Week 8: Adverse Effects of Transfusion

examples of acute transfusion reactions

• hemolytic

• febrile

• urticarial

• anaphylactic

• sepsis

• circulatory overload (TACO)

• transfusion related acute lung injury (TRALI)

examples of delayed transfusion reactions

• hemolytic

• graft-vs-host disease

• infectious disease

what is the most common cause of an acute hemolytic transfusion reaction?

incompatible RBCs

acute hemolytic transfusion reactions can also occur by transfusing ABO incompatible _________

plasma

most common antibodies associated with acute HTR

• anti-A

• anti-K

• anti-Jka

• anti-Fya

the most common antibodies associated with acute HTR bind _____________ and have efficient in-vitro lytic properties

complement

the following describes which type of hemolysis?

• RBCs destroyed in circulation

• hemoglobin is released into plasma

• hemoglobin spills into urine

intravascular

the following describes which type of hemolysis?

• incomplete activation of complement

• RBCs phagocytized by macrophages in spleen and liver

• milder

extravascular

clinical signs/symptoms of acute HTR

• fever

• chills

• hemoglobinuria

• oozing from surgical site

• hypotension

• shock

• renal failure

• DIC

management for acute HTR

• transfusion stopped ASAP

• monitor for DIC, hypotension, renal failure

what are the most common type of transfusion reactions?

• febrile non-hemolytic transfusion reaction (FNHTR)

• allergic reactions

what causes FNHTR?

• recipient antibodies attack transfused lymphocytes, platelets, and granulocytes

  • most commonly HLA

previous pregnancies and transfusions increase the risk of ___________

FNHTR

how can FNHTR be prevented?

• transfuse leukocyte-reduced blood components

• pre-medicate patient

urticaria

hives, rash, itching

urticaria can occur __________ within exposure

minutes

allergic reactions to transfusions are believed to be caused by recipient antibodies reacting with _________ in donor plasma

proteins

the release of ___________ after antibodies bind cause vascular dilation and allows fluids to escape into tissues

histamine

management of allergic reactions

antihistamines

anaphylactic transfusion reaction

immediate hypersensitivity immune system response (few minutes) that can be life threatening

symptoms of anaphylactic transfusion reaction

• respiratory distress

• hypotension

• shock

anaphylactic shock can occur which what kind of recipients?

IgA deficient with antibodies to IgA and other donor plasma proteins

prevention for anaphylactic reactions

• use washed RBCs and platelets

• use IgA deficient plasma

the _____________ produced by cold temperature growing bacteria can cause transfusion-associated sepsis

endotoxin

symptoms of transfusion-associated sepsis

• dryness and flushing of skin

• fever, shaking, chills

• vomiting, abdominal cramps

• hypotension

• shock

• DIC

what bacterial species are associated with RBC contamination?

• Yersinia enterocolitica = most common

• Serratia liquefaciens

what bacterial species are associated with platelet contamination?

• S. aureus

• Klebsiella sp.

• E. coli

• Streptococcus sp.

• Bacillus cereus

what is circulatory overload (TACO)

• physician caused (iatrogenic) transfusion reaction

• too much too fast

excessive blood volume from TACO causes what to occur in the patient?

congestive heart failure and pulmonary edema

symptoms of TACO

• dyspnea

• tachycardia

• systolic hypertension

• coughing

• chest discomfort

what kinds of patients are at risk for TACO?

• children

• elderly

• chronic normovolemic anemia

• cardiac disease

• thalassemia major

• sickle cell disease

transfusion-related acute lung injury (TRALI)

respiratory failure with pulmonary edema without evidence of cardiac failure or a cause for respiratory failure

symptoms of TRALI

• chills, fever

• hypotension

• respiratory distress

• cyanosis

what causes TRALI?

activation of recipient neutrophils caused by passively transfused HLA or human neutrophil antigens (HNA) antibodies

physical and chemical hemolysis of donor RBC unit

• hypotonic solutions (5% dextrose)

• drugs

• infusion through small needle

• extreme temperatures

delayed hemolytic transfusion reactions are usually what type of hemolysis?

extravascular

delayed hemolytic transfusion reactions are usually due to what type of response?

anamnestic or secondary

an anamnestic or secondary response to donor RBCs can occur how?

recipient previously developed antibody but was no longer detectable by pre-transfusion testing

what are the most likely associated antibodies with anamnestic or secondary responses (delayed HTR)?

• Rh

• kidd

• duffy

• kell

a delayed serologic transfusion reaction is an anamnestic response with no ____________

hemolysis

signs/symptoms of delayed HTR

fever and mild jaundice

lab values of delayed HTR

• low HGB

• discovery of previously undetected antibody

• mixed field positive DAT

• post-transfusion specimen reacts with transfused donor RBCs

in graft vs host disease, the transfused ____________ undergo clonal expansion in recipient

lymphocytes

symptoms of graft vs host disease

• diffuse skin rash

• fever

• pancytopenia

graft vs host disease has a _______ mortality rate

high

causes of blood borne pathogens with transfusions

• hepatitis

• cytomegalovirus

• HIV

• human T-cell lymphotropic virus (HTLV)

units in inventory from a donor with blood borne pathogens must be _________________, and the collecting facility be notified

quarantined

hepatitis ____________ is given to the recipient exposed to hepatitis positive unit

prophylaxis

what are the roles of clinical personnel during transfusion reactions?

• stop transfusion

• clerical check

• maintain IV access with saline

• notify transfusion service and patient’s physician

what is sent to the lab after a transfusion reaction?

• transfused unit

• IV solution

• tubing

• transfusion record filled out

• post-transfusion type and screen

• post-transfusion urine sample

what is written on the transfusion record after a reaction?

• pre- and post-transfusion vitals

• symptoms

• time of reaction

• amount of product transferred

what is the role of the lab in investigating transfusion reactions?

• find clerical errors

• visual inspection for hemolysis

• evaluate post-transfusion ABORh, antibody screen, DAT

if hemolysis is seen in a post-transfusion specimen, what is done next?

• check pre-transfusion specimen

• draw a second post-transfusion specimen to confirm

if the antibody screen on a post transfusion sample is negative…

no further testing

if the antibody screen on a post transfusion sample is positive…

repeat pre transfusion sample, antibody ID, and donor tested for antigen

what is indicated if the pre-transfused unit has a negative antibody screen, and the post-transfused unit has a positive antibody screen?

anamnestic response where the antibody was below detection level, the antigen positive unit was transfused, and the titer increased

what is indicated if both the pre-transfused and post-transfused units have positive antibody screens?

missed antibody

if the DAT on a post-transfusion sample is negative…

no further testing

if the DAT on a post-transfusion sample is positive…

perform an elution if IgG positive

what is indicated if the pre-transfused unit has a negative DAT, and the post-transfused unit has a positive DAT?

there is an antibody binding to the donor cells

what is indicated if both the pre-transfused and post-transfused units have positive DATs?

could be due to medication

what is indicated if the pre-transfusion serum is compatible with donor RBCs, but the post-transfused serum is incompatible?

• anamnestic response

• wrong patient sample

what is indicated if both the pre-transfused and post-transfused serums are incompatible with donor RBCs?

• missed antibody

• auto-antibody