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
**1. Stop the transfusion (at least temporaily)
+
*Sepsis is most commonly due to [[yersinia]], which is able to grow easily in refrigerated blood
**2. Call the blood bank
+
 
**3. Draw a new type + screen
+
{{Transfusion risk}}
 +
 
 +
==Clinical Features==
 +
*Etiology specific, see ddx below
 +
 
 +
==Differential Diagnosis==
 +
{{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
 
####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-Related Acute Lung Injury (TRALI)
 
##Due to granulocyte recruitment and degranulation within the lung
 
##More common with FFP and plt tranfusions (extremely rare with pRBC transfusion alone)
 
##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
 
##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 ==
+
==Evaluation==
#Extravascular Hemolytic Tranfusion Reaction
+
*Workup of hemolytic reaction
##Occurs days to weeks after transfusion
+
**CBC with microscopy differential
##Hemolysis occurs in spleen, liver, and bone marrow
+
**Formal urinalysis with bilirubin
##Diagnosis
+
**Haptoglobin, LDH, free hemoglobin
###Hyperbilirubinemia
+
**Serum total and direct bilirubin
###Poor response to transfusion
+
**Coombs test of pre-transfusion and post-transfusion blood
##Treatment
+
[[File:Coombs.png|thumbnail]]
###None necessary; rarely fatal
+
*Consider CXR to help differentiate anaphylaxis, TRALI, TACO
#Graft-vs-Host
+
{{TRALI vs TACO}}
##Occurs in leukemia/lymphoma or immunocompromised
 
##Diagnosis
 
###Fever, rash, N/V
 
###LFT abnormalities, pancytopenia
 
##Treatment
 
###Glucocorticoids
 
#Hemosiderosis
 
  
== Transfusion Risk Ratios ==
+
==Management==
 +
*For all reactions:
 +
**Stop the transfusion (at least temporarily)
 +
**Call the blood bank
 +
**Draw a new type + screen
  
#1:10 Febrile non-hemolytic transfusion reaction per pool of 5 donor units of platelets (1 pack)
+
==Disposition==
#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
 
#1:5000 Transfusion-related acute lung injury (TRALI)
 
#1:7000 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
 
  
 +
==See Also==
 +
{{Transfusion reactions see also}}
  
== Source  ==
+
==References==
#2/18/06 DONALDSON (adapted from Rosen)
+
<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