Difference between revisions of "Acute transfusion reaction"

(Transfusion-Related Acute Lung Injury (TRALI))
(Management)
 
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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}}
 +
 +
==Clinical Features==
 +
*Etiology specific, see ddx below
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
 
{{Transfusion reaction types}}
 
{{Transfusion reaction types}}
  
== Acute ==
+
{{Acute Allergic DDX}}
===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
 
**Replace all tubing
 
***Risk of death is proportional to amount of incompatible blood received
 
**Maintain urine output with IVF (1-2 mL/kg/hr), mannitol, and furosemide as needed
 
**Treat shock with volume and vasopressors
 
**Treat coagulopathy w/ FFP
 
  
===Febrile Nonhemolytic Tranfusion Reaction===
+
==Evaluation==
*Occurs in 20% of pts due to recipient Ab against donor leukocytes
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*Workup of hemolytic reaction
*Diagnosis
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**CBC with microscopy differential
**Fever, HA, myalgias, tachycardia, dyspnea, chest pain
+
**Formal urinalysis with bilirubin
*Treatment
+
**Haptoglobin, LDH, free hemoglobin
**Stop tranfusion pending rule-out of hemolytic transfusion reaction
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**Serum total and direct bilirubin
**Give antipyretic
+
**Coombs test of pre-transfusion and post-transfusion blood
**Restart transfusion once hemolytic transfusion reaction is ruled-out
+
[[File:Coombs.png|thumbnail]]
===Allergic Tranfusion Reaction===
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*Consider CXR to help differentiate anaphylaxis, TRALI, TACO
*Occurs due to immune response to plasma proteins
+
{{TRALI vs TACO}}
*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
 
*Frequently with rapid admin and large volume transfusions
 
*Associated with a rapid rise in blood pressure, not hypotension
 
*Diagnosis
 
**Dyspnea, orthopnea, peripheral edema, rapid rise in BP
 
**BNP or NT-proBNP to differentiate from other lung injury
 
*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
 
 
 
{| class="wikitable"
 
| align="center" style="background:#f0f0f0;"|''' '''
 
| align="center" style="background:#f0f0f0;"|'''TRALI'''
 
| align="center" style="background:#f0f0f0;"|'''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
 
|}
 
 
 
===Fluid Overload===
 
*Split pRBCs to tranfuse more slowly (as slow as 1mL/kg/hr)
 
 
 
===Sepsis===
 
*Most commonly due to yersinia which is able to grow easily in refrigerated blood
 
== Delayed ==
 
===[[Extravascular hemolytic tranfusion reaction]]===
 
 
 
 
 
===[[Graft-vs-host disease]]===
 
 
 
==Differential Diagnosis==
 
{{Acute Allergic DDX}}
 
  
 
==Management==
 
==Management==
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**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}}
  
== References ==
+
==References==
*Canadian Blood Services (Public Health Agency of Canada)
 
 
<references/>  
 
<references/>  
  
 
[[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