Transfusion Reactions

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Transfusion Reactions

• Lloyd O. Cook, M.D.
• Department of Pathology
• March 2005

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Definition Txn Rxn

• Any adverse outcome attributable to transfusion
  of a blood component or components.

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• Immediate Action to Take for Txn Rxn
• 1. STOP THE TRANSFUSION
• 2. Keep IV open with Normal Saline
• 3. Check all blood component(s) labels, forms,
  Pt. ID for errors
• 4. Notify Pt.s physician as appropriate
• 5. Treat rxn
• 6. Notify Blood Bank submit work-up specimens
  submit report forms

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Common Signs Symptoms

• Abnormal bleeding
• Chest/back pain
• Chills
• Coughing
• Cyanosis
• Dyspnea
• Facial flushing
• Fever (gt 1 C )
• Headache
• Hemoglobinuria
• Heat at infusion site

• Hypotension
• Itching
• Myalgia
• Nausea
• Oliguria/anuria
• Pulmonary edema
• Rales
• Rash
• Urticaria/hives
• Wheezing
• Uneasy feeling

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Selected Txn Rxns

• Signs/Symptoms
• Cause
• Management
• Prevention

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Acute Hemolytic

• Note Most dangerous immunologic complication of
  Red Cell unit transfusion.
• Usually due to clerical error wrong Pt. wrong
  blood component etc.
• High risk for morbidity or mortality.
• Morbidity, e.g. renal failure, DIC
• Mortality about 1 per 100,000 txn pts per year
  (cases reported to FDA)

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Acute Hemolytic

• Signs/symptoms (usual)
• Sudden chills
• Increased temp of 1 C to 2 C - fever
• Headache
• Flushing
• Anxiety
• Muscle pain
• Hemoglobinuria
• Low back apin
• Tachypnea
• Tachycardia
• Hypotension

• Vascular collapse
• Bleeding (N.B. surgical field in an anesthetized
  pt.
• Acute Renal Failure
• Hemoglobinemia
• DIC
• DIC with bleeding
• Shock
• Cardiac arrest
• DEATH

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Acute Hemolytic

• Cause
• Transfusion of incompatible donor RBCs into Pt
• Usually an ABO incompatibility
• Antibodies in Pt plasma attach to antigens on
  donor RBCs causing RBC destruction
  intravasculary
• Antibodies fix complement causing RBC lysis

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Acute Hemolytic

• Management
• Treat hypotension, renal failure, DIC, etc.
• Submit blood samples for blood bank/laboratory
  tests
• Avoid, if possible, further transfusions till
  work-up complete and/or Pt recovered from rxn

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Acute Hemolytic

• Prevention
• Meticulously verify and document Pt ID from
  sample collection for compatibility testing
  through to blood component transfusion
• Follow precisely the proper transfusion
  procedures at bedside (usually found in Nursing
  SOPs ) every time NO SHORTCUTS !!!

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Febrile Rxn

• Signs/Symptoms
• Nonhemolytic
• Sudden chills
• 1 C to 2 C temp increase
• Headache
• Flushing
• Anxiety
• Muscle pain

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Febrile Rxn

• Cause
• Pt immunologic sensitization to donor WBCs,
  platelets or plasma proteins
• Common sources prior transfusions, previous
  pregnancies, previous transplants

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Febrile Rxn

• Management
• Give antipyretics (e.g. aspirin except children
  Reyes Syndrome)
• Avoid aspirin in thrombocytopenic pts
• Do not restart transfusion

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Febrile Rxn

• Prevention
• Consider leukocyte poor blood components
• Two types of leukopoor RBCs filtered at time of
  donation and frozen/washed
• Can also use WBC filters at bedside

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Allergic Rxn

• Signs Symptoms
• Flushing
• Itching
• Urticaria (aka hives)
• Rarely, angioedema epiglottal edema bronchial
  airway constriction, hypotension, dyspnea, rales

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Allergic Rxn

• Cause
• Pt sensitized to foreign plasma antigens
• Exact mechanism not known for sensitization
• Commonly caused by transfusion of plasma
  containing blood components, e.g. FFP,
  Cryoprecipitate, Platelet Concentrates

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Allergic Rxn

• Management
• Premedicate Pt with antihistamines (e.g.
  Benadryl)
• If signs/symptoms mild /or transient, restart
  transfusion after treatment
• Do NOT restart transfusion if pulmonary
  symptoms/signs, fever present

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Allergic Rxn

• Prevention
• Prophylactically treat with antihistamines

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Anaphylactic Rxn

• Signs Symptoms
• Note very immediate type rxn
• Anxiety
• Urticaria
• Wheezing
• Severe dyspnea
• Pulmonary/laryngeal edema
• Shock
• Cardiac arrest

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Anaphylactic Rxn

• Cause
• Infusion of IgA proteins into Pt with IgA
  antibodies
• IgA deficiency about 1 in 700
• Anaphylactic rxn rate about I per 1,000,000 pts.
• Why disparity not known

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TRALI

• Transfusion Related Acute Lung Injury
• aka Noncardiogenic pulmonary edema
• Signs Symptoms
• Severe dyspnea
• Hypotension
• Fever
• Chills
• Bilateral pulmonary edema

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TRALI

• Cause
• Donor antibodies activate Pts WBCs which cause
  damage to blood vessels in lung tissue
• Then fluids and proteins leak into alveolar
  space/interstitium
• Mechanism similar to ARDS

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TRALI

• Management
• Steroids
• Aggressive ventilatory support
• Hemodynamic support

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TRALI

• Prevention
• Transfuse washed RBCs from which plasma is
  removed
• Platelet units can also be washed, but platelet
  function is significantly reduced

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Circulatory Overload

• Signs Symptoms
• Cough
• Dyspnea
• Pulmonary congestion
• Headache
• Hypertension
• Tachycardia
• Distended neck veins

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Circulatory Overload

• Cause
• Iatrogenic physician induced rxn
• Fluid(s) administered faster than Pt circulation
  can accommodate volume load
• Some at risk types of pt.s congestive heart
  failure, renal failure, hepatic cirrhosis,
  normovolemic anemia

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Circulatory Overload

• Management
• Place Pt in upright position, if possible, with
  feet in dependent position
• Diuretics
• Oxygen
• Morphine (if necessary)

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Circulatory Overload

• Prevention
• Adjust transfusion flow rate based on Pt size and
  clinical status
• Consider dividing unit(s) into smaller aliquot(s)
  to better space apart blood component(s) pace of
  transfusion

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Septic Rxn

• Signs Symptoms
• Rapid onset of chills fever
• Vomiting
• Diarrhea
• Profound hypotension
• Shock

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Septic Rxn

• Cause
• Transfusion of bacterially contaminated blood
  components
• Common problem for platelet concentrates stored
  at room temperature

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Septic Rxn

• Management
• Obtain blood cultures from Pt
• Return blood component bag(s) to blood bank for
  further laboratory work-up
• Treat septicemia with antibiotics
• Treat shock with fluids vasopressors

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Septic Rxn

• Prevention
• Collect, process, store, transport, and transfuse
  blood components according to contemporary
  standards of practice (e.g. for FDA standards
  adhere to cGMPs current good manufacturing
  practices found in Code of Federal Regulations)
• Transfuse blood components within 1 to 2 hrs do
  not exceed 4 hrs

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Delayed Hemolytic Txn Rxn

• Signs Symptoms
• Fatigue
• Malaise
• Declining hemoglobin/hematocrit
• Conjugated bilirubin may be elevated
• Falling hemoglobin/hematocrit usually noticed 3
  to 14 days post transfusion

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Delayed Hemolytic Txn Rxn

• Cause
• Anamnestic immune response in Pt to antigen(s)
  present on transfused donor cells
• Antibody attaches to transfused RBCs and RBCs
  are removed from Pts circulation by
  reticuloendothelial system (liver/spleen)
• This process is called extravascular hemolysis

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Delayed Hemolytic Trn Rxn

• Management
• Send specimen(s) to Blood Bank for antibody
  identification work-up
• Provide good Pt history

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Delayed Hemolytic Trn Rxn

• Prevention
• Transfuse RBCs that are phenotype negative for
  known clinically significant RBC antibodies in Pt
• Delayed Hemolytic Trn Rxns can not be predicted
• Good Pt records and Blood Bank records are
  essential
• Clinical treatment usually not necessary

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Txn Rxns Usual Incidence Rates

• Some Selected Rates
• Acute Hemolytic 132,000
• Febrile 1 to 2
• Allergic 1 to 3
• Anaphylactic 1170,000 to 11,000,000
• Circulatory Overload 110,000
• Delayed Hemolytic 111,000

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Infectious Risks of Transfusion(more common risk
types)

• Viral
• HIV 1 2 1493,000
• HTLV-I/II 1641,000
• Hepatitis B 163,000
• Hepatitis C 1103,000

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Infectious Risks (cont.)

• Bacterial
• Red Blood Cells (RBCs) 1500,000
• Platelets, random 1110,200
• Platelets, pheresis 119,000
• Parasites
• Chagas Dis. (T. cruzi) 142,000
• Malaria Babesia lt11,000,000

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Txn Rxns - Reminders

• 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 !!

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Txn Rxns

• The End