Detaield aggregation of notes about blood transfusion reactions in human body along with the precations and management.

1. Blood Transfusion
Reactions
By : Mohammed Al-Shalfi
Dental School – Ibb University

2. Outline :
• What is a blood transfusion ?
• What is blood transfusion reactions ?
• Causes of acute complications of transfusion .
• Blood transfusion reaction symptoms .
• Investigation .
• Blood transfusion reaction treatment and management .
• Delayed complications of transfusion .
• Surveillance and reporting ..
• Massive transfusion
• Case Study

3. Summary :
• Blood transfusions can be life-saving in
the appropriate setting. The vast majority
of transfusions are completed without
incident, but every transfusion recipient
is at risk of a variety of adverse events
(termed transfusion reactions) that can
occur during, shortly after or long after
the transfusion. Most transfusion
reactions are diagnosed by exclusion;
thus, any significant change in a patient's
condition during transfusion should
prompt an investigation. Successful
investigation of a transfusion reaction
depends on detailed observation,
documentation and reporting of the
patient's vital signs, before and after the
transfusion, and the signs and symptoms
that prompted the investigation.

4. • What is a blood transfusion ? (1)
• Blood transfusions are most commonly done for blood
components, such as red blood cells, platelets, or plasma.
Before a blood transfusion, a medical provider will draw
your blood. This sample will be sent to a laboratory for
typing and crossmatching. Typing is when the lab
determines blood type. Crossmatching is testing to
determine if your blood is compatible with a donor’s blood
of the same type.
• Knowing your blood type is important because red blood
cells contain antigens, or protein markers, corresponding
to these blood types. If a laboratory gives you the wrong
type of blood, your immune system will detect any foreign
proteins on the red blood cells of the wrong blood type
and attempt to destroy them.
• Blood banks have thorough testing processes to make
sure blood is safe and correctly typed for use. A doctor or
nurse will explain any risks of blood transfusions to you
and will closely monitor you while you’re receiving the
blood.

5. What is a blood transfusion ? (2)
• Blood transfusion can be life-saving and provides great clinical
benefit to many patients but it is not without risks[:
• Immunological complications.
• Errors and 'wrong blood' episodes - the Serious Hazards of
Transfusion (SHOT) report for the UK documented that an
error incidence of 2,623 of just over 2 million components
transfused in 2020 .
• Infections (bacterial, viral, possibly prion).
• Immunomodulation.
• Litigation.
• Growing awareness of avoidable risk, and improved reporting
systems, have led to a culture of better safety procedures as
well as steps to minimize the use of transfusion. The reporting
rate of transfusion errors is improving although un-reporting of
some serious adverse reactions still occasionally occurs.
• Alternative approaches to patient management should be
used to reduce or eliminate the need for transfusion whenever
possible

6. What is blood transfusion reactions ?
• Transfusion reactions are defined as adverse events associated with the transfusion of whole blood or one of its
components. These may range in severity from minor to life-threatening. Reactions can occur during the transfusion
(acute transfusion reactions) or days to weeks later (delayed transfusion reactions) and may be immunologic or non-
immunologic. A reaction may be difficult to diagnose as it can present with non-specific, often overlapping symptoms.

7. Causes of acute complications of transfusion
(1)
• Acute haemolytic transfusion reaction
• Incompatible transfused red cells react with the patient's own
anti-A or anti-B antibodies or other alloantibodies (eg, anti-
rhesus (Rh) D, RhE, Rhc and Kell) to red cell antigens.
Complement can be activated and may lead to disseminated
intravascular coagulation (DIC).
• Infusion of ABO incompatible blood almost always arises from
errors in labelling sample tubes/request forms or from
inadequate checks at the time of transfusion. Where red cells
are mistakenly administered, there is about a 1 in 3 risk of ABO
incompatibility and 10% mortality with the severest reaction
seen in a group O individual receiving group A red cells.
• Non-ABO red cell antibody haemolytic reactions tend to be less
severe but the Kidd and Duffy antigens also activate
complement and can cause severe intravascular haemolysis.

8. Causes of acute complications of transfusion
(2)
• Infective shock
• Bacterial contamination of a blood
component is a rare but severe and
sometimes fatal cause of
transfusion reactions.
• Acute onset of hypertension or hypotension,
rigors and collapse rapidly follows the
transfusion.
• No UK cases of bacterial contamination of
blood products were confirmed by SHOT in
2020.
• Platelets are more likely to be associated
with bacterial contamination than red cells,
as they are stored at a higher temperature.

9. Causes of acute complications of transfusion
(3)
• Transfusion-related acute lung injury (TRALI)
• TRALI is a form of acute respiratory distress due to donor
plasma containing antibodies against the patient's
leukocytes.
• Transfusion is followed within six hours of transfusion by
the development of prominent nonproductive cough,
breathlessness, hypoxia and frothy sputum. Fever and
rigors may be present.
• CXR shows multiple perihilar nodules with infiltration of
the lower lung fields.
• Implicated donors are usually multiparous women (who
are more likely to have become alloimmunised) and
should be removed from the blood panel where possible.
Gas exchange was significantly worse after transfusion of
female but not male donor blood products in one study of
high plasma volume transfusions in the critically ill.

10. Causes of acute complications of transfusion
(4)
• Fluid overload
• Fluid overload occurs when too much fluid is
transfused or too quickly, leading to pulmonary
oedema and acute respiratory failure.
• Patients at particular risk are those with chronic
anaemia who are normovolaemic or hypervolaemic
and those with symptoms of cardiac failure prior
to transfusion.
• These patients should receive packed cells rather
than whole blood via slow transfusion, with
diuretics if required.

11. Causes of acute complications of transfusion
(5)
• Fevers (>1°C above baseline) and rigors may develop during red cell
or platelet transfusion due to patient antibodies to transfused white cells.
• This type of reaction affects 1-2% of patients.
• Multiparous women and those who have received multiple
previous transfusions are most at risk. Reactions are unpleasant but not life-
threatening. Usually symptoms develop towards the end of a transfusion or
in the subsequent two hours. Most febrile reactions can be managed by
slowing or stopping the transfusion and giving paracetamol.

12. Causes of acute complications of transfusion
(6)
• Severe allergic reaction or anaphylaxis
• Allergic reactions occur when patients have antibodies that react with proteins in transfused
blood components.
• Anaphylaxis occurs where an individual has previously been sensitised to an allergen present
in the blood and, on re-exposure, releases immunoglobulin E (IgE) or IgG antibodies. Patients
with anaphylaxis become acutely dyspnoeic due to bronchospasm and laryngeal oedema and
may complain of chest pain, abdominal pain and nausea.
• Individuals with severe IgA deficiency may develop antibody to IgA and, with repeated
transfusion, are at high risk of allergic reaction.
• Urticaria and itching are common within minutes of starting a transfusion.
• Symptoms are usually controlled by slowing the transfusion and giving antihistamine, and the
transfusion may be continued if there is no progression at 30 minutes.
• Pre-treatment with chlorphenamine should be given when a patient has experienced repeated
allergic reactions to transfusion.

13. • Blood transfusion reaction symptoms .
• Symptoms
• Feeling of apprehension or 'something
wrong'.
• Flushing.
• Chills.
• Pain at the puncture site.
• Myalgia.
• Nausea.
• Pain in the abdomen, flank or chest.
• Shortness of breath.
• Signs
• Fever (rise of 1.5°C or more) and rigors.
• Hypotension or hypertension.
• Tachycardia.
• Respiratory distress.
• Oozing from wounds or puncture sites.
• Haemoglobinaemia.
• Haemoglobinuria.

14. Investigation
• Initial treatment of acute transfusion reactions
(ATRs) should be directed by symptoms and
signs. Treatment of severe reactions should
not be delayed until the results of
investigations are available. In all moderate
and severe transfusion reactions, standard
investigations, including FBC, renal and liver
function tests and assessment of the urine for
haemoglobin, should be performed.
• Patients who have experienced moderate or
severe allergic reactions should have IgA
levels measured.
• If the patient is dyspnoeic, obtain blood gases,
CXR and central venous pressure (CVP)
reading. Where TRALI is suspected, send anti-
leukocyte antibody investigations.

15. • Blood transfusion reaction treatment
and management (1)
• All patients should be transfused in clinical areas where they can be directly observed and
where staff are trained in the administration of blood components and the management of
transfused patients, including the emergency treatment of anaphylaxis. Patients should be
asked to report symptoms which develop within 24 hours of completion of the transfusion.
• If a patient being transfused for haemorrhage develops hypotension, a careful clinical risk
assessment is required. If the hypotension is caused by haemorrhage, continuation of the
transfusion may be life-saving. However, if the blood component is considered the most
likely cause of hypotension, the transfusion must be stopped or switched to an alternative
component and appropriate management and investigation commenced.
• Where the only feature is a rise in temperature of <1.5°C from baseline or urticaria,
recheck that the correct blood is being transfused, give paracetamol and antihistamine,
reset the transfusion at a slower rate and observe more frequently.

16. • Blood transfusion reaction treatment and
management (2)
• Where the reaction is more severe:
• Stop the transfusion and call a doctor
urgently to review the patient.
• Vital signs (temperature, BP, pulse,
respiratory rate, O2 saturation levels or
blood gases) and respiratory status
(dyspnoea, tachypnoea, wheeze and
cyanosis) should be checked and recorded.
• Check the patient's identity and recheck
against details on blood unit and
compatability label or tag.

17. • Blood transfusion reaction
treatment and management (3)
• Initial management where ABO incompatibility is
suspected is to:
• Keep the intravenous (IV) line open with saline.
• Give oxygen and fluid support.
• Monitor urine output, usually following catheterisation.
Maintain urine output at more than 100 ml/hour, giving
furosemide if this falls.
• Consider inotrope support if hypotension is prolonged.
• Treat DIC appropriately - seek expert advice early
and transfuse platelets/fresh frozen plasma (FFP)
guided by the coagulation screen and bleeding status.
• Inform the hospital transfusion department
immediately.

18. • Blood transfusion reaction
treatment and management (4)
• Where another haemolytic reaction or
bacterial infection of blood unit is
suspected:
• Send haematological and microbiological
investigations as outlined above.
• General supportive management is as for ABO
incompatibility.
• Start broad-spectrum antibiotics if bacterial
infection is considered likely. If expert
microbiological advice is not immediately
available, current guidance is to follow local
neutropenic sepsis protocols.
• Involve haematology and intensive care at an
early stage.

19. • Blood transfusion reaction
treatment and management (5)
• Where anaphylaxis or severe allergic
reaction is suspected:
• Adrenaline (epinephrine) 0.5-1 mg
intramuscularly (IM) and repeat every 10
minutes until improvement occurs.
• High-flow oxygen.
• IV fluids.
• Nebulised salbutamol by face mask if
required.
• Steroids are second-line and
antihistamines are third-line treatments. IV
antihistamines should be used very
cautiously as they may further lower blood
pressure.
• NB: call the anaesthetist if there is difficulty
maintaining the airway.

20. • Blood transfusion reaction
treatment and management (6)
• Where TRALI is suspected:
• Seek expert help.
• Give high-concentration oxygen, IV fluids and
inotropes (as for acute respiratory distress syndrome).
• Monitor blood gases, serial CXR and CVP/pulmonary
capillary pressure.
• Ventilation may be urgently required - discuss with
ICU.
• TRALI improves over 2-4 days in over 80% cases
with adequate ITU management and respiratory
support.
• Where fluid overload is suspected:
• Give furosemide IV and high-concentration oxygen.

21. • Delayed
complications
of transfusion
• In those who have previously been immunized
to a red cell antigen during pregnancy or by
transfusion, the level of antibody to the blood
group antigen may be so low as to be
undetectable in the pre-transfusion sample.
• However, after transfusion of red cells bearing
that antigen, a rapid, secondary immune
response raises the antibody level drastically,
leading to the rapid destruction of transfused
cells.
• 5-10 days post-transfusion, patients present
with fever, falling Hb (or unexpectedly poor
rise in Hb), jaundice and hemoglobinuria.
• A rise in bilirubin and positive DAT will also be
present.

22. • Surveillance and reporting
• All suspected transfusion reactions
should be reported immediately to the
local hospital transfusion department in
case blood packs have been accidentally
transposed and another patient is at
immediate risk.
• Transfusion reactions should be
prominently recorded in the patient's
clinical notes.
• All transfusion reactions should be
reviewed by the hospital's transfusion
committee.

23. Massive Transfusion
• Various definitions of massive blood
transfusion (MBT) have been published in
the medical literature such as:
a) Replacement of one entire blood volume within
24 h
b) Transfusion of >10 units of packed red blood
cells (PRBCs) in 24 h
c) Transfusion of >20 units of PRBCs in 24 h
d) Transfusion of >4 units of PRBCs in 1 h when
on-going need is foreseeable
e) Replacement of 50% of total blood volume
(TBV) within 3 h.

24. Case Study (1)
• A 78-year-old woman with anemia and congestive heart failure
received 200 mL of red blood cells over a 30-minute period before
tachypnea developed and she began complaining of dyspnea and
mild chest pain. The transfusion was immediately stopped. The
patient did not have fever or chills. Rales and crackles were heard in
both lung fields, jugular venous distention was apparent and
hypertension was noted. A chest radiograph showed cardiogenic
pulmonary edema. The results of a blood-bank investigation for
hemolysis were negative. Her symptoms were relieved when a
diuretic was administered and 1 L fluid was voided.

25. Case Study (2)
• This clinical scenario is typical of transfusion-associated
circulatory overload, which is underreported and should be
suspected when a patient at risk of volume overload (e.g.,
heart, lung or kidney failure) complains of dyspnea or
demonstrates signs of respiratory distress. The treatment of
transfusion-associated circulatory overload includes
supplemental oxygen and diuretics.

26. Case Study (3)
• Although much less common than transfusion-associated circulatory overload,
transfusion-related acute lung injury (TRALI) may present in a similar manner.
Transfusion-related acute lung injury can be differentiated by the typical chest radiograph
findings of noncardiogenic pulmonary edema and by the absence of jugular venous
distension and normal right-atrial pressure. Brain (b-type) natriuretic peptide is normally
used to help diagnose the presence and severity of heart failure. However, in a
transfusion setting, elevated post transfusion levels are suggestive of transfusion-
associated circulatory overload and maintenance of pre-transfusion levels is suggestive of
transfusion-related acute lung injury. This test may be used as a marker to help to
distinguish between these 2 types of reactions, although this test is not yet available at all
hospitals.