Blood

Transfusion Reactions

Indra Wijaya

Course on Medical Emergency Treatment@IPD_FKUP.2015

 Terminology

Classical Transfusion Reaction refers to

“immunologic reactions when there are interactions

between the RECIPIENTS inherited or acquired
“Any adverse outcome attributable to
antibodies with antigens that are associated with the
transfusion of a blood component”
cellular or humoral components of the DONOR’s
blood products”
 Delayed Complications
between 24 hours and 2
weeks after the
transfusion

• Transfusi
on
reactions

Acute Late Complications

During the transfusion occur up to 30 years after
event, but can occur the transfusion or series of
up to several hours transfusion episodes
(4 hours) after
completion of the
transfusion

• Transfusi
Immunologic
Alloimmunization
Hemolytic Transfusion
Febrile Transfusion
Allergic Transfusion
Urticarial transfusion
Post transfusion Purpura
Anaphylactic Rx
TRALI
GVHD
Infection
Hepatitis, HIV, HTLV
CMV, EBV, Bacterial
Syphilis, Parasites, etc
on
reactions
Non-Immunologic
Volume Overload, TACO
Iron Overload
 Massive Transfusion:
Metabolic, Hypothermia,
Dilutional, Pulmonary
Microembolism
 Non-Immune Hemolysis
Infectious Risks of Blood Transfusion

Agent Risk
Hep B 1 : 1.000.000
Hep C 1 : 1,935,000
HIV 1 : 2,135,000
CMV < 1% of CMV
Gram + Bacteria 1 : 1000
Gram – Bacteria 1 : 10,000,000  fatal sepsis
Malaria (plasmodium spp.) 1 – 5 cases/year. 10% fatal
Immune-Mediated Events

Acute Delayed
 Fever without hemolysis  Alloimmunization
 Simple allergic reactions  Post-transfusion
 TRALI purpura (PTP)
 Transfusion-associated
 Acute hemolytic
GVHD
reactions
 Anaphylatic /
anaphylactiod
Non-Infectious Complications
Reaction Risk

Fever without hemolysis 1 : 100 – 1 : 200

TRALI 1 : 5000 -1 : 7500
Acute Hemolysis 1 : 6000 (1 : 500,000 are fatal)
Alloimmunization; serologic, 1 : 1500
delayed hemolysis
Alloimmunization; clinically 1 : 4000
symptomatic, delayed hemolysis
Serious hazards of transfusion (SHOT)

Williamson et al, BMJ 1999;319:16–9

 Common Signs & Symptoms
 Dyspnea /Sudden
Tachypnea
chills
 Tachycardia
 Chest/back pain
 Hypotension
 Coughing
 Abnormal bleeding
 Fever (> 1 C )
 Vascular
 collapse
Heat at infusion site
 Cyanosis
 Headache
 Acute Renal Failure
 Flushing
 DIC  Anxiety
 Shock  Muscle pain
 Cardiacarrest
Low back pain
 DEATH  Rash, urtikaria
1. Febrile Non-hemolytic TR

• Signs and Symptoms:

– Fever = 1° centigrade ABOVE baseline
– Tends to be later in the transfusion or
up to 2 hours post transfusion
– Chills
– No findings in hemolysis, i.e.
the laboratory findings.

1
Febrile Non-hemolytic TR
• Related to the amount leukocytes in
the donated product and duration
of storage.

• Cytokines in the donated product –

they generated during the STORAGE
of the products
Febrile Non hemolytic TR
• Treat
– Stop transfusion, assure that it’s not an acute
hemolytic reaction – Signs/Symptoms
– Check the logistics – right patient, right unit,
right order?
– Acetominophen, hydrocortisone

• Prevent
– Antipyretics
– Leukoreduction
– Decrease storage time
 Algorithm for Management of
Transfusion Associated Fever (1)
 Algorithm for Management of
Transfusion Associated Fever (2)
 Algorithm for Management of
Transfusion Associated Fever (3)
 2. Acute Hemolytic Transfusion Reaction

• MEDICAL
EMERGENCY

• Typically associated with

ABO incompatibility
• ABO incompatibility is
usually related to clerical
error
• Risk of death correlates
with amount transfused

AHTR
AHTR Epidemiology
Epidemiology
Clinically Significant Antibodi

ABO (A, B)
Rh (D, C, c, E, e)

Duffy (Fya, Fyb)

Kidd (Jka, Jkb)

Kell
(K, k)

SsU
(S, s, U)

Lutheran
(Lub)
Acute Hemolytic TR
Signs and Symptoms
– Fever, Chills, Rigors, Nausea
– Hypotension
– Chest Discomfort
– Pain (chest, flank, limbs)
– Burning at transfusion administration
– Hemoglobinuria (red/brown urine)
– Bleeding, oozing at skin punctures – DIC
Clinical Presentation of AHTR
Acute Hemolytic TR
Treatment
– STOP transfusion
– Treat hypotension, maintain renal
perfusion
• Hydration, diuretics, dopamine (low-dose)
• Use 0.9% NS, not dextrose or LR
– Check for DIC
• Component therapy as needed
– Report IT
• Second patient may be at risk, if there was a
switch in blood components
Acute Hemolytic TR
Other Considerations
– Don’t wait for the lab tests if your
suspicion is high – treat with HYDRATION
to keep urine output > 100ml-200ml/hour
– Remember hyperkalemia is common –
cardiac monitoring
– Acute Hemodialysis may be required
3. Anaphylactic Transfusion
RXN
• Anaphylactic reactions are rare but may
be life-threatening
Incidence 1 in 40,000 transfusion
Etiology:
 usually (80%) unexplained
Anti IgA
Antibodies to polymorphic (genetic variable)
donor proteins (e.g. IgG)
Transfusion of an allergen in the donor to
sensitized patient
Passive transfer of IgE
Anaphylactic Transfusion
RXN
Signs and Symptoms:
– Rapid onset
– Hypotension
– Angioedema
– Shock
– Respiratory Distress
Anaphylactic Transfusion
RXN
• Treatment
– STOP TRANSFUSION
– Rapid onset  Rapid treatment
– Volume support
– Diphenhydramine
– Epinephrine
– Vasopressor intervention if necessary

• Reporting it to the Blood Bank

4. Urticarial Transfusion Rxn
• 1 in 100 transfusions
• Caused by soluble allergenic substances in
DONOR product
• React with RECIPIENT preexisting IgE
antibodies.
• Bound IgE cross links MAST CELLS and
BASOPHILS  mediator release including
histamines, and hypersensitivity reaction
Urticarial Reactions

• Simple allergic reaction

• Signs and Symptoms

– Urticaria
– Pruritus
– NO OTHER SYMPTOMS – i.e. no
bronchospasm, hoarseness,
hypotension, etc.
Urticarial Transfusion Rxn
• Treatment
– PAUSE the transfusion
– Administer diphenhydramine
– Assure it’s not a severe, anaphylactoid or
febrile reaction
– Dyspnea, hypotension, progressive
Urticaria? Do NOT RESTART transfusion.

• No need to Report simple allergic TX

RXNs
Allergic Reactions

• Prevention:
Routine premedication is not useful
For recurrent reactions the
following may be used:
Premedication
 Dihenhydramine 25-50 mg
 Hydrocortisone 100 mg
Plasma depletion
Washed RBC
 Reactions Associated With
Dyspnea

• Transfusion Related Acute Lung Injury

(TRALI)
• Transfusion Associated Circulatory
Overload (TACO)
• Anaphlaxis
(Other allergic reactions)
5. Transfusion Related Acute Lung Injury
(TRALI)

• Serious, more frequent

• 30 min  2 hours after the start of
transfusion  Up to 6 hours
• Sudden respiratory distress, hypoxemia,
pulmonary edema, fever
• Normal Central Venous Pressure, Normal
Cardiac Function
• Usually resolves in 24-72 hours
 TRALI
• Mechanism
– Endothelial Cell activation  Increased
adhesion of neutrophils to pulmonary
endothelium
– Neutrophil activation and release of
cytokines
– Clinically and mechanistically looks like
ARDS
– Patient risk factors: Recent surgery,
massive transfusion, active infection
 a b

(a) Bilateral patchy alveolar infiltrate in TRALI (b) Complete resolution

Criteria for the diagnosis of TRALI

• No acute lung injury immediately before transfusion
• New acute lung injury:
1. acute onset lung injury,
2. no circulatory overload or PA pressures <18mmHg,
3. bilateral pulm infiltrate on Cxr,
4. Hypoxemia:Pa02/FiO2 <300, or sat <90% on RA.
• Onset within 6 hours after transfusion
• No temporal relation to an alternate risk factor for acute lung injury
Popovsky TP et al TRALI; definition and review. Crit care Med 2005
Transfusion Related Acute Lung Injury
(TRALI)

• Incidence:
 Unknown
 Estimate 1 in 5,000 plasma
containing transfusions

 Often unrecognized
 Under-reported
 Third commonest cause of
transfusion associated death
 TRALI
Treatment
– STOP TRANFUSION
– Supplemental Oxygen
Mechanical ventilation required in about 75% of cases
– Confirm diagnosis – pulmonary imaging,
rule out alternative diagnoses
– ECHO can be helpful, SWANN-GANZ or
other measurement of CVP
– Critical Care Support
– Diuretics and steroids probably not useful
6. Post Transfusion Purpura

• Clinically
– Very rare
– Mostly occurs in women
– Severe thrombocytopenia
– Develops 5 to 10 days following transfusion
– Kind of like a delayed transfusion reaction
to platelets

• IVIg if very thrombocytopenic

Transfusion Rx – Reminders
(1)
• Signs & Symptoms are usually nonspecific
• No predictive tests for when a particular Txn
Rxn will occur
• Transfusion is an IRREVERSIBLE process –
always benefits against risks
• Be Prepared – a Txn Rxn can happen
unpredictably at anytime !!
Transfusion Rx – Reminders (2)

Immediate Action for Transfusion Rx:

1. STOP THE TRANSFUSION
2. Keep IV open with Normal Saline
3. Check all blood component(s) labels, forms,
Patient ID for errors
4. Notify Pt.’s physician as appropriate
5. Treat rxn
6. Notify Blood Bank; submit work-up specimens;
submit report forms
Thank you for your attention

Course on Medical Emergency and Treatment

Bandung@2015