Transfusion Reactions

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Transfusion Reactions

• Vigilance, Treatment and Reporting

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Relevance

• 24 million units of blood components transfused
  yearly in the US
• Only 5 percent of eligible donors across the
  nation donate blood, but the number of
  transfusions nationwide increases by 9 percent
  every year.
• Statistics show that 25 percent or more of us
  will require blood at least once in our lifetime.
• 12 million volunteer blood donations meet needs
  of allogeneic transfusions. Each whole blood
  donation can be divided into three parts red
  blood cells, platelets, and plasma.

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Donate Regularly

• If only one more percent of all Americans would
  give blood, blood shortages in this country would
  disappear for the foreseeable future

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To Discuss Today

• Practice Guidelines for Transfusions
• Consent
• Logistics
• Categories of transfusion reactions
• Most common reactions. What are the dangers to
  the patient? What are the treatments?
• How and when do you report a reaction?

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Very Briefly Transfusion guidelines

• When to transfuse a patient
• Issue of medical judgment
• EMR website under CLINICAL PROTOCOLS
• Usages for non-PRBC components
• Blood alternatives synthetics, blood salvage,
  growth factors like erythropoeitin

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Transfusion targets for adults

• Red blood cells
• Signs and symptoms of anemia in absence of
  pre-existing cardiovascular disease (Hct lt 21)
• Presence of Hgb lt 10 gm/dl and/or Hct lt 30 and
  significant cardiovascular disease
• Profound hypovolemia/anemia (Hct lt 21) with
  evidence of decreased oxygen delivery (e.g.,
  decreased SvO2, decreased cardiac output/index
• Actively bleeding

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Transfusion targets for adults

• Plasma transfusion (FFP)
• Thrombotic microangiopathies (TTP, HUS, HELLP
  syndrome)
• Massive transfusion (MTP and other)
• DIC/other consumptive coagulopathies
• Rapid reversal of warfarin effect with active
  bleeding or imminent invasive procedure
• Multiple factor deficiencies with active bleeding
  or PT/INR gt 1.7 prior to invasive procedure
• Documented congenital or acquired (inhibitors)
  factor deficiency
• Deficiency of Protein C, Protein S or AT (when AT
  concentrate is unavailable)

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Transfusion targets for adults

• Cryoprecipitate transfusion
• Active bleeding or before invasive
  procedure/surgery in the following
• Fibrinogen levelslt100 mg/dL
• Uremic bleeding unresponsive to DDAVP
• Dysfibrinogenemia (normal fibrinogen level)
• Factor XIII deficiency
• von Willebrand disease unresponsive to DDAVP
  and/or factor concentrate not available
• Suspected or evident hemorrhagic stroke or
  intracranial bleeding in patients receiving
  Tissue Plasminogen Activator (TPA)

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Transfusion Targets for adults

• Prophylactic
• 10,000/uL Stable patient
• 20,000/uL Recent intracranial intervention or
  pathology, hyperleukocytosis, temp gt38 C,
  coagulation abnormality, bladder cancer or
  necrotic tumor
• 25,000/uL Lumbar puncture
• 30,000/uL Neonates
• 50,000/uL Major surgery, central venous
  catheter placement, endoscopic biopsy, liver
  biopsy, other invasive procedures
• 100,000/uL Intracranial or spinal cord or
  ophthalmologic surgery DIC ECMO patients
  (pediatric patients)
• gt100,000/uL Certain platelet function defect or
  anti-platelet drugs without contemporary results
  of platelet functions prior to major
  surgery/invasive procedure
• Avoid, if clinically possible, prophylactic
  platelet transfusion if refractory to
  specially-selected platelets

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Transfusion Targets for adults

• Therapeutic
• 50,000/uL In presence of active bleeding
  during massive transfusion, cardiopulmonary
  bypass, DIC, and massive transfusion
• 100,000/uL Suspected or evident intracranial,
  intraspinal or intraorbital bleeding
• gt100,000/uL ECMO patients with bleeding
• Normal In presence of active bleeding and
  certain platelet function defects

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So, you decide to transfuse

• Consent
• Matching the blood
• What is a type and screen?
• What is a type and cross?
• Certain specific concerns for this patient?
• Transplant recipient?
• EBV, CMV status known?

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Overall Risks of Transfusion

• Allogeneic Risks
• Medical Risks
• Infectious Risks

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Adverse Effects of Transfusions
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Infectious Risks of Blood Transfusion (RBCs)
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Risks of Non-Infectious Complications
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Testing Of Donor Blood

• Most important part is screening of donors prior
  to withdrawal of product
• Confidential Exclusion
• Testing required before units of blood or
  components are available for routine transfusion.
  
• Donors ABO and Rh type
• Tested and found negative for antibodies to HIV,
  HCV, Hep B, HTLV, Ag for HIV, West Nile virus.
• Negative for syphilis
• Tested for unexpected antibodies done and found
  negative (antibody screening).

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So, you decide to transfuse

• Testing for the Donor Blood has already happened.
  
• Next you need to test the recipient
• ___________________________________
• Type and Screen
• Type and Cross

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TYPE IncludesForward and Reverse Testing
Patients Serum
Patients Cells
Known B cells
Known A cells
Mix w/ anti-B
Mix w/ anti-A
Patients Blood
O
RXN
RXN
NR
NR
RXN
NR
NR
RXN
A
NR
RXN
RXN
NR
B
NR
NR
RXN
RXN
AB
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Implications

• Group O packed cells universal donor
• Group O plasma cannot be given to Group A, B or
  AB recipients
• Platelets from Group O donor given to Groups A,B,
  AB may cause hemolysis (there is about 250ml of
  plasma in plt bag)
• Group O marrow donation can cause hemolysis

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Type and Screen

• Type
• Screen (Recipients Blood)
• looks for unexpected red cell alloantibodies
  which may form following pregnancy or prior
  transfusions.
• If the screen is positive, the antibody is
  identified and 2 units lacking the corresponding
  antigen are crossmatched for the patient. The
  physician is also notified.

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Type and Cross

• Type
• Screen (Included)
• Cross
• Determines compatibility between patient serum
  and donor red blood cells.
• Takes about 15 min.
• Every unit crossmatched is removed from the
  general inventory and reserved for the patient
  for 72 hours.

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So, you decide to transfuse

• Consent
• Matching the blood
• What is a type and screen?
• What is a type and cross?
• Certain specific concerns for this patient?
• Transplant recipient?
• CMV status known?

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Special Products CMV

• CMV
• Special maternal/neonatal situations
• Seronegative allograft recipients
• Seronegative onc patients
• Seronegative transplant candidates
• Seronegative pregnant women
• ENSURE YOUR PATIENT IS SERONEGATIVE

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Special Products

• Irradiated Products for
• Special maternal/neonatal situations
• Immunodeficiency
• Childhood solid tumors, BMT, HD, ALL, Any heme
  malignancy getting RT
• Directed blood donations
• Leukoreduced generally provided

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Between the BB and the Patient

• Blood bank gets the order to type and cross
• They do their work
• When the nurses are ready to transfuse the blood,
  they send a green card via the tube system for
  the blood
• When the blood arrives the product is checked
  against the order, the product is checked against
  the patient, the order is checked against the
  patient

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Classification of Transfusion RXN
Immunologic
Non-Immunologic
Acute
Delayed
Classical Transfusion Reaction refers to
immunologic reactions when there are interactions
between the RECIPIENTS inherited or acquired
antibodies with antigens that are associated with
the cellular or humoral components of the DONORs
blood products Recipient vs. Donor
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Acute Adverse Events

• Immune-Mediated
• Fever without hemolysis
• Simple allergic reactions
• TRALI
• Acute hemolytic transfusion reactions
• Anaphylatic / anaphylactiod reactions

• Non-Immune
• Transfusional overload
• Hypotensive Reactions
• Bacterial Sepsis
• Citrate Toxicity
• Non-Immune Hemolysis (asymptomatic

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Delayed Adverse Events

• Non-Immune
• Transfusional iron overload
• Disease transmission due to blood-borne pathogens
• Bacterial diseases
• Viral diseases
• Parasitic diseases

• Immune-Mediated
• RBC alloimmunization
• HLA alloimmunization
• Post-transfusion purpura (PTP)
• Transfusion-associated GVHD
• Immunomodulation / Immune suppression

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Major Ones to Discuss

• Febrile Non-hemolytic Transfusion Reaction
• Acute Hemolytic Transfusion Reaction
• Anaphylactic Transfusion Reaction
• Urticarial Transfusion Reaction
• Delayed Hemolytic Transfusion Reaction
• Transfusion-related Acute Lung Injury
• Posttransfusion Purpura

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Febrile Nonhemolytic 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

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Febrile Nonhemolytic TR

• Signs and Symptoms
• Fever 1degree centigrade ABOVE baseline
• Tends to be later in the transfusion or up to 2
  hours post transfusion
• Chills
• Missing some of the key findings in hemolysis,
  i.e. the laboratory findings.

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Febrile Nonhemolytic TR

• Treat
• Stop transfusion, assure yourself that its not
  an acute hemolytic reaction Signs/Symptoms
• Check the logistics right patient, right unit,
  right order??
• Acetominophen, Treat rigors with meperidine or
  hydrocortisone
• DO NOT RESTART TRANSFUSION
• Prevent
• Antipyretics
• Leukoreduction
• Decrease storage time

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Acute Hemolytic TR

• MEDICAL EMERGENCY
• Typically associated with ABO incompatibility
• Anti-A and Anti-B are IgM
• Attach to transfused cells, bind complement,
  immediate lysis of red cells
• ABO incompatibility is usually related to
  clerical error
• Usually host AB attack transfused cells

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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

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Acute Hemolytic TR

• Treat
• 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
• CONTACT BB
• Second patient may be at risk, if there was a
  switch in blood components

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Acute Hemolytic TR

• Other Considerations
• Dont wait for the lab tests if your suspicion is
  high treat with HYDRATION to keep urine output
  gt 100ml-200ml/hour
• Remember hyperkalemia is common cardiac
  monitoring
• Acute Hemodialysis may be required which is
  complicated by the likelihood of DIC

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Anaphylactic Transfusion RXN

• Nothing that starts with the word anaphylactic is
  good
• Usually to an unspecified plasma protein
• IgA deficient more likely at risk (1300 1500)
• There is a phenomenon where anti-haptoglobin AB
  occur ? at risk for ATR

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Anaphylactic Transfusion RXN

• Signs and Symptoms
• Rapid, rapid onset
• Hypotension
• Angioedema
• Shock
• Respiratory Distress

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Anaphylactic Transfusion RXN

• Treatment
• STOP THE TRANSFUSION
• Rapid, rapid onset ? Rapid, rapid treatment
• Volume support
• Diphenhydramine
• Epinephrine
• Vasopressor intervention if necessary
• Prevent the next one by reporting it to the BB
  IgA deficient or washed products

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Urticarial Transfusion Rxn

• 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

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Urticarial Reactions

• Signs and Symptoms
• Urticaria
• Pruritis
• NO OTHER SYMPTOMS i.e. no bronchospasm,
  hoarseness, hypotension, etc.
• Simple allergic reaction

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Urticarial Transfusion Rxn

• Treatment
• Pause the transfusion
• Administer benadryl
• Assure yourself its not a more severe,
  anaphylactoid or febrile reaction
• Dyspnea, hypotension, progressive Urticaria? Do
  NOT RESTART transfusion. If theses are not
  present, Can restart.
• No need to Report simple allergic TX RXNs

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Transfusion Related Acute Lung Injury

• Serious, more frequent
• 30 min ? 2 hours after the start of transfusion
• Sudden respiratory distress, hypoxemia, pulmonary
  edema
• Normal Central Venous Pressure, Normal Cardiac
  Function
• Exclusion of other precipitating causes

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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
• Better prognosis than ARDS

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TRALI

• Treatment
• STOP TRANFUSION
• Supplemental Oxygen
• Confirm diagnosis pulmonary imaging, rule out
  alternative diagnoses
• ECHO can be helpful, SWANN-GANZ or other
  measurement of CVP
• Critical Care Support

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Major Ones to Discuss

• Febrile Non-hemolytic Transfusion Reaction
• Acute Hemolytic Transfusion Reaction
• Anaphylactic Transfusion Reaction
• Urticarial Transfusion Reaction
• Transfusion-related Acute Lung Injury
• Delayed Hemolytic Transfusion Reaction
• Posttransfusion Purpura

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Delayed Transfusion Reactions

• Mechanism
• Antibodies that exist in low titers prior to the
  transfusion
• Typically to the Kidd or RH system
• Upon reexposure, titer increases from memory
  B-cells
• Clinical Picture
• Decrease in hgn, fever?, unconjugated bilirubin,
  spherocytosis
• Happens 2-10 days post transfusion

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Delayed Transfusion Reactions

• Treatment
• As long as clinically mild, no treatment
  necessary
• Monitor renal function, hgn
• PREVENT it from happening the next time REPORT
  TO THE BLOOD BANK

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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

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Other Reactions NON-Immune

• Volume Overload
• Toxic reactions to the citrate in the components
  during pheresis or exchange
• Iron Overload need for chelation therapy
• Bacterial Sepsis
• Massive transfusion ? dilutional coagulopathies

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What have we covered?

• Consent Logistics
• Categories of transfusion reactions
• Most common reactions.
• What are the dangers to the patient? What are the
  treatments?
• How and when do you report a reaction?

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Reporting a Reaction

• Check the patient
• Draw the appropriate labs for the work up
• Draw an extra lavender top tube
• PAPERWORK (not EPIC) at the nurses station
• Call the blood bank early in the process