Reaction to Platelets

[1EMT-P]

So you are called to an outpatient infusion center for an 18 year old female patient who has a history of allergies, asthma & a rare cancer & has been receiving weekly labs, followed by a scheduled platelet infusion per her MD. The nursing staff tells you that she has been receiving weekly platelet infusions for the past few months & that she has never had a reaction until today. That shortly after starting her infusion she began complaining of hives, itching, swelling of her arms, chest, face & neck. Upon exam you find her lying in bed, her skin color is pale, with noted redness & swelling. She is alert & oriented Her pupils are PERL, there is negative JVD, her trachea is midline, her lung sounds reveal some wheezing, abdomen is soft & not tender. CMS is intact. The nursing staff reports that she has allergies to Benadryl, IV Contrast, Nubain, Ragweed, , Reglan, Sulfa Drug & Vistaril. Her medications include Albuterol, Claritin,Flonase, Lortab, Zofran and an unknown drug trial medication. The infusion center has an IV of NS running at 125 ML/HR & they have placed her on 4 LPM of Oxygen via Nasal Cannula. They have also given her an Albuterol treatment, 20mg of Claritin PO, 125mg of Solumedrol IV, drawn labs & obtained an EKG. Her vital signs are as follows: BP 120/84, Pulse 110-120 Sinus Tach, RR 22, Sats 94% on Room Air. You give the patient 0.3mg of 1:1000 Epinephrine IM & transport her to the ED.

1. How many of you have ever encountered a platelet reaction?

2. Does your agency have a transfusion reaction protocol?

2. Is there anything else that could have been done for this patient?

[Spock]

I've given platelets many times and I've never seen a reaction. We don't have a protocol for EMS but there are very few facilities outside the hospital around here that would give blood products. The cancer centers are attached to a hospital so any reactions would just go to the DEM. It seems that the staff had covered all the bases regarding treatment. The benadryl allergy limits treatment. I'm not sure I would have given epi because her vitals weren't all that bad and her heart rate was already fast. What was her saturation on oxygen?

These types of reactions are not that common.

[uglyEMT]

1. Haven't experienced this kind of reaction.

2. No

3. 22 RR.. I would think 15 Lpm NRB because of the pale skin and depending on tidal volume... bagging.

What was the change with the Epi?

Sounds like a blood transfusion from someone that has bad seasonal allergies. If the Pt is in/from the Northeast we are currently in a very bad allergy season. Cold spring has led to both a tree and weed/grass pollen season happening at the same time.

Zofran is leading me to Chemo. Also said unknown treatment?!? I would find out the treatment due to the fact you may be looking at a side effect. Might be looking at a drug interaction. Has the patient vomited recently? Could be an aspirated Pt with onset pneumonia.

If nothing else I would be monitoring tidal volume and RR, sounds, and transporting. If the area has a dedicated hyperbaric and/or asthma center that would be my choice.

Edited May 27, 2013 by uglyEMT

[ChaseZ]

1. Haven't experienced this kind of reaction.

2. No

3. 22 RR.. I would think 15 Lpm NRB because of the pale skin and depending on tidal volume... bagging.

What was the change with the Epi?

Sounds like a blood transfusion from someone that has bad seasonal allergies. If the Pt is in/from the Northeast we are currently in a very bad allergy season. Cold spring has led to both a tree and weed/grass pollen season happening at the same time.

Zofran is leading me to Chemo. Also said unknown treatment?!? I would find out the treatment due to the fact you may be looking at a side effect. Might be looking at a drug interaction. Has the patient vomited recently? Could be an aspirated Pt with onset pneumonia.

Can you explain why you feel the need to use a NRB @ 15Lpm or bag this patient? Why do you think this patient has pale skin.....And why do you think more oxygen would fix that?

Aspiration pneumonia does not really fit the scenario and is a far stretch at that.

Sounds like anaphylaxis r/t transfusion reaction. Reaction to platelets is rare but does happen. I think they treated her appropriately. Monitor and transport to the ED

[uglyEMT]

My feelings for the NRB is because of the 94 sat would like to see it up around 96 or 98.

Bagging if necessary due to the shallow respirations and wheezing sounds. This Pt may need help soon especially if the tidal volume continues to decrease.

The pale skin, that was my bad last night I was thinking cyanosis not pale skin. Now thinking about it with the hx of this Pt. any number of things could be causing it. So it really isn't indicative at this point.

The other things I mentioned are more of me thinking out loud. I usually think worst case until its ruled out through assesment.

[Just Plain Ruff]

Have they or you stopped the infusion of the platelets?

[Timmy]

I have dealt with this many times in the hospital setting and as far I know the ambulance service does not have a specific guideline for such a reaction, it would most likely fall under the anaphylaxis guideline. In my experience commonly people react to blood products (blood, platelets, and immunoglobulin) due to the rate of the infusion rather than intravascular haemolysis, anaphylaxis, febrile/bacterial sepsis etc. it would be interesting to know taking into consideration she has not reacted to any previous infusions, whether the staff increased the infusion rate on this occasion. Do you know how long the infusion had been running for before the symptoms started? It would be rare, taking into consideration she has been receiving ‘weekly’ transfusions for ‘months’ that a reaction would be caused by antigen build up leading to an anaphylactic event.

I’d be interested to know:

What her platelet and neutrophil levels are on the last blood test?

What her level of respiratory distress is?

What her SP02 is now on oxygen?

Has she improved with the salbutamol & antihistamine?

Does she have any fever/rigors?

Interesting choice of pharmacology using methylprednisolone for a blood reaction, did they use that directly for the reaction or as part of her treatment for the thrombocytopenia (assuming this is why she is receiving platelets).

I think the treatment was ok, generally if a patient reacts we:

Stop the infusion

Obtain vital signs

Manage any life threats

Get secondary IV access (I wouldn’t be flushing the same line)

Back track your paper trail – confirm the right patient is receiving the right blood product

Get bloods for FBE, UEC, CRP, Cultures

Send blood product back to lab for testing

Give antihistamines/steroids/adrenaline/antibiotics

Once the patient is stable/symptom free the infusion can recommence if clinically indicated

[firemedic37]

There are a few different causes that come to mind, most probable one is an interaction with the antibodies that the patient has developed from the numerous platelet transfusions. The risk of an interaction increases every time a patient receives a transfusion of any blood product.

We do have a protocol called "Adverse Reaction to Blood Products". We routinely transfer patients that we are starting or continuing blood products on so we have prepared ourselves in case we ever need to use it.

This is what I would of done:

Ensure that the transfusion was stopped and had been sent to the lab to recheck compatibility (ensure there was not a mistake made).

Recheck vitals from the time they took them, compare for significant changes. Also obtain temperature, they should have a baseline prior to administration.

Evaluate the patient, are they still symptomatic?

If the patient complained of shortness of breath or difficulty breathing consider another albuterol or if significant consider CPAP with Albuterol. Remember patients can have flash pulmonary edema from a transfusion.

O2 to maintain O2 saturations 94%

Vitals appear to be stable, would consider TKO of fluids.

Also investigate what happens when she takes Benadryl, sometimes an adverse reaction (tachycardia, nausea, headache, sedation, etc.) is not a true allergic reaction.

And of course continue monitoring all vitals, SpO2 and EKG.

I would of held off of the Epi unless there was significant concern for the pt's airway. Vitals were stable.

I would say a majority of 911 services would have no idea how to treat an adverse reaction to blood products considering most Paramedic textbooks have about one paragraph in them about the evaluation and treatment of them. Treatment was acceptable.

[Just Plain Ruff]

"Also investigate what happens when she takes Benadryl, sometimes an adverse reaction (tachycardia, nausea, headache, sedation, etc.) is not a true allergic reaction"

Yes I agree::::: but with one caveat(at least in my opinion) ----- I would not give her any benadryl if you discover that her reaction to benadryl is not truly a reaction. I as a medic would never want to be the one to give a patient who has a documented allergy in her chart a medication that she's allergic too without much consultation with a physician.

I know that you would not either but I would leave that to her treating physician but to investigate her allergy would be an appropriate thing though.

Only with consultation with her physician of record and other medical professionals (higher up on the degree chain) than I should make the deicision to give her benadryl.

Imagine a medic determining that her reaction isn't truly a reaction and then giving benadryl only to find out that she is truly allergic to benadryl.

But again, I've never seen a benadryl allergic reaction.

Edited May 28, 2013 by Captain ToHellWithItAll

[Mateo_1387]

As far as Benadryl goes, it could be an allergy due to the dye of oral Benadryl, not necessarily to IV Benadryl. Also, remember Phenergan is also an antihistamine that could possibly be used.