Transfusion Reactions Lloyd O. Cook, M.D. Department of Pathology March 2005

Definition: Txn Rxn Any adverse outcome attributable to transfusion of a blood component or components.

Immediate Action to Take for Txn Rxn: 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

Common Signs & Symptoms Abnormal bleeding Chest/back pain Chills Coughing Cyanosis Dyspnea Facial flushing Fever (> 1 C ) Headache Hemoglobinuria Heat at infusion site Hypotension Itching Myalgia Nausea Oliguria/anuria Pulmonary edema Rales Rash Urticaria/hives Wheezing Uneasy feeling

Selected Txn Rxns Signs/Symptoms Cause Management Prevention

Acute Hemolytic Note: Most dangerous immunologic complication of Red Cell unit transfusion. Usually due to clerical error: wrong Pt.; wrong blood component; etc. High risk for morbidity or mortality. Morbidity, e.g.: renal failure, DIC Mortality: about 1 per 100,000 txn pts per year (cases reported to FDA)

Acute Hemolytic Signs/symptoms (usual) Sudden chills Increased temp of 1 C to 2 C - fever Headache Flushing Anxiety Muscle pain Hemoglobinuria Low back apin Tachypnea Tachycardia Hypotension Vascular collapse Bleeding (N.B. surgical field in an anesthetized pt. Acute Renal Failure Hemoglobinemia DIC DIC with bleeding Shock Cardiac arrest DEATH

Acute Hemolytic Cause Transfusion of incompatible donor RBC’s into Pt Usually an ABO incompatibility Antibodies in Pt plasma attach to antigens on donor RBC’s causing RBC destruction intravasculary Antibodies fix complement causing RBC lysis

Acute Hemolytic Management Treat hypotension, renal failure, DIC, etc. Submit blood samples for blood bank/laboratory tests Avoid, if possible, further transfusions till work-up complete and/or Pt recovered from rxn

Acute Hemolytic Prevention Meticulously verify and document Pt ID from sample collection for compatibility testing through to blood component transfusion Follow precisely the proper transfusion procedures at bedside (usually found in Nursing SOP’s ) every time – NO SHORTCUTS !!!

Febrile Rxn Signs/Symptoms Nonhemolytic Sudden chills 1 C to 2 C temp increase Headache Flushing Anxiety Muscle pain

Febrile Rxn Cause Pt immunologic sensitization to donor WBC’s, platelets or plasma proteins Common sources: prior transfusions, previous pregnancies, previous transplants

Febrile Rxn Management Give antipyretics (e.g. aspirin – except children – Reyes Syndrome) Avoid aspirin in thrombocytopenic pt’s Do not restart transfusion

Febrile Rxn Prevention Consider leukocyte poor blood components Two types of leukopoor RBC’s: filtered at time of donation and frozen/washed Can also use WBC filters at bedside

Allergic Rxn Signs & Symptoms Flushing Itching Urticaria (aka hives) Rarely, angioedema – epiglottal edema; bronchial airway constriction, hypotension, dyspnea, rales

Allergic Rxn Cause Pt sensitized to foreign plasma antigens Exact mechanism not known for sensitization Commonly caused by transfusion of plasma containing blood components, e.g.: FFP, Cryoprecipitate, Platelet Concentrates

Allergic Rxn Management Premedicate Pt with antihistamines (e.g. Benadryl) If signs/symptoms mild &/or transient, restart transfusion after treatment Do NOT restart transfusion if pulmonary symptoms/signs, fever present

Allergic Rxn Prevention Prophylactically treat with antihistamines

Anaphylactic Rxn Signs & Symptoms Note: very immediate type rxn Anxiety Urticaria Wheezing Severe dyspnea Pulmonary/laryngeal edema Shock Cardiac arrest

Anaphylactic Rxn Cause Infusion of IgA proteins into Pt with IgA antibodies IgA deficiency about 1 in 700 Anaphylactic rxn rate about I per 1,000,000 pts. Why disparity not known

TRALI Transfusion Related Acute Lung Injury aka Noncardiogenic pulmonary edema Signs & Symptoms Severe dyspnea Hypotension Fever Chills Bilateral pulmonary edema

TRALI Cause Donor antibodies activate Pt’s WBC’s which cause damage to blood vessels in lung tissue Then fluids and proteins leak into alveolar space/interstitium Mechanism similar to ARDS

TRALI Management Steroids Aggressive ventilatory support Hemodynamic support

TRALI Prevention Transfuse washed RBC’s from which plasma is removed Platelet units can also be washed, but platelet function is significantly reduced

Circulatory Overload Signs & Symptoms Cough Dyspnea Pulmonary congestion Headache Hypertension Tachycardia Distended neck veins

Circulatory Overload Cause Iatrogenic – physician induced rxn Fluid(s) administered faster than Pt circulation can accommodate volume load Some at risk types of pt.’s: congestive heart failure, renal failure, hepatic cirrhosis, normovolemic anemia

Circulatory Overload Management Place Pt in upright position, if possible, with feet in dependent position Diuretics Oxygen Morphine (if necessary)

Circulatory Overload Prevention Adjust transfusion flow rate based on Pt size and clinical status Consider dividing unit(s) into smaller aliquot(s) to better space apart blood component(s) pace of transfusion

Septic Rxn Signs & Symptoms Rapid onset of chills & fever Vomiting Diarrhea Profound hypotension Shock

Septic Rxn Cause Transfusion of bacterially contaminated blood components Common problem for platelet concentrates stored at room temperature

Septic Rxn Management Obtain blood cultures from Pt Return blood component bag(s) to blood bank for further laboratory work-up Treat septicemia with antibiotics Treat shock with fluids & vasopressors

Septic Rxn Prevention Collect, process, store, transport, and transfuse blood components according to contemporary standards of practice (e.g. for FDA standards adhere to cGMP’s – current good manufacturing practices – found in Code of Federal Regulations) Transfuse blood components within 1 to 2 hrs – do not exceed 4 hrs

Delayed Hemolytic Txn Rxn Signs & Symptoms Fatigue Malaise Declining hemoglobin/hematocrit Conjugated bilirubin may be elevated Falling hemoglobin/hematocrit usually noticed 3 to 14 days post transfusion

Delayed Hemolytic Txn Rxn Cause Anamnestic immune response in Pt to antigen(s) present on transfused donor cells Antibody attaches to transfused RBC’s and RBC’s are removed from Pt’s circulation by reticuloendothelial system (liver/spleen) This process is called extravascular hemolysis

Delayed Hemolytic Trn Rxn Management Send specimen(s) to Blood Bank for antibody identification work-up Provide good Pt history

Delayed Hemolytic Trn Rxn Prevention Transfuse RBC’s that are phenotype negative for known clinically significant RBC antibodies in Pt Delayed Hemolytic Trn Rxn’s can not be predicted Good Pt records and Blood Bank records are essential Clinical treatment usually not necessary

Txn Rxns Usual Incidence Rates Some Selected Rates: Acute Hemolytic~1:32,000 Febrile1% to 2% Allergic1% to 3% Anaphylactic~1:170,000 to ~1:1,000,000 Circulatory Overload~1:10,000 Delayed Hemolytic~1:11,000

Infectious Risks of Transfusion (more common risk types) Viral: HIV 1 & 21:493,000 HTLV-I/II1:641,000 Hepatitis B1:63,000 Hepatitis C1:103,000

Infectious Risks (cont.) Bacterial: Red Blood Cells (RBC’s)1:500,000 Platelets, random1:1:10,200 Platelets, pheresis1:19,000 Parasites: Chagas Dis. (T. cruzi)1:42,000 Malaria & Babesia<1:1,000,000

Txn Rxns - Reminders Signs & Symptoms are usually nonspecific No predictive tests for when a particular Txn Rxn will occur Transfusion is an IRREVERSIBLE process – always benefits against risks Be Prepared! – a Txn Rxn can happen unpredictably at anytime !!

Txn Rxns The End