blood transfusion reaction

1. BLOOD TRANSFUSION
REACTION AND
MANAGEMENT
ZIKRULLAH

2. • Classification of blood transfusion
reactions?

4.  Acute
During or within 24 hours of transfusion
 Delayed
After 24 hours of transfusion.( 5-7 days )

5. Case 1

6. • Acute Hemolytic Transfusion Reaction

7. Acute Hemolytic Transfusion
Reaction
• Rapid destruction of RBC immediately
or within 24 hours of transfusion with
any of the following:
– Chills/rigors
– Fever
– Back/flank pain
– Oliguria/Anuria
– Hypotension

8. Acute Hemolytic Transfusion
Reaction
– Hemoglobinuria occuring during or shortly
after transfusion
– Epistaxis
– Renal Failure
– DIC
– Pain and/or oozing at IV site
AND
Known ABO incompatibility or other RBC
antigen incompatibility / clerical error

9. Acute Hemolytic Transfusion
Reaction
• Lab findings
– Positive Direct Antiglobulin Test for anti-
IgG or anti-C3
– Positive elution test
– Elevated LDH
– Elevated Bilirubin
– Low haptoglobulin
– Hemoglobinuria
– Low fibrinogen
– Elevated plasma hemoglobulin

10. Case 2

11. • Allergic Reaction

12. Allergic Reaction
• Any combination (2 or more) of the
following occurring during transfusion:
– Morbilliform rash with or without pruritis
– Urticaria (hives)
– Generalized flushing
– Localized angioedema
– Edema of lips, tonguem uvula
– Pruritis, erythema and edema of periorbital
area

13. Allergic Reaction
– Conjunctival edema
– Respiratory distress, bronchospasm
– Hypotension
• It is the result of an interaction of an
allergen with preformed antibodies

14. Case 3

15. • Febrile Non hemolytic transfusion
reaction

16. Febrile Non hemolytic
transfusion reaction
• Fever (>38 C and a change of >1 C from
pre-transfusion value) and/or chills
without hemolysis
AND
• Occurs within 4 hours of transfusion
• Immune mediated, may be multifactorial
• No lab criteria, only to rule out others

17. Case 4

18. • Transfusion associated Acute Lung
Injury

19. Transfusion associated Acute
Lung Injury
• No evidence of prior Acute Lung Injury
to transfusion AND
• Acute onset of ALI during or within 6
hours of transfusion AND
• Hypoxemia
– PaO2 / FiO2 < 300 mm Hg OR
– Oxygen saturation is <90% on room air OR
– Other clinical evidence (dyspnea/tachypnea)
AND

20. Transfusion associated Acute
Lung Injury
AND (contd)
• No evidence of Left Atrial Hypertension
(circulatory overload) AND
• No temporal association to an alternative
risk factor for ALI during or within 6
hours of completion of transfusion AND
• Bilateral infiltrates on chest Xray

21. Transfusion associated Acute
Lung Injury
• Often accompanied by fever, tachycardia,
hypostension
• Occurs as a result of granulocyte
activation in the pulmonary vasculature,
resulting in increased vascular
permeability.

22. Case 5

23. • Transfusion associated Graft vs Host
disease

24. Transfusion associated Graft vs
Host disease
• Clinical syndrome occurring from 2 days
to 6 weeks following transfusion
characterized by symptoms of :
– Fever
– Characteristic rash
– Hepatomegaly
– Diarrhea
– Liver dysfunction

25. Transfusion associated Graft vs
Host disease
– Pancytopenia
– WBC chimerism
– Characteristic histological appearances on
skin biopsy or liver biopsy

26. Case 6

27. • Post Transfusion Purpura

28. Post Transfusion Purpura
• Thrombocytopenia (decrease to <20% of
pre-transfusion count)
• Occurs 5 – 12 days post transfusion
• Antibodies directed against the Human
Platelet Antigen System
• Signs of bleeding

29. Case 7

30. • Transfusion associated circulatory
overload

31. Transfusion associated
circulatory overload
• Volume infusion that cannot be
effectively processed by the recipient
either due to high rates and volumes of
infusion or underlying cardiac or
pulmonary pathology

32. Transfusion associated
circulatory overload
• Characterized by new onset or
exacerbation of > 2 of the following
within 6 hours of transfusion:
– Acute respiratory distress (dyspnea,
orthopnea, cough)
– Evidence of positive fluid balance
– Elevated BNP
– Radiographic evidence of pulmonary edema
– Evidence of right heart failure
– Elevated CVP

33. Management

34. Acute blood transfusion reaction
Category 1: Mild reactions
• Mild hypersensitivity: allergic, urticarial
reactions
Category 2: Moderately severe reactions
• Moderate—severe hypersensitivity (severe
ucticarial reactions)
• Febrile non haemolytic reactions:
• Possible bacterial contamination

35. Category 3: Life-threatening reactions
• Acute intravascular haemolysis
• Bacterial contamination and septic shock
• Fluid overload
• Anaphylactic reactions
• TRALI

36. Category 1- Mild reactions
• Signs and symptoms?

37. Category 1: Mild reactions
• Localised cutaneous reactions (urticaria
and rash), often accompanied by pruritus
(intense itching), occur within minutes of
commencing the transfusion.
• Arise as a result of hypersensitivity with
local histamine release to proteins,
probably in the donor plasma.

38. • Management?

39. Management
1 Slow the transfusion.
2 Give an antihistamine: e.g.
chlorpheniramine 0.1 mg/kg i.m.
3 Continue the transfusion at the normal
rate if there is no progression of
symptoms after 30 minutes.
4 It there is no clinical improvement within
30 minutes or if signs and symptoms
worsen, treat the reaction as a Category 2
reaction.

40. Category 2 – moderately severe
reactions
• Signs and symptoms?

41. Category 2 Moderately severe
reactions
• Sign
• Flushing
• Urticaria
• Rigors
• Fever
• Restlessness
• Tachycardia
• Symptoms
• Anxiety
• Pruritus (itching)
• Palpitations
• Mild dyspnoea
• Headache

42. • Management?

43. Management
1 Stop the transfusion, Replace the BT-set and keep
the IV line open with normal saline.
2 Notify the senior doctor and blood bank
immediately.
3 Send the blood unit with BT-set, freshly collected
urine and new blood samples (1 clotted and 1
anticoagulated) from the vein opposite the
infusion site with a request form to the blood
bank for investigations

44. 4 Administer antihistamine IV or IM and
an oral or rectal antipyretic (e.g.
paracetamol 10 mg/kg: 500 mg — 1 g in
adults). Avoid aspirin in
thrombocytopenic patients.
5 Give IV corticosteroids and
bronchodilators if there are
anaphylactoid features (e.g.
broncospasm, stridor).
6 Collect urine for the next 24 hours for
evidence of haemolysis and send to the
laboratory.

45. 7 If there is a clinical improvement, restart
the transfusion slowly with a new unit of
blood and observe carefully.
8 If there Is no clinical improvement within
15 minutes Or the patient’s condition
deteriorates, treat the reaction as a
category 3 reaction.

46. Category 3 – Life threatening
reactions
• Signs and symptoms?

47. Signs
• Rigors
• Fever
• Restlessness
• Shock
• Tachycardia
• Haemoglobinuria (red urine)
• Unexplained bleeding (DIC)

48. Symptoms
• Anxiety
• Chest pain
• Respiratory distress/shortness of breath
• Loin/back pain
• Headache
• Dyspnoea

49. • Management?

50. Management
1 Stop the transfusion. Replace the BT-set
and keep IV line open with normal saline,
2 Infuse normal saline to maintain systolic
BP (initial 20—30 mI/kg).
3 Maintain airway and give high flow
oxygen by mask.
4 Give 1:1000 adrenaline 0.01 mg/kg body
weight by intramuscular injection.

51. 5 Give iv corticosteroids and
bronchodilators if there are
anaphylactoid features (e.g.
broncospasm, stridor).
6 Give diuretic: e.g. furosemide 1 mg/kg
IV or equivalent
7 Notify the senior doctor and the blood
bank immediately.

52. 8 Send blood unit with BT-Set, fresh
urine sample and new blood Samples (1
clotted and 1 anticoagulated) from Vein
opposite infusion site with appropriate
request form to blood bank and
laboratory for investigations.
9 Check a fresh urine specimen visually
for signs of haemoglobinuria.
10 Start a 24-hour urine collection and
fluid balance chart and record all
intake and output.

53. 11 Assess for bleeding from puncture sites
or wounds, If there is clinical or
laboratory evidence of DIC give:.
Platelet concentrates (adult: 5—6
units) and Either cryoprecipitate
(adult: 12 units) or fresh frozen plasma
(adult: 3 units)
Use virally-inactivated plasma
coagulation products, wherever
possible.

54. 12 Reassess. If hypotensive:
• Give further saline 20—30 mI/kg over 5
minutes
• Give inotrope.
13 If urine output falling or laboratory
evidence of acute renal failure (rising K,
urea, creatinine):
• Maintain fluid balance accurately
• Give further furosemide

55. • Consider dopamine infusion
• Seek expert help: the patient may need
renal dialysis.
14 If bacteraemia is suspected (rigors,
fever, collapse, no evidence of a
haemolytic reaction), start broad-
spectrum antibiotics IV, to cover
pseudomonas and gram positives.

56. Send the following lab investigations:
• Immediate post transfusion blood samples (clotted and
EDTA) for:
Repeat ABO & Rh (D) grouping
Repeat antibody screen and crossmatch
Direct antiglobulin test
Complete blood count (CBC)
Plasma hemoglobin
Coagulation screen
Renal function test (urea, creatinine and electrolytes)
Liver function tests (bilirubin, ALT and AST)
Blood culture in special blood culture bottles
Blood unit alongwith BT set
Specimen of patient’s first urine following reaction

57. PTP
1 Give high dose corticosteroids.
2 Give high dose IV immunoglobulin, 2
g/kg (0.4 g/kg for 5 days.
3 Plasma exchange

58. Iron overload
• Iron-binding agents, such as
desferrioxamine

59. Transfusion transmitted
infection
• HIV-1 and HlV-2
• Hepatitis B & C
• Treponema pallidum (syphilis).
• HTLV-I and II
• Chagas disease
• Malaria
• Cytomegalovirus
• Other rare infections: e.g. human parvovirus
B19 and hepatitis A

60. Massive blood transfusion
• Replacement of a blood volume equivalent to
patient’s within 24 hours
• >10 units (wholoe blood) or 20 units PRBC
within 24 hours
• >4 units in 1 hour
• Replacement of 50% of blood volume in 3-4
hours

61. Complications of massive or large
volume transfusion
• Acidosis
• Hyperkalaemia
• Citrate toxicity and hypocalcaemia
• Depletion of fibrinogen and coagulation
factors
• Depletion of platelets
• Disseminated intravascular coagulation
(DIC)
• Hypothermia
• Reduced 2,3 diphosphcglycerate (2,3 DPG)
• Microaggregates

65. Thank you