1. Lecture 7 blood bank BLOOD TRANSFUSION REACTION Non immunological Dr. Dalia Galal

2. Transfusion reaction: Any unfavorable response by a patient that occurs as a result of the transfusion of blood or blood products. Transfusion reactions can be divided into 1. Hemolytic types It is the occurrence of abnormal destruction of red cells of either the donor or recipient following the transfusion of incompatible blood. 2. Non-hemolytic types. Are not usually associated with erythrocyte (red cells) hemolysis. It may cause due to:  Shortened post transfusion survival of erythrocytes  Febrile reactions (caused by leukocytes or platelet antibodies present in the recipient’s plasma that react with the antigen present on the cell membrane of transfused leukocytes or platelates)  Allergic response  Disease transmission.

3. Transfusion reactions can be further classified into: Acute (immediate) hemolytic reactions The most serious and potentially lethal Occur during or immediately after blood has been transfused Most commonly are caused by Ag-Ab reaction between the patient’s serum and the donor’s red cells and vice versa, of transfusing ABO incompatible blood Delayed hemolytic reactions The transfusion reaction is delayed due to weak antibody in the recipient 7 to 10 days of post transfusion. In most cases, the patient has been primarily immunized by previous transfusion or pregnancy. The antibody is too weak to be detected in routine cross-match, but becomes detectable 3 to 7 days after transfusion, eg. Antibodies of the Rh system & kidd system.

4. Factors influence whether a transfusion reaction will be acute or delayed: 1. Antibody concentration 2. Class or subclass of antibodies 3. Ability of antiboidy to fix complement 4. Temperature of activitiy of red cells 5. Concentration of red cell antigen infused

5. Most of fatal transfusion reactions result from: 1. Mis-identification of patients 2. Mis-labeling of blood sample 3. Error in laboratory records 4. Mistake in blood typing 5. Inaccurate cross-matching. Laboratory tests to be done when transfusion reaction occurs: - Check the identification of the patient and transfused unit - Obtain a post transfusion specimen from the patient and visually examine it for hemolysis - Direct Antiglobulin test from post transfusion sample, taken as soon as possible after the reaction has taken place. - Re-type the red cells of both donor and recipient for ABO and Rh grouping. - Re-cross match blood from each unit transfused using serum from both pre- and post-transfusion specimens from the patient.

6. Non immunological transfusion reaction 1. Bacterial contamination reactions. 2. Circulatory overload. 3. Transfusion haemosiderosis. 4. Complications of massive transfusion. 5. Non immune hemolytic reaction 6. Disease transmission.

7. 1. Bacterial contamination reaction. This type of specific reaction can have a rapid onset and high mortality in recipients. The presence of bacteria in transfused blood may lead either to febrile reactions in the recipient or serious symptoms of septic or endotoxic shock. Commonly caused by endotoxin produced by bacteria capable of growing in cold temperatures such as Pseudomonas species, E. coli, Yersinia enterocolitica.

8. Source of infection. Infection of stored blood is extremely rare. Skin contaminants are not infrequently present in freshly donated blood but these organisms (predominantly staphylococci ) do not survive storage at 4 º C although they will grow freely in platelet concentrates stored at 22 º C. Healthy donor who are bacteremic at the time of donation. The majority are due to Yersinia enterocolitica, which grows well in red cell components due to its dependence on citrate and Iron. Gram negative, endotoxin – producing contaminants found in dirt, soil and faeces may rarely grow in the storage condition of blood.

9. Clinical manifestation Usually appear rapidly during transfusion or within about 30 minutes after transfusion with dryness, reddening of skin. Fever, Hypotension, Chills, Muscle pain, vomiting, Abdominal cramps, Bloody diarrhea, Hemoglobinuria, Shock and Renal failure.

10. Management. Rapid recognition is essential Immediately stop the transfusion. Therapy of shock, steroids, vassopressors, fluid support, respiratory ventilation and maintenance of renal function. Broad spectrum intravenous (IV) antibiotics The blood component unit and any associated fluids and transfusion equipment should be sent immediately to blood bank for investigation ie: gram stain and culture.

11. Prevention Strict adherence to policies & procedures regarding blood component collection, storage, handling, and preparation is essential to reduce the risk. Visual examination of components before release from the transfusion service include any discolouration, visible clots, or hemolysis. Ensure the blood components are infused within standard time limits ( 4 hours ).

12. Prevention (conti.) Blood containers should never be opened for sampling, if any open method of preparation has been used, the unit should be transfused within 24 hours. Blood should always be kept in accurately controlled refrigerators (with alarms), maintained strictly at 2 – 6 º C, the blood should never be removed and taken to the ward or NOT until it is required.

13. 2. Circulatory overload All patient will experience a temporary rise in blood volume and venous pressure following the transfusion of blood or plasma except for those who are actively bleeding. However, young people with normal cardiovascular function will tolerate this changes provided it is not excessive. Pregnant women, patient with severe anaemia, elderly with compromised cardiovascular function will not tolerate the increase in plasma volume and acute pulmonary oedema may develop.

14. Clinical manifestation Frequently due to transfusion of a unit at too fast rate. Signs of cardiac failure – basal crepitations in both lungs, dry cough, breathlessness.

15. Management Stop the transfusion immediately. Prop up the patient Oxygen therapy Intravenous diuretics should be used appropriately. If more rapid volume reduction is needed, therapeutic phlebotomy can be used.

16. Prevention Packed cell should be used instead of whole blood. Packed cells should be given slowly over 4 hours.The usual rate of transfusion is about 200 ml per hour. In patient at risk rate of 100 ml per hour or less are appropriate. Diuretics should be given at the start of the transfusion and only one or two units of concentrated red cells should be transfused in any 24 hour period. Blood transfusion should be given during the daytime, Overnight transfusion should be avoided wherever possible.

17. 3. Transfusion haemosiderosis A complication of repeated long term blood transfusion. Most commonly seen in thalassaemic patient. Each unit of blood has about 200 mg of iron, while the daily excretion rate is about 1 mg. The body has no way of excreting the excess unless the patient is bleeding. Assessment of storage iron levels such as ferritin levels should be done.

18. The use of Iron chelating agent, Desferrioxamine does not completely overcome the Iron load, but has delayed the onset of problems due to haemosiderosis. Transfusion of neocytes or young red cells is the other alternative. However, it is expensive, time consuming, and the result are not as favourable as expected.

19. 4. Complication of massive transfusion Massive transfusion is defined as the replacement of total blood volume within a 24 hour period. This will inevitably lead to : 1. Dilution of platelets. Blood effectively has no functional platelets after 48 hours storage, after 8 to 10 units of blood transfusion, thrombocytopenia will usually seen. Bleeding due to a slightly low platelet is uncommon, therefore routine administration of platelet after certain amount of blood transfusion is unnecessary. Regular monitoring of platelet count is more important. Platelet transfusion may be required if platelet count <100 x 10 9 /L with continuous bleeding or surgical intervention.

20. 2. Dilution of coagulation factors. Stored Whole blood < 14 days has adequate levels of most coagulation factors for haemostasis. If stored blood of more than 14 days, or plasma reduced blood or red cells in optimal additive solution is used, replacement of coagulation factors with FFP is necessary. 3. Hypothermia ( defined as core body temperature less than 35 0 c ) is associated with large volumes of cold fluid transfusion. This may results in cardiac irregularities in particular Ventricular Fibrillation (VF) (uncoordinated contraction of the cardiac muscle of the ventricles in the heart. Therefore the use of blood warmer is important.

21. 4. Excess citrate can act on the patient’s plasma free ionized calsium and results in hypocalcaemia ( transient ). Citrate toxicity occur with extremely rapid transfusion ( one unit every 5 minute ), in premature infant having ET with blood stored in citrate for longer than 5 days. 5. Hyperkalemia Can be caused by intracellular loss of potassium from RBC during storage or infusion of intracellular potassium depleted RBC blood components such as washed RBC or frozen washed RBC.

22. The most important consideration in massive blood transfusion is to replace blood loss quickly and adequately. Too little blood, too late has more serious consequences than massive blood transfusion itself.

23. 5.Non immune hemolytic reaction Mechanical – heat damage from blood warmer, cold, small gauge needle. Environment – hypotonic or hypertonic solution.

24. 6. Disease transmission. Hepatitis Syphilis Malaria Cytomegalovirus Human immunodeficiency virus Human T cell leukaemia viruses. Donor selection criteria and subsequent screening of all donations are designed to prevent disease transmission, but these do not completely eliminate the hazards.