Transfusion Reaction

How to prevent alloimmunization events during transfusions

Quality donor screening procedures for Antibodies and other blood borne diseases

Serological crossmatching to ensure no IgG Abs present

Antigen type donors and patients, etc

What causes transfusion-related hypocalcemia

Often seen during MHPs when units are transfused quickly - citrate from the CPD causes free calcium to chelate, as the liver cannot breakdown citrate fast enough

Prevention/modification of transfusion-related hypocalcemia

- Monitor calcium levels

- Administer calcium chloride if symptomatic

- Slow down infusion if possible

What can cause transfusion-related hyperkalemia

Older units and irradiated units have weak RBC membranes. Potassium can leak out of the cells and into the bloodstream when transfused

Prevention/modification of transfusion-related hyperkalemia

- Don't give irradiated units to CPR: Cardiac, Pediatric, and Renal patients

- Monitor electrolytes

What is the issue with direct injection of drug into transfused blood

Some drugs like calcium, dextrose, antibiotics are incompatible with transfusion

Prevention of injection issues during transdusion

Do not infuse products unless approved by a TM physician

What is a hemostatic defect caused by transfusion, and how is it caused

Dilutional coagulopathy - transfused with so many RBCs that it dilutes platelets

How to prevent dilutional coagulopathy

- Balance transfusions

- monitor coagulation tests

- Supplement with plasma or PLTs if required

What causes transfusion-related hypothermia

If cold units transfused too fast

Prevention of transfusion-related hypothermia

Use blood warmers, monitor patient temperature

What can cause the transfusion of hemolyzed blood

Heating, freezing, or mechanical trauma (small bore needles) damages RBCs while being transfused

Prevention of hemolyzed blood transfusions

Use approved blood warmers, larger gauges, proper storage

Full testing procedure for Transfusion reaction

On both pre and post transfusion specimens:

- ABO Rh

- Ab screen (and ID if required)

- DAT

- Serological crossmatch

Abbreviated workup for transfusion reaction

ABO Rh grouping, DAT

If a DAT is positive during a TRXN, what evidence is indicated?

Possible hemolytic transfusion reaction (delayed, or acute), or passive antibodies from transfusion

Non-serological tests and results for hemolytic TRXN

- Serum bilirubin: increased

- LDH: increased

- Hgb: decreased

-Serum haptoglobin: decreased

- PBS: schistocytes, spherocytes

- Hemoglobinuria

What can cause a delayed hemolytic transfusion reaction to show a negative DAT and Antibody screen?

Low antibody titre (either too early or too late in Ab production)

What can cause a delayed hemolytic transfusion reaction to show a negative DAT but a positive Ab screen?

Effected donor red cells have all been removed by the spleen

What can cause a delayed hemolytic transfusion reaction to show a positive DAT but a negative Ab screen?

All antibodies are attached to donor red cells

Cause of acute hemolytic transfusion reaction

ABO incompatible units transfused. Expected Abs bind to donor cells, binding complement to C9 causing intravascular hemolysis

Also rare-preformed Abs to low frequency antigens

Symptoms of acute hemolytic transfusion reactions

fever 39C or higher, chills, nausea, vomiting, pain, dyspnea, tachycardia, hypotension, bleeding, hemoglobinuria

Findings of acute hemolytic transfusion reactions

Visible hemolysis, decreased haptoglobin, increased LDH, decreased hemoglobin, increased bilirubin

Treatment of acute hemolytic transfusion reactions

Supportive care

Cause of delayed hemolytic transfusion reactions

Antibody formation to non-ABO antigens in donor blood. Ab bind donor cells and are removed by the spleen (extravascular hemolysis)

Symptoms of delayed hemolytic transfusion reactions

Fever, chills, malaise, jaundice, or no symptoms at all

Serological findings of delayed hemolytic transfusion reactions

ABO Rh normal, Ab screen can be pos or neg, DAT can be pos or neg, XM/Ab screen can be pos or neg

Treatment of delayed hemolytic transfusion reacitons

Monitor hemoglobin, bilirubin, LDH, haptoglobin

Non-serological findings of delayed hemolytic transfusion reactions

Increased bilirubin, increased LDH, decreased/normal haptoglobin, decreased/normal Hgb, no hemoglobinuria

Timing of delayed hemolytic transfusion reactions

2-14 days, usually around 7

Which products can cause febrile non-hemolytic transfusion reactions?

RBCs + Platelets

Cause of febrile non-hemolytic transfusion reactions

Soluble vasoactive cytokines in the product from WBC breakdown.

HLA Abs in patient react with donor RBCs

Timing of febrile non-hemolytic transfusion reactions

Occurs within 2-4 hours of transfusion

Symptoms of febrile non-hemolytic transfusion reactinos

Fever with/without chills or rigors (usually no other symptoms)

Big thing is fever between 38-39C

Findings of febrile non-hemolytic transfusion reaction

Normal ABO Rh, Normal DAT. Must go off symptoms

Treatment of febrile non-hemolytic transfusion reaction

Acetaminophen, rule out hemolytic and bacterial reactions

- Wash cellular products

- Leukoreduction

What products can bacteriogenic transfusion reactions occur with

RBCs or PLTs

Cause of bacteriogenic transfusion reactions

Bacteria in blood product: normal skin flora of donor, transient bacteremia, contamination during production, poor storage

Timing of bacteriogenic transfusion reactions

Variable: minutes to hours if toxins present and high bacterial load. Days if low microbial count, immune status

Symptoms of bacteriogenic transfusion reaction

Fever of 39C or lower, rigors, chills, hypotension, shock, nausea, vomiting, headache, clammy skin, DIC, tachycardia

Look for high fever + rigors!

Findings in bacteriogenic transfusion reaction

Normal ABO Rh, normal DAT. Bacteria cultures taken from patient and from the donor product/empty bag

Treatment of bacteriogenic transfusion reaction

Broad spectrum antibiotics before taking blood products

What product does Mild Allergic - Urticarial transfusion reactions happen in?

Plasma

Cause of urticarial transfusion reaction

Patient IgE antibodies reaction with allergen in donor plasma - Type 1 hypersensitivity. Antibodies bind mat cells that release granular contents

Timing of urticarial transfusion raction

1-45 mins since start of transfusion

Symptoms of urticarial transfusion reaction

Hives on <2/3rds of body, itching

Treatment of urticarial transfusion reaction

Antihistamines, can restart transfusion slowly.

Wash products if recurrent

What products is a severe allergic - anaphylactic transfusion reaction seen in

Plasma

Cause of Anaphylactic transfusion reaction

Plasma donor IgA antibodies. IgA deficient patient makes anti-IgA from previois transfusion, causing systematic anaphylaxis

Timing of anaphylactic transfusion reaction

1-15 mins: usually starts as Urticarial and progresses

Symptoms of anaphylactic transfusion reaction

Hives (less or greater than 2/3rds of body) and other significant symptoms: Dyspnea, decreased O2 sats, hypotension, loss of consciousness

Treatment of anaphylactic transfusion reaction

Antihistamines, corticosteroids, supportive therapy

Prevention of anaphylactic transfusion reaction

Request IgA deficient products, wash RBCs/PLatelets

What is Transfusion-Associated Circulatory Overload (TACO?)

Transfusion reaction caused by too much fluid/volume infused over long period of time, or from infusing too fast

Symptoms of TACO

Dyspnea with cough, decreased O2 sats, cyanosis, hypertension, tachycardia, pulmonary edema, headache

Look for Dyspnea (SOB, low O2 sat)

How to fix TACO

Slow down transfusion rate, limit fluid intake, give diuretics (make them pee)

Timing of TACO

During or within 6 hours of transfusion

What patients is TACO often seen in

Patients with heart condition (CHF) - elevated BNP

What is a transfusion-related acute lung injury (TRALI)?

Transfusion reaction caused by HLA antibodies in donor products, causing an immune reaction in the lung with complement activation

Which product is associated with TRALI

Often plasma

Who's donation products often have high levels of HLA antibodies (and can cause TRALI?)

Women with many kids. To prevent this, women's plasma is not sourced for transfusion, only products can be fractionated

Symptoms of TRALI

Dyspnea (low O2 sats, SOB) and/with hypotension, tachycardia, fever, cyanosis

When do symptoms of TRALI occur?

within 2-4 hours of transfusion

Treatment of TRALI

Supportive care

Causes of non-serological hemolytic transfusuon reactions

- Poor handling of blood

- Hemolytic bacteria

- Poor storage of blood

- Expired blood

- Transfused through small bore needle

- Adding drugs with transfusion

What is Graft vs Host Disease

occurs when the immunocompetent cells of the donated marrow recognize the patient's cells, tissues, and organs as foreign and start an immunologic attack against them.

Occurs when patient is immunosuppressed (cancer patients for example). Normal host systems would get rid of donor WBCs

Symptoms of GvHD

Pancytopenia, nosocomial infection, often death (90% mortality)

How to prevent GVHD in transfusions?

Give irradiated blood or equivalent (14 day old blood min) to immunosuppressed patients