Transcript Blood Transfusion Reactions

Ahmad Sh. Silmi
Msc , FIBMS
Staff Specialist in Hematology
Head of Medical Laboratory sciences Dept
Islamic University of Gaza
“Blood is the
most
dangerous
medication that a
physician ever
prescribes”
Blood Transfusion Reactions
(BTR’s)

may be life-threatening and even fatal

require immediate recognition and
management

must be treated if indicated and prevented
in transfusion practice
Transfusion Reaction

any unfavorable transfusion-related
event occurring in a patient during or
after transfusion of blood components
Blood Transfusion Reactions
Haemovigilance
Serious Hazards of Transfusion ( SHOT )
65% Incorrect Blood Component
10% Acute Transfusion Reaction
10% Delayed Transfusion Reaction
5% Transfusion Lung Injury
3% Post-transfusion purpura
3% Transfusion Transmitted Infection
1% Transfusion-GVHD
Blood Transfusion:
Immediate
Reactions
1.
2.
3.
4.
5.
6.
7.
Acute Haemolytic Transfusion Reactions
Febrile Non-Haemolytic Transfusion Reactions
Allergic Reactions:
1. Anaphylaxis
2. Skin Reaction
Transfusion-related Acute Lung Injury
Bacterial Contamination
Circulatory Overload
Physically or Chemically Induced Transfusion
Reactions (PCITR’s)
Blood Transfusion:
Delayed
Reactions
1.
2.
3.
4.
5.
6.
Delayed Haemolytic Transfusion
Reactions
Post- transfusion Purpura
Infection Transmission
Transfusion-related Graft-versus-Host
Disease
Immune Modulation
Iron Overload
Immediate Blood Transfusion Reactions:
Acute Haemolytic Transfusion
Reactions

Intra-vascular

Extra-vascular
Immediate Blood Transfusion Reactions:
Acute Intra-vascular Haemolytic
Transfusion Reactions


Trigger: ABO antigens on transfused red
cells Not shared by the Recipient
Reactor: Anti-A or Anti-B of Ig M type
Immediate Blood Transfusion Reactions:
Acute Intra-vascular Haemolytic
Transfusion Reactions
Pathophysiology
Full Complement Cascade Activation
1.
Complement Components C3a,C5a
2. Cytokines: IL-1, IL-6,IL-8, TNF
3. Free Haemoglobin.
4. DIC
Immediate Blood Transfusion Reactions:
Acute Intra-vascular Haemolytic Transfusion
Reactions
Clinical Picture










Fever, Flushing, Rigors
Headache
Heat or pain at cannulated vein
Restlessness
Bronchospasm
Hypotension
Back or loin pain
Oozing in the surgical field
Red urine ( haemoglobinuria )
Oliguria or anuria
Immediate Blood Transfusion Reactions:
Acute Intra-vascular Haemolytic Transfusion
Reactions
Diagnosis





Clinical picture
Transfusion Mistake
Red urine
Red plasma
Lab Confirmation
Immediate Blood Transfusion Reactions:
Acute Intra-vascular Haemolytic Transfusion
Reactions
Laboratory Workup









Obtain Blood and urine samples, inspect color
Check paper work
Repeat cross Match
CBC
Direct Coombs’ test
DIC screen: PT,PTT, Fibrinogen
BUN, Cr, electrolytes
Haemolysis screen: LDH, Haptoglobin
Blood culture if sepsis is suspected
Immediate Blood Transfusion Reactions:
Acute Intra-vascular Haemolytic Transfusion
Reactions
Management





Stop transfusion Immediately
Replace giving set, keep IV line with Normal
saline
Check patient ID against donor unit
Cardio-pulmonary support
Insert urine cath. And start Forced Diuresis
( ensure 100 ml/h for 24 h to get rid of free Hb)
Immediate Blood Transfusion Reactions:
Acute Intra-vascular Haemolytic Transfusion
Reactions
Outcome
Mortality ~ 10 %
Immediate Blood Transfusion Reactions:
Acute Extra-vascular Haemolytic
Transfusion Reactions
Trigger: Rh antigens not shared by the
patient
Reactor: Anti-Rh antibodies of Ig G type
Immediate Blood Transfusion Reactions:
Acute Extra-vascular Haemolytic
Transfusion Reactions
Response: Pathophysiology
 Incomplete complement activation
Coating of transfused red cells with C3b
 Extravascular phagocytosis by RES
 Cytokines from activated RES
Immediate Blood Transfusion Reactions:
Acute Extra-vascular Haemolytic
Transfusion Reactions
Clinical Features





Less severe, may be no signs
Onset > I hour
Fever
+ Jaundice
Rarely Haemoglobinuria or renal dysfunction
Immediate Blood Transfusion Reactions:
Acute Extra-vascular Haemolytic
Transfusion Reactions

Laboratory
Anti-complementary Coombs positive
Immediate Blood Transfusion Reactions:
Acute Extra-vascular Haemolytic
Transfusion Reactions



Managment
Stop Transfusion
Supportive
Mortality very rare
Immediate Blood Transfusion Reactions:
Febrile Non-Haemolytic Transfusion
Reaction ( FNHTR)
Trigger: Leucocyte antigens on infused blood
not shared by the patient
Reactors: Leuco-agglutinins in the patient
from previous exposure
Immediate Blood Transfusion Reactions:
Febrile Non-Haemolytic Transfusion
Reaction ( FNHTR)
Pathophysiology

Cytokine released from the transfused activated
leucocytes
Immediate Blood Transfusion Reactions:
Febrile Non-Haemolytic Transfusion
Reaction ( FNHTR)
Clinical Features
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Fever after 30-90 min
+ Rigors
+ Headache
No Hypotension
No Bronchospasm
No flank pain
No haemoglobinaemia
No Haemoglobinuria
Immediate Blood Transfusion Reactions:
Febrile Non-Haemolytic Transfusion
Reaction ( FNHTR)

Management
If Temp < 40 + Stable patient:

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Stop transfusion
Antipyretics ( No rule of Anti-histamines )
Check the bag and cross match
Exclude red urine or red plasma
Resume transfusion at a slower rate
If recurrent: Leucodepleted transfusion in the future
Immediate Blood Transfusion Reactions:
Febrile Non-Haemolytic Transfusion
Reaction ( FNHTR)

Management
If Temp 40 or more + Unstable patient:


Stop transfusion
Manage as possible acute haemolytic
reaction till lab. Confirmation or
exclusion.
Immediate Blood Transfusion Reactions:
Febrile Non-Haemolytic Transfusion
Reaction ( FNHTR)

Prevention/ Recurrence of FNHTR’s:

pre-transfusion administration of antidotes


use leukocyte-depleted blood



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documented BTR, warrants pre-transfusion medications
30 minutes before blood transfusion
removal of buffy coat
sedimentation
red cell washing
use of micro-aggregate filtration (leukoreduction)
Immediate Blood Transfusion Reactions:
Transfusion- Related Acute Lung Injury
( TRALI)
Sudden onset of acute respiratory distress
within 6 hours( u. 1-2h) of transfusion
Immediate Blood Transfusion Reactions:
Transfusion- Related Acute Lung Injury
(TRALI)
Rare: 1/5000 transfusions
Immediate Blood Transfusion Reactions:
Transfusion- Related Acute Lung Injury
( TRALI)



Pathophysiology
Trigger: Leucoagglutinins in the bag
against patient’s leucocytes
Reactors: Patient leucocytes
Result: massive Leucocyte activation
 Cytokine storm
 Pulmonary Endothelial and
Epithelial Injury  ARDS
Pathophysiology of (TRALI)
Leukocyte Ab in donor react with pt. leukocytes
Activate complements
Adherence of granulocytes to pulmonary endothelium with release
of proteolytic enz.& toxic O2 metabolites
Endothelial damage
Interstitial edema and fluid in alveoli
Immediate Blood Transfusion Reactions:
Transfusion- Related Acute Lung Injury
( TRALI)
Clinical Features
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
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Fever, chills
Acute Respiratory Distress
Normal CVP (Central Venous Pressure)
CXR: Pulmonary Infiltrate
Immediate Blood Transfusion Reactions:
Transfusion- Related Acute Lung Injury
( TRALI)
Management



Cardio-Pulmonary Support
Steroids
Diuretics of No value
Mortality
High
Immediate Blood Transfusion Reactions:
Allergic Acute Transfusion Reactions
Pathophysiology

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Trigger: Plasma proteins in the transfused blood
Reactors: Patient antibodies of IgE type
Response:

Mast cell degranulation

+ Complement Activation

+ Cytokines
Immediate Blood Transfusion Reactions:
Allergic Acute Transfusion Reactions
Clinical Features
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Mild / Skin-restricted ( common: 1%):
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Pruritus, Uerticaria, No fever or Hypotension
Severe / Systemic ( Anaphylaxis):
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As above +

Fever
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Hypotension

Bronchospasm, Angio-edema
Immediate Blood Transfusion Reactions:
Allergic Acute Transfusion Reactions
Management

Mild / Skin-restricted :

Stop transfusion temporary
 Anti-histamines
 Resume Transfusion
Immediate Blood Transfusion Reactions:
Allergic Acute Transfusion Reactions
Management

Severe / Systemic ( Anaphylaxis):

Stop transfusion
 Anti-histamines ( H1+H2 blockers)
 Epinephrine: 1 ml of 1/1000 IM
 Hydrocortisone 100 mg IV
 Cardio-pulmonary support
Immediate Blood Transfusion Reactions:
Acute Pyrogenic Transfusion Reactions
Pathophysiology

Trigger: Bacterial Pyrogens/Endotoxins in the
transfused blood contaminated with cold-growing
organisms as:

Pseudomonas

Yersinia

Some Staph

Reactors: Patient Mono-nuclear cells

Response:

Cytokine Storm
Immediate Blood Transfusion Reactions:
Acute Pyrogenic Transfusion Reactions
Clinical Features

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Like :
Acute Haemolytic reaction BUT:
 No Hemoglobinuria
 No Hemoglobinaemia
FNHTR BUT More Severe
Immediate Blood Transfusion Reactions:
Acute Pyrogenic Transfusion Reactions
Management

As Acute Haemolytic reaction
BUT
Add Broad- spectrum Antibiotics
Immediate Blood Transfusion Reactions:
Acute Circulatory Overload


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Acute cardiogenic pulmonary edema
In rapidly transfused, non-bleeding
(euovolemic) patients
More in infants, elderly or cardiac patients
Immediate Blood Transfusion Reactions:
Acute Circulatory Overload


D.D. from other Acute transfusion reactions:
No Fever ( DD from TRALI, FNHTR)
No red urine or plasma and Negative Coombs
( DD from Acute haemolytic reaction)
Immediate Blood Transfusion Reactions:
Acute Circulatory Overload
Prevention


Never exceed 2-3 ml/kg/hour Unless Bleeding
Pre-medicate with Diuretics in Cardiac or
severely anemic patients
Management

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Diuretics
Consider Haemodialysis
Supportive
Immediate Blood Transfusion Reactions:
Physically or Chemically Induced Transfusion
Reactions (PCITR’s)

heterogenous group of conditions including:
 physical RBC damage
 depletion and dilution of coagulation factors
and platelets
 hypothermia
 citrate toxicity
 hypokalemia / hyperkalemia
Immediate Blood Transfusion Reactions:
Physically or Chemically Induced Transfusion
Reactions (PCITR’s)

Physical Damage to RBC’s
intravascular lysis due to hypertonic or hypotonic
solutions
 heat damage from blood warmers, during shipping,
in hot rooms
 freeze damage in absence of cryoprotective agent
during shipping

Immediate Blood Transfusion Reactions:
Physically or Chemically Induced Transfusion
Reactions (PCITR’s)

Mechanical Damage


blood pumps, roller pumps
infusion under pressure through small bore needles
Immediate Blood Transfusion Reactions:
Physically or Chemically Induced Transfusion
Reactions (PCITR’s)

Citrate toxicity

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
ACD/ CPD has 1.4-1.6 g of citrate - no toxicity
citrate > 100 mg/ dl - citrate toxicity
Causes
 ADULTS
 rate of BT > 1 liter/ 10 min or BT volume
exceeds 6 L administered in < 2 hours
 CHILDREN
 exchange transfusion - hypocalcemia
Immediate Blood Transfusion Reactions:
Physically or Chemically Induced Transfusion
Reactions (PCITR’s)

Potassium toxicity:
Mechanism: high potassium load with prolonged
blood storage - hyperkalemia
 Clinical manifestations: cardiac excitability
 ECG findings: peak T waves
 Laboratory findings: hyperkalemia
 Management: calcium gluconate

Delayed Blood Transfusion
Reactions
1. Delayed Haemolytic transfusion reactions
2. Post-transfusion Purpura
3. Infection transmission
4. Transfusion GVHD
5. Iron Overload
6. Immune Modulation
Delayed Blood Transfusion Reactions
Post-Transfusion Purpura (PTP)

Consists of profound thrombocytopenia
occurring 1-2 weeks after transfusion

Pathophysiology:
 Effect of antibody directed against donor
platelet antigens that the recipient lacks
 Commonly associated with human plateletspecific alloantigen 1a (HPA-1a)
Delayed Blood Transfusion Reactions
Post-Transfusion Purpura (PTP)

Treatment and Prevention of PTP:
 IVIG
 plasmapheresis
 steroids
 avoidance of antigen-positive platelet
transfusion with previous PTP
Delayed Blood Transfusion Reaction
Transfusion-associated Graft-versus-Host
Disease ( TA-GVHD)
Pathophysiology
Infusion of Immunocompetent Cells
(Lymphocyte)
Patient at risk
proliferation of donor T lymphocytes
attack against patient tissue
Delayed Blood Transfusion Reaction
Transfusion Associated Graft versus Host
Disease (TA-GVHD)

Clinical Manifestations of GVHD:
 onset: 7-10 days from transfusion
 fever
 reddish, raised rash spreading from trunk or face to
extremities - bullous lesions -- erythroderma
 hepatitis
 watery diarrhea
 non-specific signs: anorexia, nausea and vomiting
Delayed Blood Transfusion Reaction
Iron Overload

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common in patients with chronic diseases
requiring multiple and prolonged transfusions
(thalassemia)
on the average, 1 unit PRBC = 200 mg iron
also “transfusion hemosiderosis”
chronic iron overload leads to hepatic, cardiac
and pancreatic disease.
prevention:
 iron chelation therapy (desferoxamine)
Delayed Blood Transfusion Reaction
Alloimmunization

Pathophysiology:
after first exposure to donor antigen - recipient
memory lymphocytes are invoked -- moderate
production of IgG and IgM
 on second exposure to donor antigen -- rapid and
large production of IgG within the first 2 days

Delayed Blood Transfusion Reaction
Alloimmunization
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Clinical manifestations:
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
Laboratory tests:


mild to severe
antibody screening
Treatment of Alloimmunization:

Accurate matching of donor and recipient RBC
phenotypes
Delayed Blood Transfusion Reaction
Immunosuppression


generalized non-specific effect diminishing the activity
of the recipient’s immune system soon after blood
transfusion
pathophysiology:
 unknown
 rapid uptake of blood component cellular matter
into the RES
Massive Blood Transfusion
Massive Blood Transfusion
Definition
Transfusion of Blood ~ Blood Volume within
24 hours
•20 units whole blood
•10 units packed cells
Massive Blood Transfusion
Complications
• Dilutional Thrombocytopenia
•Dilutional Coagulopathy
•Metabolic
•Hypothermia
Massive Blood Transfusion
Complications
• Dilutional Thrombocytopenia
•Common after 10 units
•Severe after 20 units
•Give platelet transfusion if < 80,000 +
bleeding
Massive Blood Transfusion
Complications
•Dilutional Coagulopathy
•Particularily if blood stored > 2 weeks
•Monitor Coagulation profile
•FFP if Abnormal lab
•DIC is Rare
Massive Blood Transfusion
Complications
•Metabolic: Citrate Intoxication
•Acidosis, Hypocalacemia, Hyperkalaemia
•Rare Except in Infants or Hepatic
patients
CONCLUSION



How much important?
How much safe?
How much benefit?
- Someone needs blood every 3 seconds
-One in ten hospitalized patients needs
blood
-4.5 million lives are saved by blood
transfusions/year
-One unit of blood saves three lives
How safe?
 The
risks from blood transfusion is 1 in
12,000, less than the risk of being killed in
a road traffic accident or of dying from
flu.
 The
risk of contracting HBV, HCV or
HIV from blood transfusion is minimal.
ALL RISKS
Serious complications, such as:
 Intravascular
haemolysis.
 Transfusion-induced coagulopathy.
 Renal impairment and failure.
 Admission to intensive care.
 Persistent viral infection.
 Death.
 Occur
at a rate of 1 in 67,000 transfusions.
RISKS OF NOT BEING TRANSFUSED
 The
rate of fatal complications due to
anaemia in 16 reports ranges between
0.5% and 1.5%.
RISKS OF NOT BEING TRANSFUSED
 Evidence
from observational studies
suggests that the elderly and those patients
suffering from cardiovascular and peripheral
vascular disease are less tolerant of
preoperative anaemia and should therefore
be transfused at a higher haemoglobin level
 (i.e.
a lower threshold for transfusion).
To Conclude
Immediate Action to Take for Txn Rxn:

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1. STOP THE TRANSFUSION
2. Keep IV open with Normal Saline
3. Check all blood component(s) labels, forms, Pt. ID for
errors
4. Notify Pt.’s physician as appropriate
5. Treat rxn
6. Notify Blood Bank; submit work-up specimens; submit
report forms