1. Transfusion Reactions June 2015

2. Objectives  Be able to recognize the more common transfusion reactions  Learn about treatment and prevention of transfusion reactions

3. Frequency of Transfusion Reactions

4. Case 1  Mr Red is a 17 year old male is brought to the ER after a motor vehicle accident. He is in pain, tachycardic to 100s, but normotensive.  Given his acute blood loss, transfusion of 2u PRBC is initiated (after appropriate type and cross- matching revealing no antibodies, and compatibility with donor blood).  During transfusion, he develops a fever but otherwise has no new signs or symptoms.  What is the diagnosis?

5. Febrile Nonhemolytic Transfusion Reaction  Fevers are common during transfusion  Pathophysiology: likely involves recipient-derived leukoreactive antibodies + donor-derived cytokines  Workup/Treatment: stop the transfusion!  Must r/o acute hemolytic transfusion reaction (AHTR)  Consider non-transfusion causes of fevers  Once AHTR is ruled out, may continue transfusion with antipyretics  Prevention: antipyretics or leukoreduction of blood products

6. Case 1 (continued)  Mr Red does well following discharge. Fifteen years later (age 32), however, he is unfortunately in a second MVA. He is brought to the ER, again requiring blood products.  He is type and cross-matched, found to have no antibodies. He is pre-treated with acetaminophen, and transfused 2 units PRBC without issue.  The remainder of his hospital course is unremarkable and the pt is discharged home.  Ten days after the accident he follows up at his PCP’s office with a complaint of fatigue, fevers, and yellowing of his skin.  What is the diagnosis?

7. Delayed Hemolytic Transfusion Reaction  Onset of symptoms: 5-10 days after RBC transfusion  S/S: hemolytic anemia, jaundice, fever (can also be asymptomatic)  Life-threatening complications are rare  Confirmation: repeat type and screen to detect alloantibody  Treatment: supportive  Abrupt onset of S/S  S/S: intravascular hemolysis, hypotension, fevers, AKI, pain at the infusion site, DIC, pink plasma or urine  Treatment: stop the transfusion!  Send blood back to blood bank to check for incompatibility, hemolysis  Supportive treatment with IVF, pressors, diuresis Acute Hemolytic Transfusion Reaction http://arimmuneresponseassignment.weebly.com/report.html

8. Case 1 (continued)  Mr Red is now 78 years old. Since we last saw him, he has been diagnosed with diabetes, complicated by ESRD 2/2 diabetic nephropathy for which he is dialyzed three times per week.  He is admitted for a suspected GI bleed for which he is transfused 2 units PRBC. An hour after transfusion, he starts to complain of shortness of breath and chest tightness. HR 120s, BP 180/90, an S3 gallop is noted, and new bibasilar crackles are heard on pulmonary exam. Post-transfusion CXR is shown (was previously normal).  What is the diagnosis? https://www.med-ed.virginia.edu/courses/ rad/cxr/pathology2chest.html

9. Transfusion-Associated Circulatory Overload (TACO)  Risk factors  Patients with limited cardiopulmonary reserve (very young and elderly)  High volume transfusion  History of cardiac or renal disease  Onset: within 1-2 hours after transfusion  S/S: shortness of breath, cough, tachycardia, cyanosis, chest tightness, volume overload (JVD, S3 gallop, peripheral edema)  Tx: supplemental O2, diuretics or other means of removing volume  Prevention: slow administration of blood, pretreatment with diuretics (or blood administration with dialysis) deltaco.com

10. Case 2  Mr Red’s hospital roommate also happens to be a 78 year old male admitted for likely GI bleed. He also underwent transfusion with 2 units PRBC 1 hour ago and reports shortness of breath.  He is febrile to 38.5C, HR 120s, BP 70/40, SpO2 is 85% on RA. New bibasilar crackles are heard on pulmonary exam. Post-transfusion CXR is shown (was normal previously).  What is the diagnosis? https://www.med-ed.virginia.edu/courses/ rad/cxr/pathology2chest.html

11. Transfusion-Related Acute Lung Injury (TRALI)  Onset: during or within 6 hours of transfusion  S/S: hypoxia, dyspnea, fevers, hypotension, pulmonary edema  Treatment: stop the transfusion!  Supportive (may need intubation), O2  Prevention: notify blood bank of reaction thelancet.com

12. TRALI versus TACO Kim et al. 2015.

13. Back to Mr Red…  Mr Red is now 80 years old and is admitted after a fall during which he sustained a left hip fracture. Following surgery, he requires 1 unit PRBC. He is appropriately type and crossmatched, pretreated with acetaminophen, and a slow transfusion is initiated during dialysis. During the transfusion, he develops diffuse urticaria but is otherwise stable.  What is the diagnosis? umm.edu

14. Allergic Reactions and Anaphylaxis  Mild allergic reactions (urticaria) are common, especially in pts who have undergone multiple transfusions  Prevention: pretreat with anti histamines, or wash blood products to remove plasma proteins  Severe anaphylaxis is rare  Mechanism: recipient who is IgA deficient and has anti-IgA antibodies reacts to IgA in donor blood  Prevention: wash all subsequent blood products to remove plasma proteins  If IgA deficient, then only give blood products from IgA deficient donors

15. Summary  It is important to recognize the possible reactions that can be associated with blood transfusions  If you suspect a reaction, stop the transfusion and assess the patient’s vital signs, signs and symptoms as some reactions may be life- threatening  Notify the blood bank if serious reactions are suspected

17. References  Kim J, Na S. Transfusion-related acute lung injury; clinical perspectives. Korean J Anesthesiol. 2015 Apr;68(2):101-5.  MKSAP 16  UpToDate