Blood Transfusion Reactions

Blood Transfusions (From USC Essentials lecture by Dr Arora)

1. Acute: while transfusion is going on

2. Delayed

WELL ONES

1. Febrile, Non-hemolytic Transfusion Reaction FNHTR

• during or up to 4 hours (therefore, must admit)
• low grade fever, o/w asymptomatic
• cytokine-mediated
• common in old blood products and platelets
• lower in leukocyte reduced products (can give this if patient has recurrent fever during transfusion)
• incidence: 1:5000
• Tx: Paracetamol

2. Simple Allergic (Urticarial) Reaction

• during or a few hours after
• incidence: 1:3-1:300
• if mild (no oral involvement), can continue transfusion
• Tx: Diphenhydramine
• Can premeditate if known hx of same

SICK ONES (MAJOR REACTIONS)

3. Fever, shocky, sick: Acute Hemolytic Transfusion Reaction vs Sepsis

AHTR

• during or up to 4 hours
• true emergency
• incidence: 1:38,000-1:70,000
• mortality: 1:30
• usually ABO incompatibility
• can lead to DIC/shock/ARF
• triad: fever (usually high grade), flank pain, hematuria -- don't wait
• Dx: Pink Plasma, (+) Coombs test: patient's blood send to lab, add Coomb's reagent (antihuman antibodies), if there's antibodies in RBC = agglutinate
• Tx: stop transfusion, recheck patient and blood, notify blood bank, send coombs, T&C, chemistry, Hb
• Tx: supportive (monitor, airway, hemodynamics), 1L NS IV bolus (keep UO >100-200cc/hr), treat HyperKalemia if present

SEPSIS

• usually in first hour
• very rare
• stop transfusion, notify blood blank
• culture blood (recipient and donor blood)
• Broad spectrum antibiotics

4. SOB, uncomfortable

Severe Allergic (Anaphalylactic) Reaction

TRALI (Transfusion-Related Acute Lung Injury)

TACO (Transfusion-Associated Circulatory Overload)

Severe Allergic (Anaphalylactic) Reaction

• usually right at the start, can up to 4 hours
• incidence: 1:20,000-1:50,000
• shock/hypotension/angioedema/respiratory distress
• normal CXR
• Tx: Stop transfusion, supportive, epinephrine (tx as anaphylaxis)

TRALI

• during-4 hours
• 1:5,000-1:150,000 (?)
• pathophys: (not clear): leading theory - HLA antibodies; react with Ag on recipient granulocytes; initiate inflammatory response in the pulmonary vasculature
• more common in female donors (esp with babies cuz they have more HLA antibodies)
• reduced incidence in male donors and females screened for HLA antibodies
• Two-Hit Theory: Patients with underlying systemic inflammation (SIRS/sepsis/trauma/Massive transfusion), likely to get TRALI
• Dx: non cardiogenic pulmonary edema (patchy bilateral alveolar infiltrates); tachypneoa/cardia, hypotension, frothy pink sputum, fever -- well before transfusion
• Tx: Stop transfusion, (NIV), NO lasix (just like non cardiogenic pulmonary edema)

TACO

• during or few hours later
• incidence variable: high in CHF
• symptoms similar with TRALI
• overload: high JVP, Supportive high BP, high BNP
• Tx: stop, supportive, lasix

5. Premedication

Adv: Eliminates minor reactions, patient comfort

Disadv: Masks major reaction, delay treatment

[Volume 48, November 2008, Transfusion]

- n = 315

- placebo vs premed with acetaminophen + diphenhydramine

- no difference in transfusion reactions

ALGORITHM:

1. Suspect acute transfusion reaction?

• Stop
• Recheck Patient and Blood identifiers
• Notify Blood bank

2. If Major/severe: LABS

• Coombs test
• Repeat T&C
• Chemistry
• LDH
• Visual inspection of plasma ?pink
• UA (Hb)
• ?Blood culture

3. 4 Categories (with some overlap)

1. LG fever: FNHTR: antipyretics
2. Isolated Urticaria: Simple Allergic reaction: antihistamines
3. High Fever/Shock: AHTR vs Sepsis: antipyretics, vasopressors, fluids, +/- antibiotics
4. Respiratory distress: Hypotensive (Anaphylaxis vs TRALI), Hypertensive (TACO)

--

Push EM pushemcc+canned.response@gmail.com to me

show details 11:42 PM (2 minutes ago)

Answer Key for PushEM Case of the Week for 9/22/11 - Blood, blood, everywhere...

While consenting a 50-year old man for blood transfusion, you discover that he has had febrile reactions to multiple transfusions in the past, but that these were treated successfully with acetaminophen...

Which of the following products is the best choice to decrease the likelihood of another similar reaction?

a. irradiated packed RBCs

b. leukocyte-reduced packed RBCs

c. regular packed RBCs

d. type-specific packed RBCs

e. whole blood

The answer is B: leukocyte-reduced packed RBCs. Nonhemolytic simple febrile reactions are the most common transfusion reactions and have an incidence of approximately 1%. These are thought to occur from a combination of recipient anti-leukocyte antibodies to transfused cells, and transfused pyrogenic cytokines that accumulate as leukocytes break down. Therefore, administration of leukocyte-reduced packed RBCs can decrease the likelihood of this reaction. Simple febrile reactions can also be prevented and treated with antipyretics. At first, these can resemble more serious transfusion-related reactions such as a hemolytic transfusion reaction and sepsis, which must remain on the differential. Leukocyte-reduced packed RBCs also decrease risk of HIV and CMV transmission and prevent sensitization in patients who might need a bone marrow transplant. Irradiated packed RBCs prevent the capacity of T cells to proliferate and should be considered for neonates and immunocompromised patients, including those with transplants. Whole blood is not as economical as component therapy and is essentially unavailable in the United States; and since it contains WBCs like regular and type-specific packed RBCs, would not be expected to prevent simple febrile reactions.