Transfusion ReactionsJune 2015

ObjectivesBe able to recognize the more common

transfusion reactions

Learn about treatment and prevention of transfusion reactions

Frequency of Transfusion Reactions

Case 1Mr Red is a 17 year old male is brought to the

ER after a motor vehicle accident. He is in pain, tachycardic to 100s, but normotensive.

Given his acute blood loss, transfusion of 2u PRBC is initiated (after appropriate type and cross-matching revealing no antibodies, and compatibility with donor blood).

During transfusion, he develops a fever but otherwise has no new signs or symptoms.

What is the diagnosis?

Febrile Nonhemolytic Transfusion ReactionFevers are common during transfusion

Pathophysiology: likely involves recipient-derived leukoreactive antibodies + donor-derived cytokines

Workup/Treatment: stop the transfusion! Must r/o acute hemolytic transfusion reaction (AHTR) Consider non-transfusion causes of fevers Once AHTR is ruled out, may continue transfusion with

antipyretics

Prevention: antipyretics or leukoreduction of blood products

Case 1 (continued) Mr Red does well following discharge. Fifteen years later

(age 32), however, he is unfortunately in a second MVA. He is brought to the ER, again requiring blood products.

He is type and cross-matched, found to have no antibodies. He is pre-treated with acetaminophen, and transfused 2 units PRBC without issue.

The remainder of his hospital course is unremarkable and the pt is discharged home.

Ten days after the accident he follows up at his PCP’s office with a complaint of fatigue, fevers, and yellowing of his skin.

What is the diagnosis?

Delayed Hemolytic Transfusion Reaction Onset of symptoms: 5-10 days

after RBC transfusion

S/S: hemolytic anemia, jaundice, fever (can also be asymptomatic)

Life-threatening complications are rare

Confirmation: repeat type and screen to detect alloantibody

Treatment: supportive

Abrupt onset of S/S

S/S: intravascular hemolysis, hypotension, fevers, AKI, pain at the infusion site, DIC, pink plasma or urine

Treatment: stop the transfusion! Send blood back to blood bank to

check for incompatibility, hemolysis Supportive treatment with IVF,

pressors, diuresis

Acute Hemolytic Transfusion Reaction

http://arimmuneresponseassignment.weebly.com/report.html

Case 1 (continued) Mr Red is now 78 years old. Since we last

saw him, he has been diagnosed with diabetes, complicated by ESRD 2/2 diabetic nephropathy for which he is dialyzed three times per week.

He is admitted for a suspected GI bleed for which he is transfused 2 units PRBC. An hour after transfusion, he starts to complain of shortness of breath and chest tightness. HR 120s, BP 180/90, an S3 gallop is noted, and new bibasilar crackles are heard on pulmonary exam. Post-transfusion CXR is shown (was previously normal).

What is the diagnosis?

https://www.med-ed.virginia.edu/courses/rad/cxr/pathology2chest.html

Transfusion-Associated Circulatory Overload (TACO) Risk factors

Patients with limited cardiopulmonary reserve (very young and elderly)

High volume transfusion History of cardiac or renal disease

Onset: within 1-2 hours after transfusion

S/S: shortness of breath, cough, tachycardia, cyanosis, chest tightness, volume overload (JVD, S3 gallop, peripheral edema)

Tx: supplemental O2, diuretics or other means of removing volume

Prevention: slow administration of blood, pretreatment with diuretics (or blood administration with dialysis)

deltaco.com

Case 2 Mr Red’s hospital roommate also

happens to be a 78 year old male admitted for likely GI bleed. He also underwent transfusion with 2 units PRBC 1 hour ago and reports shortness of breath.

He is febrile to 38.5C, HR 120s, BP 70/40, SpO2 is 85% on RA. New bibasilar crackles are heard on pulmonary exam. Post-transfusion CXR is shown (was normal previously).

What is the diagnosis?

https://www.med-ed.virginia.edu/courses/rad/cxr/pathology2chest.html

Transfusion-Related Acute Lung Injury (TRALI)

Onset: during or within 6 hours of transfusion

S/S: hypoxia, dyspnea, fevers, hypotension, pulmonary edema

Treatment: stop the transfusion! Supportive (may need intubation),

O2

Prevention: notify blood bank of reaction

thelancet.com

TRALI versus TACO

Kim et al. 2015.

Back to Mr Red…Mr Red is now 80 years old and is admitted

after a fall during which he sustained a left hip fracture. Following surgery, he requires 1 unit PRBC. He is appropriately type and crossmatched, pretreated with acetaminophen, and a slow transfusion is initiated during dialysis. During the transfusion, he develops diffuse urticaria but is otherwise stable.

What is the diagnosis?

umm.edu

Allergic Reactions and AnaphylaxisMild allergic reactions (urticaria) are common,

especially in pts who have undergone multiple transfusions Prevention: pretreat with anti histamines, or wash

blood products to remove plasma proteins

Severe anaphylaxis is rare Mechanism: recipient who is IgA deficient and has

anti-IgA antibodies reacts to IgA in donor blood Prevention: wash all subsequent blood products to

remove plasma proteins If IgA deficient, then only give blood products

from IgA deficient donors

Summary It is important to recognize the possible

reactions that can be associated with blood transfusions

If you suspect a reaction, stop the transfusion and assess the patient’s vital signs, signs and symptoms as some reactions may be life-threatening

Notify the blood bank if serious reactions are suspected

ReferencesKim J, Na S. Transfusion-related acute lung

injury; clinical perspectives. Korean J Anesthesiol. 2015 Apr;68(2):101-5.

MKSAP 16

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