Acute transfusion reaction

Background

Transfusion Risk Ratios

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

Differential Diagnosis

Transfusion Reaction Types

• Acute
  • Intravascular hemolytic tranfusion reaction
  • Febrile nonhemolytic tranfusion reaction
  • Allergic tranfusion reaction
  • Transfusion-associated circulatory overload (TACO)
  • Transfusion-related acute lung injury (TRALI)
  • Transfusion-associated graft-versus-host disease
  • Fluid overload
  • Sepsis
• Delayed
  • Extravascular hemolytic tranfusion reaction
  • Graft-vs-host disease
  • Transfusion infections

Acute

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
• 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

	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

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 reaction

• Allergic reaction/urticaria
• Anaphylaxis
• Angioedema
• Anxiety attack
• Asthma exacerbation
• Carcinoid syndrome
• Cold urticaria
• Contrast induced allergic reaction
• Scombroid
• Shock
• Transfusion reaction

Management

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

See Also

• Transfusions
• Acute transfusion reaction
• Extravascular hemolytic tranfusion reaction
• Graft-vs-host disease

References

• Canadian Blood Services (Public Health Agency of Canada)