also bound by citrate Actions: Slow rate of infusion, return speed↓ / Increase the blood to • During plateletapheresis: 30% drop in magnesium lev els citrate ratio • Steeper decrease and recovers more slow ly than calcium 2. Moderate: complains persist despite measures + nausea, shivering, • Muscle spas ms & w eakness light-headedness, paraesthesia and tremors, hypotension • Decreased vascular tonus (blood pressure) + abnormal cardiac Actions: stop, keep needle in situ, c alcium tablets contractibility • Interference w ith potassium and calcium homeostasis 3. Severe: Carpopedal spas m, muscle cramps + laryngeal spas m, sw allow complains, Chvostek’s and Trousseau’s sign positive, arrhythmia (prolongation QT interval) Actions: stop, keep needle in situ: 10 mL calc ium i.v. Long term effects? Dettk e J . Cli n Ap he resi s 2 00 3 Comparis on bone density of 45 donors >100 PLT-apheres is w ith 40 donors <50 procedures. 35% of >100 procedures donors show ed significant osteoporos is. 31 32 Local Adverse Events Cubital fossa • Good access sufficient blood flow Contents • Several veins (e.g. median cubital vein, c ephalic vein, and bas ilic vein) • Brachial artery • Biceps brachii tendon • Radial nerve • Medial nerve 33 Ganfyd & Wikipedia Frequent venous variations Hematoma 35 36 6 Hematomas in multicomponent apheresis Hematomas in multicomponent apheresis Related factors Related factors 1375 donors, retrospective 5177 procedures, A micus / Trima Hematoma • Correlated to: 170 (3,3%) hematoma • Race • Correlated to: less bruising in Afro-A meric an donors (p<0.05) • Experience operator (<500 proc edures) • Prior donations (1st versus 16th, arm movements) • Vena Bas ilica > Cephalica, Mediana • Low blood pressure: more frequent hematoma • No correlation to prior hematoma, age, gender 37 38 Bueno et al, Transfusion 2006 Newman et al, Transfusion 2003 Nervus cutaneus antebrachii Cubital fossa Superficial veins and nerves • In general: “veins overlie nerves” • Exc eption: medial antebrachial cutaneous nerve • 7 randomly chosen cadavers: 14 fossa cubiti dissections 6 out of 14: nerves w ere superficial to and overlay veins many intertw ines betw een superficial veins and cutaneous nerves frequent contact needle and nerve. Injuries are rare. 39 Horowitz Transfusion 2000 Wikipedia Venipuncture-induced causalgia Phlebitis Superficial veins and nerves • Inflammation vein • 24 patients w ith causalgia after venipuncture: 22 immediate pain, 2 after 12 to 18 hours, 16 hematoma 1,5 to13 years follow up • Slow onset of a painful, red area 3 improved s pontaneously • Long thin red area along the vein 6 no change: persisting burning, numbness, hyperpathia (hard, w arm, sw ollen and cord- 15 w orsened pain or numbness (11 developed dystrophy) like). Horowitz Transfusion 2000 • 1:6300 blood donors, 56 of 66 follow up: 52 full recovery, 4 mild residual numbness. Newman Transfusion 1996 41 42 7 Rare side effects & apheresis In summary • Hemolysis • Citrate effect • Kinks • Venipuncture related problems • Vasovagal reactions • Air embolus • Side effects from blood components • Medication • Registration is needed 43 44 8.
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