AAFP Journal Review

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AAFP Journal Review

• Karam Makhni

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Health Maintenance in School-aged Children
History, Physical Examination, Screening, and
Immunizations

• The aim of the well-child examination in
  school-aged children is to promote health and
  prevent future health problems.
• Lack of time limits provision on preventive care.
• This section focuses on history, physical
  examination and screening for health maintenance
  in school-aged children

3
SORT KEY RECOMMENDATIONS FOR PRACTICE
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History

• A complete well-child examination history
  includes multiple screening questions.
• Social history, living situation and lifestyle
  habits, can be particularly important in this age
  group
• Important to inquire about safety habits and the
  presence of firearms in the home.
• Consider giving a questionnaire to the family to
  complete before the visit.

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Physical Examination

• A full physical examination should be performed
  during any health maintenance visit.
• Abnormality found in less than 4 percent of
  patients, and most of these abnormalities are not
  clinically significant.
• More than 1 million abused children are
  identified annually in the United States.

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Screening Recommendations for School-aged
Children and Adolescents
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Supplements

• VITAMIN D
• Inadequate vitamin D levels are associated with a
  wide range of conditions
• Studies have shown that up to 50 percent of
  children are vitamin D deficient
• The AAP recommends 400 IU of vitamin D daily for
  all
• There are no clear guidelines for screening for
  vitamin D deficiency in children.

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Supplements

• Children six months to 16 years of age living in
  areas with inadequate fluoride in the water
  supply should be counseled on fluoride
  supplementation.

9
Immunizations

• Two sets of immunizations recommended for
  school-aged children.
• In addition to these primary vaccines, the
  influenza virus vaccine is recommended annually
  for all children older than six months.
• Certain high-risk groups may need additional
  vaccines. At every well-child visit, the
  immunization record should be reviewed to ensure
  that catch-up immunizations are not needed.
• Nationally, there is a high level of vaccine
  completion for the four- to six-year-old
  vaccines.
• Completion rates for vaccines recommended in
  early adolescence are significantly less,
• Less than 20 percent completing the human
  papillomavirus vaccine series.
• physicians should adopt strategies to increase
  immunization completion in their patients.

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Health Maintenance in School-aged Children
Counseling Recommendations

• Anticipatory guidance is appropriate at all ages,
  but it is particularly important in school-aged
  children
• Focus on counseling recommendations
• There is little evidence to suggest the best
  methods for health counseling in school-aged
  children
• School aged children are concrete thinkers
• Discuss high risk behaviours

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SORT KEY RECOMMENDATIONS FOR PRACTICE
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Screening and Counseling Recommendations for
School-aged Children and Adolescents
13
Screening and Counseling Recommendations for
School-aged Children and Adolescents
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Counseling

• Well-child visits for school-aged children are
  typically conducted with a parent present.
• Discussions about sensitive issues, such as
  substance use and sexual activity, should occur
  without the parent in the room.

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DIETARY COUNSELING

• Poor definitive evidence on how to best advise
  patients and families.
• The most effective are comprehensive behavioral
  interventions
• Most experts recommend providing some dietary
  counseling to children and their families at the
  well-child examination focusing
• Families should also be advised to limit sugary
  beverages, fast food, and highly processed foods,
  and be educated on appropriate portion sizes.

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Dietary Counseling Recommendations for
School-aged Children
17
NIH Recommendations for Physical Activity in
School-aged Children

• At least 60 minutes of physical activity per day
• Moderate-intensity aerobic activity, such as
  walking, running, skipping, playing on the
  playground, playing basketball, and biking, on
  most days
• Vigorous-intensity aerobic activity, such as
  running, doing jumping jacks, and swimming fast,
  at least three days per week
• Muscle-strengthening activities, such as climbing
  trees, playing tug-of-war, and doing push-ups and
  pull-ups, at least three days per week
• Bone-strengthening activities, such as hopping,
  skipping, doing jumping jacks, playing
  volleyball, and working with resistance bands, at
  least three

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Screen Time

• The average child spends 7.5 hours per day in
  front of a screen
• Obesity rates are lowest in children who have
  less than one hour of screen time daily, and are
  highest in those who have greater than four hours
  of screen time daily.
• Screen time may also negatively affect body image
  and school performance, and promote violent
  behavior.
• Physicians should counsel families to limit
  screen time, and encourage children to replace
  screen time with physical activity.
• The AAP recommends limiting screen time to no
  more than one to two hours of quality programming
  daily.

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High-Risk Behaviors

• Tobacco, alcohol, and illicit drug use may begin
  in early adolescence.
• According to a 2007 survey of youth in the United
  States, 24 percent of those younger than 13 years
  had had their first drink of alcohol, 15 percent
  had smoked an entire cigarette, and 8 percent had
  tried marijuana.
• The effectiveness of physician counseling in this
  area is unknown.
• The AAP recommends asking adolescents directly
  about tobacco alcohol, and drug use annually
  beginning at 11 years of age.
• If the patient reports substance use, additional
  questioning on duration, amount, and frequency is
  appropriate

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High Risk Behavior

• The CRAFFT (car, relax, alone, forget, friends,
  trouble) questionnaire is one brief screening
  tool that has been validated in the primary care
  setting to identify substance abuse in
  adolescents
• Have you ever ridden in a car driven by someone
  who was high or had been using alcohol or
  drugs?
• Do you ever use alcohol or drugs to relax, feel
  better about yourself, or fit in?
• Do you ever use alcohol or drugs when you are by
  yourself?
• Do you ever forget things you did while you were
  using alcohol or drugs?
• Do your family or friends ever tell you that you
  should cut down on your drinking or drug use?
• Have you ever gotten into trouble while you were
  using alcohol or drugs?
• Physicians would give one point for each yes
  answer to the previous questions. A score of 2 or
  more should prompt concern for substance abuse or
  dependence

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Differentiation and Diagnosis of Tremor

• Tremor is an involuntary, rhythmic, oscillatory
  movement of a body part.
• It is the most common movement disorder
  encountered in clinical practice.
• There is no diagnostic standard to distinguish
  among common types of tremor
• History and physical examination can provide a
  great deal of certainty in diagnosis.
• The most common tremor in patients presenting to
  primary care physicians is enhanced physiologic
  tremor, followed by essential tremor and
  parkinsonian tremor.
• All tremors are more common in older age

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SORT KEY RECOMMENDATIONS FOR PRACTICE
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Broad Classification of Tremor

• Action -Occurs with voluntary contraction of
  muscle. Includes postural, isometric, and kinetic
  tremors
• Postural - Occurs when the body part is
  voluntarily maintained against gravity. Includes
  essential, physiologic, cerebellar, dystonic, and
  drug-induced tremors
• Kinetic- Occurs with any form of voluntary
  movement. Includes classic essential, cerebellar,
  dystonic, and drug-induced tremors
• Intention-Subtype of kinetic tremor amplified as
  the target is reached.Presence of this type of
  tremor implies that there is a disturbance of the
  cerebellum or its pathways
• Rest- Occurs in a body part that is relaxed and
  completely supported against gravity. Most
  commonly caused by parkinsonism, but may also
  occur in severe essential tremor

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Tremors

• http//www.youtube.com/watch?vxVRKO-Sz0x4
• http//www.youtube.com/watch?vGQm8klm6ub8
• http//www.youtube.com/watch?vDaIN2zRQn8w

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ESSENTIAL TREMOR

• The most common pathologic tremor is essential
  tremor.
• In one-half of cases, it is transmitted in an
  autosomal dominant fashion, and it affects 0.4 to
  6 percent of the population.
• Careful history reveals that patients with
  essential tremor have it in early adulthood (or
  sooner), but most patients do not seek help for
  it until 70 years
• Despite being sometimes called benign essential
  tremor, essential tremor often causes severe
  social embarrassment, and up to 25 percent of
  those afflicted retire early or modify their
  career path
• Essential tremor is an action tremor, usually
  postural, but kinetic and even sporadic rest
  tremors have also been described. It is most
  obvious in the wrists and hands when patients
  hold their arms out
• It is generally bilateral, is present with a
  variety of tasks, and interferes with activities
  of daily living.

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DRUG- AND METABOLIC-INDUCED TREMORS

• Dozens of medications can cause or exacerbate
  tremor
• Patients with new-onset tremor should have a
  comprehensive medication review with specific
  attention to medications prescribed and
  over-the-counter
• Medications particularly prone to inducing or
  exacerbating tremor are those that stimulate the
  sympathetic nervous system (e.g., amphetamines,
  terbutaline, pseudoephedrine) and psychoactive
  medications (e.g., tricyclic antidepressants,
  haloperidol, fluoxetine Prozac).
• Metabolic causes of tremor are varied.8 Initial
  workup of tremor may include blood testing for
  hepatic encephalopathy, hypocalcemia,
  hypoglycemia, hyponatremia, hypomagnesemia,
  hyperthyroidism, hyperparathyroidism, and vitamin
  B12 deficiency

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Selected Medications and Substances That May
Exacerbate Tremor

• Amphetamines
• Atorvastatin (Lipitor)
• Beta-adrenergic agonists (e.g., albuterol)
• Caffeine
• Carbamazepine (Tegretol)
• Corticosteroids
• Cyclosporine (Sandimmune)
• Epinephrine
• Fluoxetine (Prozac)
• Haloperidol
• Hypoglycemic agents
• Lithium
• Metoclopramide (Reglan)
• Methylphenidate (Ritalin)
• Pseudoephedrine
• Terbutaline
• Theophylline

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PSYCHOGENIC TREMOR

• Differentiation of organic from psychogenic
  tremor can be difficult.
• Features consistent with psychogenic tremor are
  abrupt onset, spontaneous remission, changing
  tremor characteristics, and extinction with
  distraction.
• Often, there is an associated stressful life
  event.
• Based on clinical experience, the prevalence of
  psychogenic tremor is thought to be high, but
  there are no precise estimates.

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Physiological Tremor

• A physiologic tremor is present in all persons
• It is a low-amplitude, high-frequency tremor at
  rest and during action that is not reported as
  symptomatic.
• This tremor can be enhanced by anxiety, stress,
  and certain medications and metabolic conditions.
• Patients with a tremor that comes and goes with
  anxiety, medication use, caffeine intake, or
  fatigue do not need further testing.

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Diagnostic Approach
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Diagnosis of Tremor with an Organic Cause
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Diagnostic Approach

• The diagnosis of tremor is based on clinical
  information obtained from a thorough history and
  physical examination. Although there is overlap
  and variability among the individual tremor
  syndromes, the intrinsic features of the tremor
  usually provide key diagnostic clues
• The first step in the evaluation of a patient
  with tremor is to categorize the tremor based on
  its activation condition, topographic
  distribution, and frequency. The activation
  condition should be described as rest, kinetic
  (or intention), postural, or isometric
• The examiner can have the patients sit with their
  hands in their laps to check for rest tremor. A
  sequential test for postural and kinetic tremors
  can be done by having the patient stretch his or
  her arms and hands out, followed by a simple
  finger-to-nose test.
• A rest tremor is virtually synonymous with
  parkinsonism, whereas an intention tremor often
  indicates a cerebellar lesion.
• Several historical clues can play important roles
  in the differentiation of tremors Tremor in older
  patients is more likely to be parkinsonian or
  essential tremor. Patients with sudden onset of
  tremor should be evaluated to determine if the
  tremor is caused by medications, toxins, a brain
  tumor, or a psychogenic cause. Patients with a
  gradual onset of tremor should prompt questions
  about Parkinson disease.

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Features of Common Tremor Syndromes
34
Transfusion of Blood and Blood Products
Indications and Complications

• Blood transfusion can be a lifesaving procedure,
  but it has risks, including infectious and
  noninfectious complications. There is debate in
  the medical literature concerning the appropriate
  use of blood and blood products. Clinical trials
  investigating their use suggest that waiting to
  transfuse at lower hemoglobin levels is
  beneficial.1,2 This review will consider the
  indications for transfusion of blood and blood
  products, and will discuss common noninfectious
  complications associated with transfusion

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SORT KEY RECOMMENDATIONS FOR PRACTICE
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Red Blood Cells

• Packed red blood cells (RBCs) are prepared from
  whole blood by removing approximately 250 mL of
  plasma. One unit of packed RBCs should increase
  levels of hemoglobin by 1 g per dL (10 g per L)
  and hematocrit by 3 percent. In most areas,
  packed RBC units are filtered to reduce
  leukocytes before storage, which limits febrile
  nonhemolytic transfusion reactions (FNHTRs), and
  are considered cytomegalovirus safe
• RBC transfusions are used to treat hemorrhage and
  to improve oxygen delivery to tissues.
  Transfusion of RBCs should be based on the
  patient's clinical condition.4 Indications for
  RBC transfusion include acute sickle cell crisis
  (for stroke prevention), or acute blood loss of
  greater than 1,500 mL or 30 percent of blood
  volume.4 Patients with symptomatic anemia should
  be transfused if they cannot function without
  treating the anemia.4 Symptoms of anemia may
  include fatigue, weakness, dizziness, reduced
  exercise tolerance, shortness of breath, changes
  in mental status, muscle cramps, and angina or
  severe congestive heart failure. The 10/30
  ruletransfusion when a patient has a hemoglobin
  level less than or equal to 10 g per dL (100 g
  per L) and a hematocrit level less than or equal
  to 30 percentwas used until the 1980s as the
  trigger to transfuse, regardless of the patient's
  clinical presentation.4,5
• In 1999, a randomized, multicenter, controlled
  clinical trial evaluated a restrictive
  transfusion trigger (hemoglobin level of 7 to 9 g
  per dL 70 to 90 g per L) versus a liberal
  transfusion trigger (hemoglobin level of 10 to 12
  g per dL 100 to 120 g per L) in patients who
  were critically ill.1 Restrictive transfusion
  practices resulted in a 54 percent relative
  decrease in the number of units transfused and a
  reduction in the 30-day mortality rate. The
  authors recommended transfusion when hemoglobin
  is less than 7 g per dL, and maintenance of a
  hemoglobin level between 7 to 9 g per dL.1 A
  recently updated Cochrane review supports the use
  of restrictive transfusion triggers in patients
  who do not have cardiac disease.6

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Red Blood Cells

• similar study was carried out in critically ill
  children.2 The restrictive transfusion trigger
  was a hemoglobin level of 7 g per dL, with a
  target level of 8.5 to 9.5 g per dL (85 to 95 g
  per L). The liberal transfusion trigger was a
  hemoglobin level of 9.5 g per dL, with a target
  level of 11 to 12 g per dL (110 to 120 g per L).
  Patients in the restrictive group received 44
  percent fewer blood transfusions, with no
  difference in rates of multiple organ dysfunction
  syndrome or death. The restrictive transfusion
  strategy is useful for children who are stable
  patients in intensive care. It should not be used
  in preterm neonates or in children with severe
  hypoxemia, active blood loss, hemodynamic
  instability, or cyanotic heart disease.2

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Plasma

• Plasma products available in the United States
  include fresh frozen plasma and thawed plasma
  that may be stored at 33.8 to 42.8F (1 to 6C)
  for up to five days. Plasma contains all of the
  coagulation factors. Fresh frozen plasma infusion
  can be used for reversal of anticoagulant
  effects. Thawed plasma has lower levels of
  factors V and VIII and is not indicated in
  patients with consumption coagulopathy (diffuse
  intravascular coagulation).
• Plasma transfusion is recommended in patients
  with active bleeding and an International
  Normalized Ratio (INR) greater than 1.6, or
  before an invasive procedure or surgery if a
  patient has been anticoagulated.7,8  Plasma is
  often inappropriately transfused for correction
  of a high INR when there is no bleeding.
  Supportive care can decrease high-normal to
  slightly elevated INRs (1.3 to 1.6) without
  transfusion of plasma. Table 1 gives indications
  for plasma transfusion

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(No Transcript)
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Platelets

• Platelet transfusion may be indicated to prevent
  hemorrhage in patients with thrombocytopenia or
  platelet function defects.
• Contraindications to platelet transfusion include
  thrombotic thrombocytopenic purpura and
  heparin-induced thrombocytopenia
• Transfusion of platelets in these conditions can
  result in further thrombosis.10,11 One unit of
  apheresis platelets should increase the platelet
  count in adults by 30 to 60 103 per µL (30 to
  60 109 per L).3 In neonates, transfusing 5 to
  10 mL per kg of platelets should increase the
  platelet count by 50 to 100 103 per µL (50 to
  100 109 per L).12 One apheresis platelet
  collection is equivalent to six pooled random
  donor platelet concentrates

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Indications for Transfusion of Platelets in Adults
42
Cryoprecipitate

• Cryoprecipitate is prepared by thawing fresh
  frozen plasma and collecting the precipitate.
  Cryoprecipitate contains high concentrations of
  factor VIII and fibrinogen. Cryoprecipitate is
  used in cases of hypofibrinogenemia, which most
  often occurs in the setting of massive hemorrhage
  or consumptive coagulopathy.
• Each unit will raise the fibrinogen level by 5 to
  10 mg per dL with the goal of maintaining a
  fibrinogen level of at least 100 mg per dL. The
  usual dose in adults is 10 units of pooled
  cryoprecipitate.

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Indications for Transfusion of Cryoprecipitate
44
Infectious Complications of Blood Transfusions
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Transfusion Complications

• Transfusion-related complications can be
  categorized as acute or delayed, which can be
  divided further into the categories of
  noninfectious and infectious.
• Acute complications occur within minutes to 24
  hours of the transfusion, whereas delayed
  complications may develop days, months, or even
  years later.
• Transfusion-related infections are less common
  because of advances in the blood screening
  process the risk of contracting an infection
  from transfusion has decreased 10,000-fold since
  the 1980s.
• Noninfectious serious hazards of transfusion are
  up to 1,000 times more likely than an infectious
  complication. However, there has been no progress
  in preventing noninfectious serious hazards of
  transfusion, despite improvements in blood
  screening tests and other related medical
  advances. Therefore, patients are far more likely
  to experience a noninfectious serious hazard of
  transfusion than an infectious complication.

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Noninfectious Serious Hazards of Transfusion
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• Hemolytic transfusion reactions are caused by
  immune destruction of transfused RBCs, which are
  attacked by the recipient's antibodies. The
  antibodies to the antigens of the ABO blood group
  or alloantibodies to other RBC antigens are
  produced after immunization through a previous
  transfusion or pregnancy. There are two
  categories of hemolytic transfusion reactions
  acute and delayed. Nonimmune causes of acute
  reactions include bacterial overgrowth, improper
  storing, infusion with incompatible medications,
  and infusion of blood through lines containing
  hypotonic solutions or small-bore intravenous
  tubes.16,18,19
• In acute hemolytic transfusion reactions, there
  is a destruction of the donor's RBCs within 24
  hours of transfusion. Hemolysis may be
  intravascular or extravascular. The most common
  type is extravascular hemolysis, which occurs
  when donor RBCs coated with immunoglobulin G
  (IgG) or complement are attacked in the liver or
  spleen.17 Intravascular hemolysis is a severe
  form of hemolysis caused by ABO antibodies.
  Symptoms of acute hemolytic transfusion reactions
  include fever, chills, rigors, nausea, vomiting,
  dyspnea, hypotension, diffuse bleeding,
  hemoglobinuria, oliguria, anuria, pain at the
  infusion site and chest, back, and abdominal
  pain.19 Associated complications are clinically
  significant anemia, acute or exacerbated renal
  failure, disseminated intravascular coagulation,
  need for dialysis, and death secondary to
  complications.18
• The incidence of acute hemolytic reactions is
  approximately one to five per 50,000
  transfusions.19 From 1996 to 2007, there were 213
  ABO-incompatible RBC transfusions with 24
  deaths.17 Systems using bar codes for blood and
  patient identification have decreased errors.17

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ALLERGIC REACTIONS

• Allergic reactions range from mild (urticarial)
  to life threatening (anaphylactic). Urticarial
  allergic reactions are defined by hives or
  pruritus.20 Patients experiencing allergic
  transfusion reactions have been sensitized to the
  antigens in the donor unit. These antigens are
  soluble, and the associated reaction is
  dose-dependent. Allergic transfusion reactions
  occur in 1 to 3 percent of transfusions.16
• Patients with anaphylactic transfusion reactions,
  like those with urticarial reactions, may present
  with hives, but they are distinct in that they
  also develop hypotension, bronchospasm, stridor,
  and gastrointestinal symptoms.16 Anaphylaxis
  occurs in response to a recipient's
  presensitization to a variety of proteins in
  donor plasma. For example, anaphylaxis occurs
  because of donor IgA being infused into a
  recipient who is IgA deficient and has
  preexisting circulating anti-IgA.17 In addition,
  antihuman leukocyte antigen (HLA) antibodies and
  anticomplement antibodies have been linked to
  anaphylactic reactions, which are estimated to
  occur in one in 20,000 to 50,000 transfusions
• Prevention of anaphylactic transfusion reactions
  includes avoiding plasma transfusions with IgA in
  patients known to be IgA deficient. Cellular
  products (e.g., RBCs, platelets) may be washed to
  remove plasma in patients with an IgA
  deficiency.16 The best precaution is observation
  of the patient during the initial 15 minutes of
  transfusion.

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FEBRILE NONHEMOLYTIC TRANSFUSION REACTIONS

• An FNHTR is defined as a rise in body temperature
  of at least 1.8F (1C) above 98.6F (37C)
  within 24 hours after a transfusion it may
  involve rigors, chills, and discomfort.10 The
  fever occurs more often in patients who have been
  transfused repeatedly and in patients who have
  been pregnant.25 Leukoreduction, which is the
  removal or filtration of white blood cells from
  donor blood, has decreased FNHTR rates.26 FNHTRs
  are caused by platelet transfusions more often
  than RBC transfusions and have an incidence that
  ranges from less than 1 percent to more than 35
  percent.
• Two mechanisms have been proposed to explain
  FNHTRs a release of antibody-mediated endogenous
  pyrogen, and a release of cytokines. Common
  cytokines that may be associated with FNHTRs
  include interleukin-1, interleukin-6,
  interleukin-8, and tumor necrosis factor.25 FNHTR
  is a diagnosis of exclusion that can be made only
  after ruling out other causes of fever (e.g.,
  hemolysis, sepsis).

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TRANSFUSION-ASSOCIATED CIRCULATORY OVERLOAD

• Transfusion-associated circulatory overload is
  the result of a rapid transfusion of a blood
  volume that is more than what the recipient's
  circulatory system can handle. It is not
  associated with an antibody-mediated reaction.
  Those at highest risk are recipients with
  underlying cardiopulmonary compromise, renal
  failure, or chronic anemia, and infants or older
  patients.17 Signs and symptoms include
  tachycardia, cough, dyspnea, hypertension,
  elevated central venous pressure, elevated
  pulmonary wedge pressure, and widened pulse
  pressure. Cardiomegaly and pulmonary edema are
  often seen on chest radiography
• The diagnosis is made clinically, but may be
  assisted by measuring brain natriuretic peptide
  levels, which are elevated in response to an
  increase in filling pressure.28 A study comparing
  patients who have transfusion-associated
  circulatory overload with patients who have TRALI
  found significantly greater levels of brain
  natriuretic peptide in those with
  transfusion-associated circulatory overload.28
  Transfusion of lower volumes or at a slower rate
  may help prevent it.16 The treatment is diuresis
  to decrease volume overload.