Difference between revisions of "Acute transfusion reaction"

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==Background==
 
==Background==
#For all reactions:
+
*If concern for fluid overload, may need to transfuse as split pRBCs to tranfuse as slow as 1mL/kg/hr
##Stop the transfusion (at least temporaily)
+
*Sepsis is most commonly due to [[yersinia]], which is able to grow easily in refrigerated blood
##Call the blood bank
 
##Draw a new type + screen
 
  
== Acute ==
+
{{Transfusion risk}}
===Intravascular Hemolytic Tranfusion Reaction===
 
#Occurs due to ABO incompatibility
 
#Diagnosis
 
##Back pain, headache, hypotension, dyspnea, pulmonary edema, bleeding, renal failure
 
##Labs c/w hemolysis
 
#Treatment
 
##Stop transfusion
 
###Risk of death is proportional to amount of incompatible blood received
 
##Maintain urine output with IVF, mannitol, and furosemide as needed
 
##Treat shock with volume and vasopressors
 
##Treat coagulopathy w/ FFP
 
===Febrile Nonhemolytic Tranfusion Reaction===
 
#Occurs in 20% of pts due to recipient Ab against donor leukocytes
 
#Diagnosis
 
##Fever, HA, myalgias, tachycardia, dyspnea, chest pain
 
#Treatment
 
##Stop tranfusion pending rule-out of hemolytic transfusion reaction
 
##Give antipyretic
 
##Restart transfusion once hemolytic transfusion reaction is ruled-out
 
===Allergic Tranfusion Reaction===
 
#Occurs due to immune response to plasma proteins
 
#Diagnosis
 
##Symptoms range from urticaria/pruritus to bronchospasm, wheezing, anaphylaxis (rare)
 
#Treatment
 
##Stop transfusion until able to evaluate severity of allergic reaction
 
##Give diphenhydramine
 
##Restart transfusion if symptoms are mild
 
===Transfusion-associated circulatory overload (TACO)===
 
#Often confused with TRALI
 
#Associated with a rapid rise in blood pressure, not hypotension
 
#Diagnosis
 
##Dyspnea, orthopnea, peripheral edema, rapid rise in BP
 
#Treatment
 
##O2, supportive care, diuretics
 
===Transfusion-Related Acute Lung Injury (TRALI)===
 
#Due to granulocyte recruitment and degranulation within the lung
 
#More common with FFP and plt transfusions (extremely rare with pRBC transfusion alone)
 
##pRBCs do contain residual plasma and can have TRALI
 
#Time Frame: abrupt to within 6 hours of transfusion initiation
 
#Diagnosis
 
##ARDS-like symptoms
 
##B/l pulmonary infiltrates due to noncardiogenic pulmonary edema w/in 6h of transfusion
 
#Treatment
 
##Strop transfusion
 
##Treat like ARDS
 
##Avoid diuresis
 
  
===Fluid Overload===
+
==Clinical Features==
#Split pRBCs to tranfuse more slowly (as slow as 1mL/kg/hr)
+
*Etiology specific, see ddx below
===Sepsis===
 
#Most commonly due to yersinia which is able to grow easily in refrigerated blood
 
== Delayed ==
 
===Extravascular Hemolytic Tranfusion Reaction===
 
#Occurs days to weeks after transfusion
 
#Hemolysis occurs in spleen, liver, and bone marrow
 
#Diagnosis
 
##Hyperbilirubinemia
 
##Poor response to transfusion
 
#Treatment
 
##None necessary; rarely fatal
 
===Graft-vs-Host Disease===
 
*Acute vs Chronic
 
**Acute: 1-12 weeks post graft
 
**Chronic: >12 weeks
 
#Transplanted graft with immunologically competent cells stimulated by host antigens and host is incapable of mounting an effective immunologic response
 
#Occurs in leukemia/lymphoma or immunocompromised
 
#Diagnosis
 
##Nonspecific rash, mucositis, fever, and diarrhea
 
##LFT abnormalities, pancytopenia
 
#Treatment
 
##Glucocorticoids
 
  
== Transfusion Risk Ratios ==
+
==Differential Diagnosis==
#1:10 Febrile non-hemolytic transfusion reaction per pool of 5 donor units of platelets (1 pack)
+
{{Transfusion reaction types}}
#1:100 Minor allergic reactions (urticaria)
+
 
#1:300 Febrile non-hemolytic transfusion reaction per unit of RBC (1 pack)
+
{{Acute Allergic DDX}}
#1:700 Transfusion-associated circulatory overload per transfusion  episode
+
 
#1:5000 Transfusion-related acute lung injury (TRALI)
+
==Evaluation==
#1:7000 Delayed hemolytic transfusion reaction
+
*Workup of hemolytic reaction
#1:10,000 Symptomatic bacterial sepsis per pool of 5 donor units of platelets
+
**CBC with microscopy differential
#1:40,000 Death from bacterial sepsis per pool of 5 donor units of platelets
+
**Formal urinalysis with bilirubin
#1:40,000 ABO-incompatible transfusion per RBC transfusion episode
+
**Haptoglobin, LDH, free hemoglobin
#1:40,000 Serious allergic reaction per unit of component
+
**Serum total and direct bilirubin
#1: 82,000 Transmission of hepatitis B virus per unit of component
+
**Coombs test of pre-transfusion and post-transfusion blood
#1:100,000 Symptomatic bacterial sepsis per unit of RBC
+
[[File:Coombs.png|thumbnail]]
#1:500,000 Death from bacterial sepsis per unit of RBC
+
*Consider CXR to help differentiate anaphylaxis, TRALI, TACO
#1:1,000,000 Transmission of West Nile Virus
+
{{TRALI vs TACO}}
#1:3,000,000 Transmission of HTLV per unit of component
+
 
#1:3,100,000 Transmission of hepatitis C virus per unit of component
+
==Management==
#1:4,700,000 Transmission of HIV per unit of component
+
*For all reactions:
 +
**Stop the transfusion (at least temporarily)
 +
**Call the blood bank
 +
**Draw a new type + screen
 +
 
 +
==Disposition==
  
 
==See Also==
 
==See Also==
[[Transfusions]]
+
{{Transfusion reactions see also}}
  
== Source  ==
+
==References==
*Tintinalli
+
<references/>
*Canadian Blood Services (Public Health Agency of Canada)
 
  
 
[[Category:Heme/Onc]]
 
[[Category:Heme/Onc]]

Latest revision as of 14:25, 19 September 2017

Background

  • If concern for fluid overload, may need to transfuse as split pRBCs to tranfuse as slow as 1mL/kg/hr
  • Sepsis is most commonly due to yersinia, which is able to grow easily in refrigerated blood

Transfusion Risk Ratios[1]

Rate Complication
1:10 Febrile non-hemolytic transfusion reaction per pool of 5 donor units of platelets (1 pack)
1:100 Minor allergic reactions (urticaria)
1:300 Febrile non-hemolytic transfusion reaction per unit of RBC (1 pack)
1:700 Transfusion-associated circulatory overload per transfusion episode
1:5,000 Transfusion-related acute lung injury (TRALI)
1:7,000 Delayed hemolytic transfusion reaction
1:10,000 Symptomatic bacterial sepsis per pool of 5 donor units of platelets
1:40,000 Death from bacterial sepsis per pool of 5 donor units of platelets
1:40,000 ABO-incompatible transfusion per RBC transfusion episode
1:40,000 Serious allergic reaction per unit of component
1:82,000 Transmission of hepatitis B virus per unit of component
1:100,000 Symptomatic bacterial sepsis per unit of RBC
1:500,000 Death from bacterial sepsis per unit of RBC
1:1,000,000 Transmission of West Nile Virus
1:3,000,000 Transmission of HTLV per unit of component
1:3,100,000 Transmission of hepatitis C virus per unit of component
1:4,700,000 Transmission of HIV per unit of component

Clinical Features

  • Etiology specific, see ddx below

Differential Diagnosis

Transfusion Reaction Types

Acute allergic reaction

Evaluation

  • Workup of hemolytic reaction
    • CBC with microscopy differential
    • Formal urinalysis with bilirubin
    • Haptoglobin, LDH, free hemoglobin
    • Serum total and direct bilirubin
    • Coombs test of pre-transfusion and post-transfusion blood
Coombs.png
  • Consider CXR to help differentiate anaphylaxis, TRALI, TACO

TRALI vs TACO

TRALI TACO
Onset Acute, within 6hrs Often more gradual
BP Low High
Temp Febrile Normal
JVD/pedal edema Unlikely Likely
CVP/PAWP Normal Elevated
BNP Normal Elevated
Resp Dyspneic Dyspneic
CXR B/l infiltrates B/l infiltrates

Management

  • For all reactions:
    • Stop the transfusion (at least temporarily)
    • Call the blood bank
    • Draw a new type + screen

Disposition

See Also

References

  1. Wagner, L. Why Should Clinicians Be Concerned about Blood Conservation? ITACCS. 2005 PDF