1. Blood Transfusion Reactions Col.Dr.Mohamed H Khalaf,MD Head, Department of Haematology Maadi A F Medical Compound Blood Transfusion Reactions Col.Dr.Mohamed H Khalaf,MD Head, Department of Haematology Maadi A F Medical Compound

2. Blood Transfusion Reactions Haemovigilance Serious Hazards of Transfusion ( SHOT )

3. Blood Transfusion Reactions Haemovigilance Serious Hazards of Transfusion ( SHOT ) 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

4. Blood Transfusion: Immediate Reactions 1.Acute Haemolytic Transfusion Reactions 2.Febrile Non-Haemolytic Transfusion Reactions 3.Allergic Reactions: 1.Anaphylaxis 2.Skin Reaction 4.Transfusion-related Acute Lung Injury 5.Bacterial Contamination 6.Circulatory Overload 7.Citrate Intoxication

5. Blood Transfusion: Delayed Reactions 1.Delayed Haemolytic Transfusion Reactions 2.Post- transfusion Purpura 3.Infection Transmission 4.Transfusion-related Graft-versus-Host Disease 5.Immune Modulation 6.Iron Overload

6. Immediate Blood Transfusion Reactions: Acute Haemolytic Transfusion Reactions Intra-vascular Extra-vascular

7. 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

8. 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 – ATN 4.DIC

9. 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

10. Immediate Blood Transfusion Reactions: Acute Intra-vascular Haemolytic Transfusion Reactions Diagnosis Clinical picture Transfusion Mistake Red urine Red plasma Lab Confirmation

11. 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

12. 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 and prevent renal VC)

13. Immediate Blood Transfusion Reactions: Acute Intra-vascular Haemolytic Transfusion Reactions Management Saline Diuresis If urine < 1.5 ml/kg/h + Low CVP: More Fluid If urine < 1.5 ml/kg/h + Normal CVP: –Fluid Challenge + 80 -120 mg Frusemide + Renal dose Dopamine ( 1-2 ug/kg/min) If No response: Consult Nephrologist

14. Immediate Blood Transfusion Reactions: Acute Intra-vascular Haemolytic Transfusion Reactions Outcome Mortality ~ 10 %

15. 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

16. 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

17. 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

18. Immediate Blood Transfusion Reactions: Acute Extra-vascular Haemolytic Transfusion Reactions Laboratory Anti-complementary Coombs positive

19. Immediate Blood Transfusion Reactions: Acute Extra-vascular Haemolytic Transfusion Reactions Managment Stop Transfusion Supportive Mortality very rare

20. 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

21. Immediate Blood Transfusion Reactions: Febrile Non-Haemolytic Transfusion Reaction ( FNHTR) Pathophysiology Cytokine released from the transfused activated leucocytes

22. Immediate Blood Transfusion Reactions: Febrile Non-Haemolytic Transfusion Reaction ( FNHTR) Clinical Features Fever after 30-90 min + Rigors + Headache No Hypotension No Bronchospasm No flank pain No haemoglobinaemia No Haemoglobinuria

23. Immediate Blood Transfusion Reactions: Febrile Non-Haemolytic Transfusion Reaction ( FNHTR) Management If Temp < 40 + Stable patient: –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

24. 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

25. Immediate Blood Transfusion Reactions: Transfusion- Related Acute Lung Injury ( TRALI) Sudden onset of acute respiratory distress within 6 hours( u. 1-2h) of transfusion

26. Immediate Blood Transfusion Reactions: Transfusion- Related Acute Lung Injury ( TRALI) Rare: 1/5000 transfusions

27. 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

28. Immediate Blood Transfusion Reactions: Transfusion- Related Acute Lung Injury ( TRALI) Clinical Features Fever, chills Acute Respiratory Distress Normal CVP CXR: Pulmonary Infiltrate

29. Immediate Blood Transfusion Reactions: Transfusion- Related Acute Lung Injury ( TRALI) Management Cardio-Pulmonary Support Steroids Diuretics of No value Mortality High

30. Immediate Blood Transfusion Reactions: Allergic Acute Transfusion Reactions Pathophysiology Trigger: Plasma proteins in the transfused blood Reactors: Patient antibodies of IgE type Response: –Mast cell degranulation –+ Complement Activation –+ Cytokines

31. Immediate Blood Transfusion Reactions: Allergic Acute Transfusion Reactions Clinical Features Mild / Skin-restricted ( common: 1%): – Pruritus, Uerticaria, No fever or Hypotension Severe / Systemic ( Anaphylaxis): – As above + –Fever –Hypotension –Bronchospasm, Angio-edema

32. Immediate Blood Transfusion Reactions: Allergic Acute Transfusion Reactions Management Mild / Skin-restricted : – Stop transfusion temporary –Anti-histamines –Resume Transfusion

33. 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

34. Immediate Blood Transfusion Reactions: Acute Pyrogenic Transfusion Reactions Pathophysiology Trigger: Bacterial Pyrogens/Endotoxins in the transfused blood contaminated with cold-growing organisms as: –Psudomonas –Yersinia –Some Staph Reactors: Patient Mono-nuclear cells Response: –Cytokine Storm

35. Immediate Blood Transfusion Reactions: Acute Pyrogenic Transfusion Reactions Clinical Features Like : Acute Haemolytic reaction BUT: –No Hemoglobinuria –No Hemoglobinaemia FNHTR BUT More Severe

36. Immediate Blood Transfusion Reactions: Acute Pyrogenic Transfusion Reactions Management As Acute Haemolytic reaction BUT Add Broad- spectrum Antibiotics

37. Immediate Blood Transfusion Reactions: Acute Circulatory Overload Acute cardiogenic pulmonary edema In rapidly transfused, non-bleeding ( euovolemic) patiens More in infants, elderly or cardiac patients

38. 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)

39. 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 Diuretics + Inotropics Consider Haemodialysis Supportive

40. Other Immediate Blood Transfusion Reactions: Other Immediate Blood Transfusion Reactions: Hypothermia Citrate Intoxication

41. Delayed Blood Transfusion Reactions 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

42. Massive Blood Transfusion Massive Blood Transfusion

43. Definition Transfusion of Blood ~ Blood Volume within 24 hours 20 units whole blood 10 units packed cells

44. Massive Blood Transfusion Massive Blood Transfusion Complications Dilutional Thrombocytopenia Dilutional Coagulopathy Metabolic Hypothermia

45. Massive Blood Transfusion Massive Blood Transfusion Complications Dilutional Thrombocytopenia Common after 10 units Severe after 20 units Give platelet transfusion if < 80,000 + bleeding

46. Massive Blood Transfusion Massive Blood Transfusion Complications Dilutional Coagulopathy Particularily if blood stored > 2 weeks Monitor Coagulation profile FFP if Abnormal lab DIC is Rare

47. Massive Blood Transfusion Massive Blood Transfusion Complications Metabolic : Citrate Intoxication Acidosis, Hypocalacemia, Hyperkalaemia Rare Except in Infants or Hepatic patients