Blood transfusions reactions is one of the major important issues in clinical practice

1. BLOOD TRANSFUSION AND
TRANSFUSION REACTIONS
Banadir Hospital-somalia
Pediatric department
Emergency ward –CME lectures
Mohamed Adan Aweys (Marwan)
dr.awies02@gmail.com

2. Life Saving &
Life Threatening Process

3. LEARNING OUTCOMES
At the end of this topic, you should able to:
• Understand concept of Whole blood and blood
components
• Discuss types and indications of blood transfusion
• Enlist tests to be performed prior to blood transfusion
• Understand transfusion reactions and their
managements.

4. Blood Transfusion
• Process of transferring blood-based products from one person into
the circulatory system of another through an intravenous line.
• The appropriate use of blood means the transfusion of safe blood
products only to treat a condition leading to significant morbidity or
mortality that cannot be prevented or managed effectively by other
means.
• Transfusion carries the risk of adverse reactions and transfusion-
transmitted infection. Plasma can transmit most of the infections
present in whole blood and there are very few indications for its

5. TRANSFUSION
THERAPY
* REPLACEMENT
* THERAPEUTIC
1.To restore intravascular volume
with whole blood or albumin.
2. To restore the oxygen capacity
of blood by replacing red blood
cells.
3. To replace clotting factor and
correction of anemia
PURPOSE OFBLOOD

6. Blood safety
 transfusion-transmissible infection
 window period : is the period during the development of a new
infection in a previously non-infected person in which the person’s
blood may be very infectious, but the detectable antibody has not yet
appeared.

7. WHOLE BLOOD AND BLOOD COMPONENTS
• 350ml /450 ml of blood is collected from a donor into a
plastic bag containing an anticoagulant
• This is called 1 “unit” of whole blood
• Types of blood components:-
• Red blood cell concentrate (packed red blood cells)
• Platelet concentrate
• Fresh frozen plasma Cryoprecipitate
Plasma or platelets collected by apheresis.
Apheresis: a method of collecting plasma or platelets directly from
the donor, usually by a mechanical method

9. Dr. Salwa Hindawi
Whole
blood
Platelets
rich
plasma
1st
centrifugation
Platelets
concentrate
Whole
blood
Whole
blood
2nd
centrifugation
Fresh plasma
FFP for
clinical use
FFP for
fractionation
Optimal additive
solution
Red cells in
OAS
Cryoprecipitate
Red
Cell
concentrate

10. Effects of storage on whole blood
■ Reduction in the pH (blood becomes more acidic)
■ Rise in plasma potassium concentration (extracellular K+)
■ Progressive reduction in the red cell content of 2,3 diphosphoglycerate
(2,3 DPG) which may reduce the release of oxygen at tissue level until
2,3 DPG is restored
■ Loss of all platelet function in whole blood within 48 hours of donation
■ Reduction in Factor VIII to 10–20% of normal within 48 hours of
donation. Coagulation factors such as VII and IX are relatively stable in
storage

11. TYPES OF BLOOD TRANSFUSION
• FRESH BLOOD TRANSFUSION
Blood less than 24 hours old from the time of collection
• AUTOLOGOUS TRANSFUSION
Blood collected from a patient for re-transfusion at a later time
into the same individual
• MASSIVE TRANSFUSION
Number of units transfused in a 24 hours period exceeds the
recipient’s blood volume
• MULTIPLE TRANSFUSION
Repeated transfusion of blood over a long period of time
(months or year)

12. INDICATIONS OF BLOOD TRANSFUSION
• Whole Blood:
Storage -4° for up to 35 days
• Acute blood loss (trauma )
• Shock
• Exchange transfusion in neonate
• Considerations
• Use filter as platelets and coagulation factors will not be active
after 3-5 days
• Packed red blood cells:
Storage - 2 – 6 O C
• Chronic severe Anemia
• Leukemia
• Thalassemia

13. • Platelets concentrate:
Platelet viability is optimal at 22° C but storage is limited
to 4-5 days .
1 unit/10 kg of body weight increases Plt count by 50,000
• Thrombocytopenia <15,000
• Bleeding due to platelet dysfunction
• Malignancy
• Major surgery
• Fresh frozen plasma:
Storage FFP-12 months at –18 degrees or colder
• Liver disorders
• DIC
• Coagulation factor deficiency (V, VII)

14. Cryoprecipitate:
Description
Precipitate formed/collected when FFP is thawed at 4°
Storage
After collection, refrozen and stored up to 1 year at -18
• Hemophilia A (Factor VIII or XIII deficiency )
• von Willebrand’s disease
• Fibrinogen deficiency

15. PRE-TRANSFUSION TESTING
• ABO and Rh (D) blood grouping :
• Patient’s and donor’s blood sample
• Cross matching of blood sample:
• Major cross match- Pt’s serum + Donor cells
• Minor cross match- pt’s cells + Donor serum

16. BLOOD GROUPING

17. PRE-TRANSFUSION TESTING (contd.)
• Screening for Transfusion transmitted diseases
(Donor Sample)
HIV 1 and 2 AIDS
HBsAg Hepatitis B
HCV Hepatitis C
Treponema pallidum Syphilis
Plasmodium species Malaria

19. Transfusion Reactions
• Infectious
• Viral
• Bacterial
• Noninfectious
• Reaction to RBC Antigens
• Acute Hemolytic Transfusion Reactions (AHTR)
• Delayed Hemolytic Transfusion Reactions (DHTR)
• Reactions to Donor Proteins
• Minor Allergic Reactions
• Anaphylactic Reactions
• White Cell-Related Transfusion Reactions
• Febrile Reactions
• Transfusion-Related Acute Lung Injury (TRALI)

20. CAUSES OF TRANSFUSION REACTIONS
• Clerical errors:
• Inadequate labeling
• Wrong blood issued
• Technical errors:
• Error in blood grouping & cross matching
• Incorrect interpretation of test results
• Others:
• Blood contamination during phlebotomy
• Blood infusion thr’ small bore needle
• Blood cooler to -30⁰C or warmed to > 42⁰ C
• Concomitant administration blood & drugs thr’ common set

21. How to Prevent Errors in the Transfusion Chain
Where in the process do errors occur?
Who is making the errors?
Why are the errors occuring – which elements of good
transfusion practice are failing
Sample Error
Sample Error Technical Error
Technical Error
Wrong Blood
Wrong Blood
Issued
Issued
Storage Error
Storage Error
Patient
Patient
Misidentification
Misidentification
Administrative
Administrative
Error
Error

22. CLASSIFICATION
Transfusion reaction
acute delayed
Immunologic Non immunologic Immunologic Nonimmunologic

23. Acute Transfusion Reactions
• Hemolytic Reactions (AHTR)
• Febrile Reactions (FNHTR)
• Allergic Reactions
• TRALI(Transfusion related acute lung injury)
• Coagulopathy with Massive transfusions
• Bacteremia

24. Febrile (non haemolytic) Transfusion Reaction
(FNHTR)
 Rise in patient temperature >1°C (associated with transfusion without
other fever precipitating factors
 Onset during or within 4 hours following transfusion , Reaction
induced by cytokines.
 Occurs with approx 1% of PRBC transfusions and approx 20% of Plt
transfusions

25. • Mild: unexplained fever ≥38°C and a temperature rise of at
least 1°C but <1.5°C from pre-transfusion baseline, occurring in
the absence of chills, rigors, respiratory distress and
haemodynamic instability
• Moderate: unexplained fever ≥38°C and a temperature rise of
at least 1°C but not meeting criteria for either mild or severe
FNHTR
• Severe: unexplained fever >39°C and a temperature rise ≥2.0°C
from pre-transfusion baseline and chills/rigors .
• STOP TRANSFUSION
• Check label and recipient identity
•  Slow the transfusion if reaction is mild and MO elects to
continue transfusion
•  Antipyretic Paracetamol 1g po and monitor closely
•  Steroids are not appropriate treatment for minor reactions

26. Acute Hemolytic Transfusion Reactions
(AHTR)
• Occurs when incompatible RBC’s are transfused into a recipient who has pre-
formed antibodies (usually ABO or Rh)
• Antibodies activate the complement system, causing intravascular hemolysis
• Symptoms occur within minutes of starting the transfusion
• This hemolytic reaction can occur with as little as 1-2 cc of RBC’s
• Labeling error is most common problem
• Can be fatal

27. Signs and Symptoms
• Fever , Chills, rigors
• Nausea and vomiting
• Hypotension and tachycardia (bradykinin)
• Flushed and dyspneic (histamine)
• Chest, abdominal or low back pain (cytokine release)
• Headache
• Haemoglobinaemia and haemoglobinuria 
• Oliguria with dark urine or anuria
• Pallor, jaundice - Bleeding (due to DIC)

28. • Stop transfusion
• Check label and recipient identify
• Replace IV set and start normal saline
• Treat shock and maintain blood pressure with IV saline
infusion
• Investigate possible DIC and treat if clinically significant
bleeding
• Diuretic, eg Frusemide 1-2 mg/kg IV and/or Mannitol, may
help maintain urine flow
• Hydrocortisone may be considered
• Samples to assess renal and liver function, DIC and
haemolysis, eg full blood count, unconjugated bilirubin, LDH
and haptoglobin
• Send Haemovigilance notification to Blood Bank

29. Delayed Hemolytic Transfusion
Reactions
• Onset usually 1-7 days post transfusion but may be up to 28
days.
• Worsening anaemia and jaundice from destruction of red cells
 Often asymptomatic but rarely splenomegaly,
haemoglobinaemia and haemoglobinuria .
• Renal impairment may occur in severe cases
Investigate haemolysis:  Full blood count with film comment 
Direct antiglobulin test (may be negative when most red cells
cleared)
Blood group antibody screen (may be negative until red cells
cleared)  Liver function tests  Haptoglobin concentration
falls while haemolysis is occurring

30. Allergic Transfusion Reactions
Allergic Reaction (minor)
Frequency: 1:100 - 1:500 More common with Plasma and Platelet Components .
Onset: from commencement to 4 hours after transfusion  Recipient may have an antibody
reacting with an antigen in the transfused product .
Minor or localised reaction:
 Flushed skin
 Morbilliform rash with itching
 Urticaria (hives)
 Angioedema
 Periorbital itch, erythema and oedema
 Conjunctival oedema
 Minor oedema of lips, tongue and uvula

31. Management
 Slow transfusion
 Check label and recipient identity
Antihistamine, eg Loratadine 10mg or Cetirizine
10mg po if symptoms are troublesome
If symptoms mild and transient, transfusion may
resume
Continue transfusion at a slower rate with increased
monitoring, eg BP/TPR 15 – 30min
Send Haemovigilance notification to Blood Bank
 If symptoms increase treat as a moderate or severe
reaction

32. Allergic Reaction (moderate)
 Frequency: 1:500–1:5,000
 Onset usually within first 50-100 mL infused and within
4 hours of transfusion .
Moderate or widespread reaction:
 Symptoms as for minor reactions, and –
 Cough
 Hypotension and tachycardia
 Dyspnoea and oxygen desaturation are common
 Chills and rigors
 Loin pain and angina
 Severe anxiety

33. Management
• Stop transfusion
• Check label and recipient identity
• Replace IV set and give saline to keep vein open and/or
maintain BP
• Monitor closely and treat symptomatically as required
with IV fluids, oxygen and antihistamine, eg
Promethazine 25-50 mg IV (max rate 25 mg/min) or
Loratadine 10mg or Cetirizine 10mg po. Hydrocortisone
may be considered
• Send Haemovigilance notification to Blood Bank
• Discuss with TMS promptly if mod - severe reaction
present

34. Anaphylactic / Anaphylactoid Allergic Reaction (severe)
 Frequency: 1:20,000 – 1:50,000
 Rapid onset :
- May be due to an antibody in the recipient reacting with a plasma protein in a blood component
- IgA
- Haptoglobin o Other plasma protein.
Life-threatening reaction:
 Symptoms as for moderate reactions, and
 Severe hypotension, shock and tachycardia
 Widespread urticaria with skin flushing and itching
 Wheezing, stridor, change in voice
 Severe anxiety

35. Management
 Stop transfusion
 Check label and recipient identity
 Follow Anaphylaxis Guidelines:
• Adrenalin 1:1000 IM and repeat at 5- 10 min intervals if required: - Adult:
0.5mg / 0.5 mL - Children 0.01mg/kg IM; min dose 0.1mL, max dose 0.5mL
• Replace IV set and give rapid IV colloid or saline, eg adults 2 L, children 20
mL/kg, until SBP>90 mmHg, then titrate
• Consider Hydrocortisone 4mg/kg (200- 400 mg IV)
• Consider H1-antihistamine, eg Loratadine or Cetirizine 10 mg po for itch or
angioedema.
• H2-antihistamine, eg Ranitidine may be added for severe reactions.
• Note: Sedating antihistamines, eg Promethazine contraindicated
 CPAP ventilation, chest X-ray
 ICU liaison
 Discuss severe reactions with TMS

36. TRALI: Transfusion Associated Lung Injury
• Frequency: <1:5,000
• Onset within 6 hours following transfusion of plasma or plasma-
containing cellular components
• A complex group of disorders indistinguishable clinically from ARDS
• One recognised mechanism involves a donor antibody reacting with
recipient neutrophil- or HLA-antigens causing cell activation that
results in acute severe microvascular lung injury .

37. • Onset of severe dyspnoea and cyanosis proceeding to
respiratory failure with bilateral infiltrates on CXR within 6
hours of transfusion .
• Absence of left atrial hypertension (circulatory overload)
Distinguish from:
 cardiovascular overload (TACO) o
other causes of acute respiratory distress syndrome (ARDS)
 or less severe acute lung injury (ALI)
Management
- Intensive care management for respiratory failure
- Diuretics are not usually helpful

38. TACO: Transfusion Associated
Circulatory Overload
• Rapid onset after infusion of a volume of fluid that is clinically
significant for the affected recipient.
• Main risk factors: premature/ new borne or Elderly patients
recipient with impaired cardiovascular state or renal impairment o
Infusion too rapid for recipient o Volume infused too great, especially
if normovolaemic.
• Clinics: Acute heart failure
Prophylaxis: Slow infusion rate, low volume of transfusion

39.  Increased blood pressure
 Rapid bounding pulse
Respiratory distress with raised resp. rate, dyspnoea, cough, pink
frothy sputum, crepitations and oxygen desaturation consistent with
pulmonary oedema
 Raised JVP and CVP
 Nausea
 Acute or worsening pulmonary oedema on CXR
Restlessness, anxiety
Management
 Stop transfusion
 Seek urgent medical assessment 
Sit recipient upright with legs over side of bed, administer oxygen,
diuretic (Frusemide 1-2 mg/kg IV), CPAP ventilation.
Demonstration of raised BNP may help to distinguish from TRALI

40. TRALI versus TACO
Kim et al. 2015.

41. Bacterial Contamination(Bacterial Sepsis)
• More common and more severe with platelet transfusion (platelets are stored at room
temperature)
• Organisms
• Platelets—Gram (+) organisms, ie Staph/Strep
• RBC’s—Yersinia, enterobacter
Symptoms :
- Rigor, chills, fever
-Shock, usually within minutes of starting transfusion 
-Respiratory distress, wheezing and oxygen desaturation
-Pain up arm , Chest and back / loin pain Nausea,
Give antibiotics: a broad-spectrum penicillin or cephalosporin and gentamicin 5mg/kg.

42. Cooling
 Progressive onset during rapid infusion of large
volumes of cold fluids, including blood products (more
than 50 mL/kg/h in adults or 15 mL/kg/h in children.
Signs And Symptoms
• Reduced temperature
• May be associated with cardiac rhythm irregularity and
a negative inotropic effect
• Impaired platelet function and coagulation
Limit heat loss from the recipient and monitor BP/TPR
 If further blood components required, infuse through a
warmer

43. Chronic Transfusion Reactions
oAlloimmunization
oTransfusion Associated Graft Verses Host Disease (GVHD)
oIron Overload
oTransfusion Transmitted Infection
oPost Transfusion Purpura :
(Onset about 5-12 days after transfusion of cellular blood components ,
• Severe thrombocytopenia often with purpura and possibly other
bleeding .
• Thrombocytopenia will persist for 1-2 weeks

44. Transfusion Related Graft- versus
-Host Disease

47. General managements of Acute transfusion reactions
• category 1: Mild reactions
• Urticaria and itching are not uncommon reactions following transfusion. They arise as a result of
hypersensitivity with local histamine release to proteins, probably in the donor plasma.
• Signs and symptoms
• Localised cutaneous reactions (urticaria and rash), often accompanied by pruritus (intense itching), occur
within minutes of commencing the transfusion. The symptoms usually subside if the transfusion is slowed
and antihistamine is given.
Management
1- Slow the transfusion.
2 -Give an antihistamine: e.g. chlorpheniramine 0.1 mg/kg by intramuscular injection.
3- Continue the transfusion at the normal rate if there is no progression of symptoms after 30 minutes.
4- If there is no clinical improvement within 30 minutes or if signs and symptoms worsen, treat the reaction as
a Category 2 reaction.

48. Category 2: Moderately severe reactions
Signs and symptoms usually occur 30–60 minutes after the start of the transfusion.
Signs
■ Flushing Urticaria
■
■ Rigor Fever
■
■ Restlessness Tachycardia
■
Symptoms
■ Anxiety Pruritus (itching)
■
■ Palpitation Mild dyspnoea
■
■ Headache

49. 1- Stop the transfusion. Replace the infusion set and keep the IV
line open with normal saline.
3- Administer antihistamine IV or IM (e.g. chlorpheniramine
0.01 mg/kg or equivalent) and an oral or rectal antipyretic (e.g.
paracetamol 10 mg/kg: 500 mg – 1 g in adults). Avoid aspirin in
thrombocytopenic patients.
4- Give IV corticosteroids and bronchodilators if there are
anaphylactoid features (e.g. broncospasm, stridor).
5- Collect urine for the next 24 hours for evidence of haemolysis
and send to the laboratory.
6- If there is a clinical improvement, restart the transfusion
slowly with a new unit of blood and observe carefully.

50. Category 3: Life-threatening
reactions
The most common causes of life-threatening transfusion reactions are:
■ Acute intravascular haemolysis
■ Bacterial contamination and septic shock
■ Fluid overload
■ Anaphylactic shock
■ Transfusion-associated lung injury (TRALI)
Signs
• Rigors
• Fever
• Restlessness
• Shock
• Tachycardia
• Haemoglobinuria (red urine)
• Unexplained bleeding (DIC)

51. Symptoms
■ Anxiety
■ Chest pain
■ Respiratory distress/shortness of breath
■ Loin/back pain
■ Headache
■ Dyspnoea
Management
1- Stop the transfusion and Check label and recipient identity
- Replace the infusion set and keep IV line open with normal saline.
2- Infuse normal saline to maintain systolic BP (initial 20–30 ml/kg).
If hypotensive, give over 5 minutes and elevate patient’s legs.
3- Maintain airway and give high flow oxygen by mask.

52. 4 -Give 1:1000 adrenaline 0.01 mg/kg body weight by
intramuscular injection.- Children 0.01mg/kg IM; min
dose 0.1mL, max dose 0.5mL
5- Give IV corticosteroids ( Consider iv Hydrocortisone
4mg/kg (200- 400 mg ) and bronchodilators if there
are anaphylactoid features (e.g. broncospasm,
stridor).
6 -Give diuretic: e.g. frusemide 1 mg/kg IV or
equivalent
7- Consider H1-antihistamine, eg Loratadine or
Cetirizine 10 mg po for itch or angioedema.
o H2-antihistamine, eg Ranitidine may be added for
severe reactions.

53. Reference
• American Society of Hematology 2021 L Street NW, Suite 900
Washington, DC 20036
• www.hematology.org
• 2012 Clinical Practice Guide on Red Blood Cell Transfusion
• Handbook of Transfusion Medicine. Fourth Edition.
www.transfusionguidelines.org.uk

54. ThAnk You!
Hope you learned
something!

55. Case 1
Mr gulled is a 14 year old male is brought to
the ER after a motor vehicle accident. He is in
pain, tachycardic to 120s, but normotensive.
• Given his acute blood loss, transfusion of 1u
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?

56. Febrile Nonhemolytic Transfusion
Reaction

57. Case 1 (continued)
• Mr gulled does well following discharge. Fifteen years
later (age 29 ), 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?

58. Delayed Hemolytic Transfusion Reaction

59. Case 1 (continued)
• Mr gulled 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

60. CXR w/ Sudden SOB.

61. What is The Most Likely Diagnosis
A) Pulmonary Embolism
B) Transfusion Related Acute Lung Injury
C) Transfusion Associated Circulatory Overload
D) Anaphylaxis
E) Acute Respiratory Distress Syndrome
More common than TRALI (1 in 100 vs 1 in 10,000). This case was confirmed
to be TACO.
PE usually causes respiratory alkalosis with hypoxia on ABG.
Anaphylaxis should be considered but TACO is more likely in this scenario.
ARDS is less likely given no evidence of infection or inflammation prior to the
sudden event.

62. Transfusion-Associated Circulatory
Overload (TACO)

63. Case 3. Back to Mr gulled…
• Mr gulled 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

64. Allergic Reactions and Anaphylaxis