11 - TRANSFUSION REACTION

Transfusion Reaction

Any transfusion-related adverse event that occurs during or after the transfusion of whole blood, blood components, or human-deprived plasma products

Transfusion Reaction

Substances are foreign that may produce alloantibodies hence the numerous tests done

Based on Time Interval

Main Classification of TR

Acute Transfusion

Delayed Transfusion

Main Classification of TR

Based on Time Interval (2)

Acute transfusion

Main Classification of TR

Based on Time Interval

Sign and symptoms presenting within 24 hours after transfusion

Delayed transfusion

Main Classification of TR

Based on Time Interval

Sign and symptoms presenting after 24 hours

Immune

Non-immune

Infectious

Non-infectious

Other Classifications of TR (4)

immediately

0.9 NaCl

Workup of Transfusion Reaction

At Bedside: Nurse and Physician Responsibilities

• Nurse:

  • Stop transfusion _

  • Maintain IV access open with infusion of _ _ (normal saline) – this is to dispose all foreign blood component that entered the recipient's circulation

  • Perform clerical check on the blood bag/transfusion reaction record the patient identification band

  • Notify patient physician

transfusion reaction

Workup of Transfusion Reaction

At Bedside: Nurse and Physician Responsibilities

• Physician:

  • Evaluate patient and treat as needed

  • Physician order _ _ workup, notify transfusion service, and follow standard operating procedures

  • Consult with transfusion service physician for guidance regarding further evaluation and treatment

primary testing

Workup of Transfusion Reaction

Transfusion Service: Laboratory Technologist/Physician Responsibilities

• Laboratory Technology

  • Perform _ _ on postreaction sample

  • Report findings to the transfusion service physician

  • Perform additional testing as per transfusion service physician orders

hemolysis, bacterial contamination, TRALI

Workup of Transfusion Reaction

Transfusion Service: Laboratory Technologist/Physician Responsibilities

• Transfusion Service Physician:

  • Evaluate initial transfusion reaction workup

  • Order additional testing as needed

  • Report to patient physician immediately if _, _, _ or other serious adverse event related to transfusion is suspected

  • Generate a final transfusion report, including interpretation of the transfusion reaction and recommendations for future transfusions

  • Notify blood centers and other outside agencies if applicable

Immediate Hemolytic TR

Febrile Non-Hemolytic TR

Allergic Reaction

Anaphylaxis/Anaphylactoid Reaction

TRALI (Transfusion Related Acute Lung Injury)

Immune-Immediate Transfusion Reaction (5)

Immediate Hemolytic TR

Immune-Immediate Transfusion Reaction

Caused by incompatible blood group

Febrile Non-Hemolytic TR

Immune-Immediate Transfusion Reaction

Caused by leukocyte antibody

Allergic Reaction

Immune-Immediate Transfusion Reaction

Urticarial allergens

Anaphylaxis/Anaphylactoid Reaction

Immune-Immediate Transfusion Reaction

Involvement of mast cells (IgA)

TRALI (Transfusion Related Acute Lung Injury)

Immune-Immediate Transfusion Reaction

Can cause pulmonary edema

Immediate Hemolytic Transfusion Reaction

Immune-Immediate Transfusion Reaction

Reaction period varies from 1-2 hours

Hemolyzed blood

Blood pressure and hemoglobin count drop

Immediate Hemolytic Transfusion Reaction

Immune-Immediate Transfusion Reaction

Main cause is INCOMPATIBLE BLOOD

Intravascular

Extravascular

Immune-Immediate Transfusion Reaction

Immediate Hemolytic Transfusion Reaction

RBCs are destroyed by 2 mechanisms

Febrile Non-Hemolytic Transfusion Reaction

Immune-Immediate Transfusion Reaction

Acute complication of transfusion presenting with at least a 1-degree celsius increase in body temperature

Febrile Non-Hemolytic Transfusion Reaction

Immune-Immediate Transfusion Reaction

Normally, patients experience a drop of blood pressure and increase of body temperature

Immune-mediated

Platelet Storage Changes

Immune-Immediate Transfusion Reaction

Febrile Non-Hemolytic Transfusion Reaction

2 mechanisms

Immune-mediated

Immune-Immediate Transfusion Reaction

Febrile Non-Hemolytic Transfusion Reaction

2 mechanisms

There is antibodies against white cells in the blood component

Immune-mediated

Immune-Immediate Transfusion Reaction

Febrile Non-Hemolytic Transfusion Reaction

2 mechanisms

That is why it is important to keep history of leukocyte antibody in our patient and remove the WBC (leuko-induced blood products)

Platelet Storage Changes

Immune-Immediate Transfusion Reaction

Febrile Non-Hemolytic Transfusion Reaction

2 mechanisms

There is a production and release of biological reactive cytokines

Platelet Storage Changes

Immune-Immediate Transfusion Reaction

Febrile Non-Hemolytic Transfusion Reaction

2 mechanisms

Platelets are placed in RT and if u don't agitate them continuously then definitely there are some biochemical changes that can be expected from the platelets

Allergic Reaction

Immune-Immediate Transfusion Reaction

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

weals, hives, erythema, or pruritus

Immune-Immediate Transfusion Reaction

Allergic Reaction

The more common, milder reactions consist of (4)

“Anaphylactoid or anaphylactic”

Cytokine involvement

Patient can no longer breathe

Immune-Immediate Transfusion Reaction

Allergic Reaction

Severe reactions (3)

antibodies

Immune-Immediate Transfusion Reaction

Allergic Reaction

To prevent this, we have to screen properly _ present in our donor

Transfusion Related Acute Lung Injury

Immune-Immediate Transfusion Reaction

With respiratory distress and severe hypoxemia during or within 6 hours of transfusion in the absence of other causes of acute lung injury

anti-WBC antibodies

Immune-Immediate Transfusion Reaction

Transfusion Related Acute Lung Injury

Mediated by _-_ _

Transfusion associated fatalities

Immune-Immediate Transfusion Reaction

Transfusion Related Acute Lung Injury

Considered as leading cause of “_ _ _”

high mortality

Immune-Immediate Transfusion Reaction

Transfusion Related Acute Lung Injury

TRALI causes _ _ compared to ABO incompatible and bacterial contamination

DHTR

Alloimmunization (platelet refractoriness)

PTP (anti-PLA1)

TA-GVHD (Transfusion-Associated Graft-Versus-Host Disease)

Immunosuppression

Immune-Delayed Transfusion Reaction (5)

Delayed Hemolytic Transfusion Reaction

Immune-Delayed Transfusion Reaction

Detection of “new” red cell antibodies after 24 hours of transfusion

anamnestic response

delayed hemolytic

delayed serologic

Immune-Delayed Transfusion Reaction

Delayed Hemolytic Transfusion Reaction

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

Kidd Blood group

Immune-Delayed Transfusion Reaction

Delayed Hemolytic Transfusion Reaction

most notorious blood group associated with DHTR

Post Transfusion Purpura

Immune-Delayed Transfusion Reaction

Presents with profound thrombocytopenia, frequently accompanied by bleeding, 1 to 24 days after a blood transfusion

human platelet antigen (HPA)1a

Immune-Delayed Transfusion Reaction

Post Transfusion Purpura

The antigen most commonly implicated in this condition is the _ _ _ _

Transfusion-Associated Graft-Versus-Host Disease

Immune-Delayed Transfusion Reaction

Due to an immunologic attack by viable donor lymphocytes contained in the transfused blood-component against the transfusion recipient

Irradiated

Immune-Delayed Transfusion Reaction

Transfusion-Associated Graft-Versus-Host Disease

_ blood components are given to this type of patients

Human-leukocyte antigen

Immune-Delayed Transfusion Reaction

Transfusion-Associated Graft-Versus-Host Disease

_-_ _ typing must be also done

Bacterial Contamination

TACO (Transfusion-Associated Circulatory Overload)

Physical and Mechanical RBC Damage

Dilution and Deletion of Coagulation Factors and Platelets

Non-Immune Immediate Transfusion Reaction (4)

Yersinia enterocolitica

Red cells

Non-Immune Immediate Transfusion Reaction

Bacterial Contamination

_ _ thrives at ref temperature

_ _ that are stored in ref temperature

Staphylococcus, Streptococcus

Platelets

Non-Immune Immediate Transfusion Reaction

Bacterial Contamination

_ and _

_ that are stored in room temperature

TACO (Transfusion-Associated Circulatory Overload)

Non-Immune Immediate Transfusion Reaction

Overload of blood products

Bacterial Contamination

Non-Immune Immediate Transfusion Reaction

Occurs when a bacteria-contaminated blood component is transfused

Staphylococcus spp.

Streptococcus spp.

Bacillus spp.

Non-Immune Immediate Transfusion Reaction

Bacterial Contamination

Gram Positive species (3)

Serratia spp.

Yersinia spp.

Acinetobacter spp.

Escherichia spp.

Pseudomonas spp.

Providencia spp.

Non-Immune Immediate Transfusion Reaction

Bacterial Contamination

Gram Negative species (6)

Skin flora

Natural environment

Non-Immune Immediate Transfusion Reaction

Bacterial Contamination

Gram Positive species sources (2)

Blood streams

Natural environment

Non-Immune Immediate Transfusion Reaction

Bacterial Contamination

Gram Negative species sources (2)

1:500,000

1:10,000,000

1:75,000

1:500,000

Non-Immune Immediate Transfusion Reaction

Bacterial Contamination

Gram Positive & Negative

Red Blood Cells:

Risk: _

Mortality: _

Platelets:

Risk: _

Mortality: _

Transfusion Associated Circulatory Overload

Non-Immune Immediate Transfusion Reaction

With respiratory distress and hypoxemia that can be accompanied by cough, headache, chest tightness, hypertension, jugular vein distension, elevated central venous pressure, and elevated pulmonary wedge pressure during or after transfusion

TACO

Non-Immune Immediate Transfusion Reaction

cardiogenic edema

TRALI

Non-Immune Immediate Transfusion Reaction

pulmonary edema

congestive heart failure

Non-Immune Immediate Transfusion Reaction

Transfusion Associated Circulatory Overload

Occurs when the patient’s cardiovascular system’s ability to handle additional workload is exceeded, manifesting as _ _ _

BNP (Brain Natriuretic Peptide)

N-Terminal Pro-BNP (more sensitive than BNP)

Non-Immune Immediate Transfusion Reaction

Transfusion Associated Circulatory Overload

Analytes to evaluate TACO (2)

EDTA or green top

Non-Immune Immediate Transfusion Reaction

Transfusion Associated Circulatory Overload

Tube used

Whole blood

Non-Immune Immediate Transfusion Reaction

Transfusion Associated Circulatory Overload

Specimen used

Iron Overload

Citrate Toxicity

Air Embolism

Non-Immune Delayed Transfusion Reaction (3)

Iron Overload

Non-Immune Delayed Transfusion Reaction

AKA “transfusion hemosiderosis”

Iron Overload

Non-Immune Delayed Transfusion Reaction

Excessive iron accumulation

Caused by massive transfusion

Prussian Blue Stain

Non-Immune Delayed Transfusion Reaction

Iron Overload

Stain used to visualize hemosiderin granules

FNHTR (Febrile Non-Hemolytic Transfusion Reactions)

Allergic Reaction

Most Common Cause of Transfusion Reaction (2)

Non Cardiogenic Pulmonary Edema (TRALI)

DHTR (Delayed Hemolytic Transfusion)

IHTR (Immediate Hemolytic Transfusion Reaction)

Most Common Cause of Death Associated with TR (3)

Clerical Check

Visual Inspection

Do DAT Testing

Investigation of a Transfusion Reaction (3)

Mislabeling

Misidentification

Investigation of a Transfusion Reaction

Clerical Check (2)

Pretransfusion Sample

Post Transfusion Sample

Investigation of a Transfusion Reaction

Visual Inspection (2)

Pretransfusion Sample

Investigation of a Transfusion Reaction

Visual Inspection

Blood product of donor

Blood product of patient

Post Transfusion Sample

Investigation of a Transfusion Reaction

Visual Inspection

After transfusion, collect blood from the patient

Do DAT Testing

Investigation of a Transfusion Reaction

To check for in vitro sensitization

IHTR

IHTR VS DHTR

Minutes

DHTR

IHTR VS DHTR

Days (3-7)

IHTR

IHTR VS DHTR

Incompatible blood

DHTR

IHTR VS DHTR

Blood: Bilirubin, Methemalbumin

IHTR

IHTR VS DHTR

Free hemoglobin

DHTR

IHTR VS DHTR

Urine: Urobilinogen, hemosiderin

IHTR

IHTR VS DHTR

DAT (+) – minutes

DHTR

IHTR VS DHTR

DAT (+) – days

IHTR

IHTR VS DHTR

Urine – free hemoglobin

DHTR

IHTR VS DHTR

Extravascular hemolysis

IHTR

IHTR VS DHTR

Intravascular hemolysis

IHTR

IHTR VS DHTR

Hypotension w/c leads to DIC, acute renal failure

DHTR

IHTR VS DHTR

Unexplained depletion of Hgb and Hct leading to anemia

ABO and Rh Typing

Urine test

Antibody screening

Bilirubin test

Hgb and Hct

Additional Testing (5)