Acute transfusion reaction

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Background

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

Acute

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

  • 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

  • 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

Management

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

See Also

Source

  • Tintinalli
  • Canadian Blood Services (Public Health Agency of Canada)
  • Wagner, L. Why Should Clinicians Be Concerned about Blood Conservation? ITACCS. 2005 PDF