BLOOD TRANSFUSION REACTIONS

Undesirable response or effect to the patient temporarily associated with the administration of the blood or any blood component

Blood Transfusion Reactions

an unintended and deleterious occurrence associated with blood component transfusion

Adverse events

It may occur before, during, or after a transfusion

Adverse events

any error that could affect the quality or effectiveness of a blood product or could have led to an adverse reaction to a transfusion recipient

Incidents

a harmful effect observed in a transfusion recipient that is temporally associated with a blood component transfusion

Adverse reactions

Any favorable transfusion related event occurring in a patient during or after transfusion of blood components

Transfusion Reaction

immediately or within 24 hours

Acute reaction

>24 hours

Delayed reaction

reactions involving antigen-antibody complexes, cytokine release, or complement activation

Immune-mediated reactions

reactions that may be due to the component transfused, the patient's underlying condition, or the method of infusion (no involvement of antigen antibody complexes or the recognition of proteins and cells by the immune system)

Non-immune-mediated reactions

• Hemolytic transfusion reaction

• Febrile Non-hemolytic transfusion reaction

• Allergic reaction

• Anaphylactic and Anaphylactoid Reaction

• Transfusion-related Acute Lung Injury

immediate immune transfusion reaction

• Hemolytic transfusion Reaction

• Alloimmunization

• Post-Transfusion purpura

• Transfusion Associated Graft vs Host Disease

delayed immune transfusion reaction

• Bacterial Contamination

• Transfusion associated Circulatory Overload

• Physical and Chemical RBC damage

• Depletion and Dilution of Coagulation Factors and Platelets

immediate non-immune transfusion reaction

• Iron Overload

• Air embolism

delayed non-immune transfusion reaction

_________by the person administering the transfusion that a suspected transfusion reaction may be occurring or has occurred

Clinical recognition

_____________if the infusion is still in process

Immediately stop the transfusion

to send appropriate specimens to the laboratory for investigation

Follow a standard procedure

_____________of the component bag, label, paperwork, and pretransfusion patient specimen

Clerical check

____________on the post-transfusion sample

Repeat ABO testing

____________of the pre- and post-transfusion specimens for hemolysis

Visual check

___________on the post-transfusion specimen

Direct antiglobulin test (DAT)

___________additional components prepared from the same donor collection

Quarantine

_____________to transfusion service supervisor or medical director

report findings

Identify a possible hemolytic reaction

main objective of the investigation of a transfusion reaction

During the transfusion or within 24 hours of reaction

Acute Transfusion Reactions

Febrile (symptoms of fever)

AHTR

TAS

FNHTR

Allergic

Mild

urticaria, rashes

Allergic

Severe

anaphylactoid

Pulmonary (involvement of the lungs)

TACO

TRALI

Destruction of transfused red cells that results in intravascular or extravascular hemolysis

Acute hemolytic Transfusion Reaction (AHTR)

Complement activation

ABO incompatibility

Clerical and misidentification errors

Acute hemolytic Transfusion Reaction (AHTR)

Most common cause of AHTRS

Clerical and misidentification errors

hypotension

irreversible shock

renal failure

disseminated intravasculat coagulation

Acute hemolytic Transfusion Reaction (AHTR)

Alloimmune acute and delayed HTRs

Autoimmune hemolytic anemia

Cold agglutinin disease

Drug-induced hemolytic anemia

Paroxysmal cold hemoglobinuria

Paroxysmal nocturnal hemoglobinuria

IVIG administration

Immune hemolysis

incompatible fluids, improper deglycerolization

Nonimmune Hemolysis

osmotic

malfunctioning blood warmer, improper storage or transport

Maintain the 1-10°C to RBC/WB

Nonimmune Hemolysis

thermal

small needles, malfunctioning infusion pumps, artificial heart valves

Nonimmune Hemolysis

mechanical

sickle cell disease, HbC disease

Nonimmune Hemolysis

hemoglobinopathies

hereditary spherocytosis. G6PD

Nonimmune Hemolysis

RBC membrane/enzyme disorders

TTP, HUS

Nonimmune Hemolysis

Microangiopathic hemolytic anemias

Clostridial sepsis, malaria, babesiosis

Nonimmune Hemolysis

infections

treatment

Discontinue transfusion

Maintain vascular access Maintain blood pressure Maintain renal blood flow

Treat DIC if present

An acute complication of transfusion presenting with at least a 1°C increase in body temperature

Febrile Nonhemolytic Transfusion Reaction

Most commonly encountered type of transfusion reaction

Febrile Nonhemolytic Transfusion Reaction

immune mediated and is due to the presence of preformed antibodies, release of endogenous pyrogens

Febrile Nonhemolytic Transfusion Reaction

Due to platelet storage changes, production and release of biologically active cytokines

Febrile Nonhemolytic Transfusion Reaction

Fever, chills, nausea or vomiting, tachycardia, increase in blood pressure, and tachypnea

Febrile Nonhemolytic Transfusion Reaction

Pre storage leukocyte reduction

Febrile Nonhemolytic Transfusion Reaction

prevention

Treat with antipyretics

For rigors, treat with meperidine

Febrile Nonhemolytic Transfusion Reaction

treatment

Acute nonimmune transfusion reaction presenting with body temperature usually 2°C or more above normal and rigors that can be accompanied by hypotension

Transfusion-Associated Sepsis (TAS)

Occurs when bacteria are introduced to the patient via a contaminated blood product

Transfusion-Associated Sepsis (TAS)

Fever/chills

Hypotension

Shock

Transfusion-Associated Sepsis (TAS)

Occurs as a response of recipient antibodies to an allergen present in the blood component

Allergic Mild

(Urticarial Transfusion Reaction)

Activation of mast cells in the recipient triggered most frequently by an allergen present in the plasma of the blood component

Allergic Mild

(Urticarial Transfusion Reaction)

Weals, hives, erythema, or pruritus

Allergic Mild

(Urticarial Transfusion Reaction)

For repeated reactions, consider premedication with antihistamines, transfuse washed components

Allergic Mild

(Urticarial Transfusion Reaction)

prevention

treat with antihistamines

Allergic Mild

(Urticarial Transfusion Reactio)

treatment

IgA-deficiency-related anaphylactic reaction

Allergic Severe

(Anaphylactoid or Anaphylactic)

Caused by transfusion of IgA positive blood to an IgA-deficient recipient who have developed anti-IgA

Allergic Severe

(Anaphylactoid or Anaphylactic)

Bronchoconstriction, angioedema, diarrhea, and cardiovascular instability

Allergic Severe

(Anaphylactoid or Anaphylactic)

Hypotension, cardiac arrythmia, loss of consciousness, shock, cardiac arrest

Allergic Severe

(Anaphylactoid or Anaphylactic)

For IgA absolute deficient patients provide IgA deficient blood components

Allergic Severe

(Anaphylactoid or Anaphylactic)

prevention

treat with subcutaneous epinephrine

Allergic Severe

(Anaphylactoid or Anaphylactic)

treatment

Acute transfusion reaction presenting with respiratory distress and severe hypoxemia during or within 6 hours of transfusion

Transfusion-Related Acute Lung Injury (TRALI)

Leading cause of transfusion-associated fatalities

Transfusion-Related Acute Lung Injury (TRALI)

No diagnostic test

Transfusion-Related Acute Lung Injury (TRALI)

Caused by antibodies against leukocytes present in donor plasma (antibody against human neutrophil antigens)

Transfusion-Related Acute Lung Injury (TRALI)

severe hypoxemia, hypotension, may or may not have fever

Transfusion-Related Acute Lung Injury (TRALI)

TRALI is treated symptomatically with oxygen support

Transfusion-Related Acute Lung Injury (TRALI)

treatment

Absence of acute lung injury (ALI) prior to transfusion

Clinical Criteria for Diagnosis of TRALI

ALI during or within 6 hours after transfusion o Acute onset of hypoxemia

Clinical Criteria for Diagnosis of TRALI

Evidence of hypoxemia by blood gas or oxygen saturation testing

Clinical Criteria for Diagnosis of TRALI

Radiographic evidence of bilateral pulmonary edema

Clinical Criteria for Diagnosis of TRALI

Classical bilateral __________appearance of acute pulmonary edema

"white-out"

Iatrogenic, transfusion-induced hypervolemia

Transfusion-Associated Circulatory Overload (TACO)

2 nd most common cause of transfusion-related deaths reported to the FDA

Transfusion-Associated Circulatory Overload (TACO)

Patients with pre-existing CHF(congestive heart failure), elderly patients, children, patients with renal failure

Transfusion-Associated Circulatory Overload (TACO)

Occurs when the patient's cardiovascular system's ability to handle additional workload is exceeded, manifesting as congestive heart failure

Transfusion-Associated Circulatory Overload (TACO)

severe hypoxemia, ↑Blood pressure Jugular Vein distention, ↑Central venous pressure

Transfusion-Associated Circulatory Overload (TACO)

Give supplemental oxygen and diuretics

Transfusion-Associated Circulatory Overload (TACO)

treatment

TACO can diagnose by measuring the

brain natriuretic peptide or the BAP levels

Delayed Transfusion Reactions

Serological hemolytic

TAGVHD

PTP

Iron overload

Detection of "new" red cell antibodies after 24 hours of transfusion

Delayed Serologic/Hemolytic Transfusion Reaction

Occurs secondarily to an amnestic response but can also occur during a primary immune response and may or may not be associated with shortened survival of the transfused cell

Delayed Serologic/Hemolytic Transfusion Reaction

Transfusion of incompatible blood during emergency or massive transfusion may occasionally be the cause of a delayed hemolytic reaction

Delayed Serologic/Hemolytic Transfusion Reaction

flulike symptoms, Pallor, Jaundice

o ↓Hemoglobin ↑ total bilirubin

Delayed Serologic/Hemolytic Transfusion Reaction

accurate record-keeping, obtain transfusion history and limit transfusions

Delayed Serologic/Hemolytic Transfusion Reaction

prevention

transfuse antigen negative, AHG crossmatched compatible PRBC

Delayed Serologic/Hemolytic Transfusion Reaction

treatment

Delayed immune transfusion reaction due to an immunologic attack by viable donor lymphocytes contained in the transfused blood component against the transfusion recipient

Transfusion-Associated Graft-Versus-Host Disease (TAGVHD)

HLA antigen difference between donor and recipient

Transfusion-Associated Graft-Versus-Host Disease (TAGVHD)

Presence of donor immunocompetent cells in the blood component

Transfusion-Associated Graft-Versus-Host Disease (TAGVHD)

Recipient incapable of rejecting the donor immunocompetent cells

Transfusion-Associated Graft-Versus-Host Disease (TAGVHD)

infants, patients with cancer or compromised immune systems

Transfusion-Associated Graft-Versus-Host Disease (TAGVHD)

rash, fever and diarrhea

Transfusion-Associated Graft-Versus-Host Disease (TAGVHD)

gamma irradiation of cellular blood components as indicated

Transfusion-Associated Graft-Versus-Host Disease (TAGVHD)

Delayed immune complication of transfusion that presents with profound thrombocytopenia, frequently accompanied by bleeding, 1 to 24 days after a blood transfusion

Post-Transfusion Purpura

Occurs when a patient who is previously sensitized to a human platelet antigens by pregnancy or transfusion is re-exposed via a transfusion

Post-Transfusion Purpura

Most commonly implicated is the human platelet antigen (HPA)1a

Post-Transfusion Purpura

bleeding

Post-Transfusion Purpura

limit transfusion

Post-Transfusion Purpura

prevention