Acute transfusion reaction: Difference between revisions

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==Background==
==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}}
{{Transfusion risk}}


== Acute ==
==Clinical Features==
===Intravascular Hemolytic Tranfusion Reaction===
*Etiology specific, see ddx below
*Occurs due to ABO incompatibility
 
*Diagnosis
==Differential Diagnosis==
**Back pain, headache, hypotension, dyspnea, pulmonary edema, bleeding, renal failure
{{Transfusion reaction types}}
**Labs c/w hemolysis
 
*Treatment
{{Acute Allergic DDX}}
**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===
==Evaluation==
*Split pRBCs to tranfuse more slowly (as slow as 1mL/kg/hr)
*Workup of hemolytic reaction
===Sepsis===
**CBC with microscopy differential
*Most commonly due to yersinia which is able to grow easily in refrigerated blood
**Formal urinalysis with bilirubin
== Delayed ==
**Haptoglobin, LDH, free hemoglobin
===Extravascular Hemolytic Tranfusion Reaction===
**Serum total and direct bilirubin
*Occurs days to weeks after transfusion
**Coombs test of pre-transfusion and post-transfusion blood
*Hemolysis occurs in spleen, liver, and bone marrow
[[File:Coombs.png|thumbnail]]
*Diagnosis
*Consider CXR to help differentiate anaphylaxis, TRALI, TACO
**Hyperbilirubinemia
{{TRALI vs TACO}}
**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


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