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1. BLOOD
TRANSFUSION
REACTION
Non immunological

2. Non immunological transfusion
reaction
1. Bacterial contamination reactions.
2. Circulatory overload.
3. Transfusion haemosiderosis.
4. Complications of massive transfusion.
5. Non immune hemolytic reaction
6. Disease transmission.

3. 1. Bacterial contamination reaction.
 Although uncommon,but this type of specific
reaction can have a rapid onset and high
mortality in recipients.
 The presence of bacteria in transfused blood
may lead either to febrile reactions in the
recipient ( due to pyrogens ) or serious
manifestations of septic or endotoxic shock.
 Commonly caused by endotoxin produced by
bacteria capable of growing in cold temperatures
such as Pseudomonas species, E. coli, Yersinia
enterocolitica.

4. Source of infection.
 Infection of stored blood is extremely rare.
 Skin contaminants are not infrequently present in
freshly donated blood but these organisms
( predominantly staphylococci ) do not survive
storage at 4 º C although they will grow profusely
in platelet concentrates stored at 22 º C.
 Healthy donor who are bacteremic at the time of
donation. The majority are due to Yersinia
enterocolitica, which grows well in red cell
components due to its dependence on citrate and
Iron.
 Gram negative, endotoxin – producing
contaminants found in dirt, soil and faeces may
rarely grow in the storage condition of blood.

5. •According to CDC , most are caused by blood
components contaminated by Yersinia
enterocolitica.
•Since 1987, from 20 cases reported to CDC, 12
are caused by this organism.

6. Clinical manifestation
 Usually appear rapidly during transfusion
or within about 30 minutes after
transfusion with dryness, flushing of skin.
 Fever, Hypotension, Chills, Muscle pain,
vomiting, Abdominal cramps, Bloody
diarrhoea, Hemoglobinuria, Shock, Renal
failure, DIC.

7. Management.
 Rapid recognition is essential
 Immediately stop the transfusion.
 Therapy of shock, steroids, vassopressors, fluid
support, respiratory ventilation and maintenance
of renal function.
 Broad spectrum IV antibiotics
 The blood component unit and any associated
fluids and transfusion equipment should be sent
immediately to blood bank for investigation ie:
gram stain and culture.
 Blood C & S from the recepient.

8. Prevention
 Strict adherence to policies & procedures
regarding blood component collection,
storage, handling,and preparation is
essential to reduce the risk.
 Visual Inspection of components before
release from the transfusion service include
any discolouration, visible clots, or
hemolysis.
 Ensure the blood components are infused
within standard time limits ( 4 hours ).

9. Prevention
 Blood packs should never be opened for
sampling, if any open method of
preparation has been used, the unit
should be transfused within 24 hours.
 Blood should always be kept in accurately
controlled refrigerators (with alarms),
maintained strictly at 2 – 6 º C, the blood
should never be removed and taken to the
ward or OT until it is recquired.

10. 2. Circulatory overload
 All patient will experience a temporary rise in
blood volume and venous pressure following the
transfusion of blood or plasma except for those
who are actively bleeding. However, young
people with normal cardiovascular function will
tolerate this changes provided it is not
excessive.
 Pregnant women, patient with severe anaemia,
elderly with compromised cardiovascular
function will not tolerate the increase in plasma
volume and acute pulmonary oedema may
develop.

11. Clinical manifestation
 Frequently due to transfusion of a unit at
too fast rate.
 Signs of cardiac failure – raised JVP,
basal crepitations in both lungs, dry
cough, breathlessness.

12. Management
 Stop the transfusion immediately.
 Prop up the patient
 Oxygen therapy
 Intravenous diuretics should be used
appropriately.
 If more rapid volume reduction is needed,
therapeutic phlebotomy can be used.

13. Prevention
 Packed cell should be used instead of whole blood.
 Packed cells should be given slowly over 4
hours.The usual rate of transfusion is about 200 ml
per hour. In patient at risk rate of 100 ml per hour or
less are appropriate.
 Diuretics should be given at the start of the
transfusion and only one or two units of
concentrated red cells should be transfused in any
24 hour period.
 Blood transfusion should be given during the
daytime, Overnight transfusion should be avoided
wherever possible.

14. 3. Transfusion haemosiderosis
 A complication of repeated long term blood
transfusion.
 Most commonly seen in thalassaemic patient.
 Each unit of blood has about 200 mg of iron,
while the daily excretion rate is about 1 mg. The
body has no way of excreting the excess unless
the patient is bleeding.
 Assessment of storage iron levels such as
ferritin levels should be done.

15. The use of Iron chelating agent,
Desferrioxamine does not completely
overcome the Iron load, but has delayed the
onset of problems due to haemosiderosis.
Transfusion of neocytes or young red cells is
the other alternative. However, it is expensive,
time consuming, and the result are not as
favourable as expected.

16. 4. Complication of massive
transfusion
 Massive transfusion is defined as the replacement of
total blood volume within a 24 hour period.
 This will inevitably lead to :
1. Dilution of platelets.
Blood effectively has no functional platelets after 48
hours storage, after 8 to 10 units of blood transfusion,
thrombocytopenia will usually seen.
Bleeding due to a slightly low platelet is uncommon,
therefore routine administration of platelet after certain
amount of blood transfusion is unnecessary.
Regular monitoring of platelet count is more important.
Platelet transfusion may be recquired if platelet count
<100 x 10 9 /L with continous bleeding or surgical
intervention.

17. 2. Dilution of coagulation factors.
Stored Whole blood < 14 days has adequate levels of
most coagulation factors for haemostasis.
If stored blood of more than 14 days, or plasma reduced
blood or red cells in optimal additive solution is used,
replacement of coagulation factors with FFP is necessary.
3. Hypothermia ( defined as core body temperature
less than 35 c ) is associated with large volumes of cold
fluid transfusion. This may results in cardiac irregularities in
particular VF. Therefore the use of blood warmer is
important.

18. 4. Excess citrate can act on the patient’s plasma free
ionized calsium and results in hypocalcaemia ( transient ).
Citrate toxicity occur with extremely rapid transfusion ( one
unit every 5 minute ), in premature infant having ET with
blood stored in citrate for longer than 5 days.
5. Hyperkalemia
Can be caused by intracellular loss of potassium from
RBC during storage or infusion of intracellular
potassium depleted RBC blood components such as
washed RBC or frozen washed RBC .

19. The most important consideration in massive
blood transfusion is to replace blood loss
quickly and adequately. Too little blood , too
late has more serious consequences than
massive blood transfusion itself.

20. 5.Non immune hemolytic reaction
 Mechanical – heat damage from blood
warmer, cold, small gauge needle.
 Environment – hypotonic or hypertonic
solution.

21. 6. Disease transmission.
 Hepatitis
 Syphilis
 Malaria
 Cytomegalovirus
 Human immunodeficiency virus
 Human T cell leukaemia viruses.
Donor selection criteria and subsequent screening of all
donations are designed to prevent disease transmission,
but these do not completely eliminate the hazards.

22. Hepatitis
 Hepatitis A is rarely transmitted by transfusion. Any
donor who has been in close contact with Hepatitis A
patient or develops hepatitis A is deffered for 12 months.
 Hepatitis B is a frequent sequel to blood transfusion.
Currently all blood donations are tested for HBsAg by
very sensitive third generation techniques ( eg; ELISA ),
able to detect at least 0.5 iu of HBsAg per ml of serum.
In HUSM, EIA method is used with 99.9 % sensitivity.
HBsAg positive subjects are permanently excluded from
donations.

23. Hepatitis
 Hepatitis C
All donated blood are tested for anti – HCV.
Improved screening assays based on
multiple recombinant or synthetic antigens
including viral core protein are now
available.
 Individuals with a history of jaundice may be
accepted as donors 1 year after the illness
provided they tested and negative for HBsAg
and anti HCV.

24. Syphilis
 The organism is more likely to be transmitted in platelet
concentrate due to their room temperature storage and
short shelf life.
 Treponema pallidum does not survive well at 4º c and
red cell preparation are likely to be non infective after 4
days refrigeration. Passive transmission of the antibody
to the recepient may cause diagnostic confusion.
 Any donations with positive result is discarded, any
subjects with positive tests are permanently deferred,
even after effective therapy.

25. Malaria
 Malarial parasites remain viable in blood stored
at 4º C and easily transmitted by blood
transfusion.
 In some endemic areas, all recipients are
treated with antimalarial drugs.
 Donors who come from endemic area or have
had an attack of malaria can be accepted, their
plasma can be used for fractionation but red
cells must be discarded.
 In HUSM , BFMP should be tested for certain
group of donors ie : army, donors from endemic
area.

26. Cytomegalovirus
 Post transfusion CMV infection is not
uncommon.
 The infection is characterised by fever
spleenomegaly, and atypical lymphoid cells in
the peripheral blood.
 Due to its benign course, screening for past
infection among donors are not necessary.
 However, there are patient at risk of developing
fatal pneumonitis or disseminated CMV infection
: prem baby < 1500g, BM or and other organ
transplant recipient, pregnant women ( risk to
fetus ).

27. •For them, anti – CMV free blood & components
should be provided.
•In UK, incidence of CMV antibodies in adult
population is 50 to 60 %.
•As an alternative, since CMV is cell associated,
leukodepleted blood may be used.

28. Human immunodeficiency virus
 HIV can be transmitted both in cellular and
plasma components.
 The majority of recipient of blood or blood
products who have been infected in the past
were transfused before 1985 with unheated,
non pasteurized pooled plasma products, Factor
VIII and IX.
 HIV is heat labile, therefore prolonged heat
treatment of Factor VIII for heomophiliacs is
effective.

29. Human immunodeficiency virus
 Routine screening of all donated blood started in
October 1985 in UK. This in combination with donor
education, and self deferral has reduced the risk of HIV
transmission through contaminated blood. There were 2
documented cases in the UK since screening program
introduced.
 With screening programe, HIV transmission still occur
through donations given in the window period of
infectivity.
 With current antibody screening technique, the estimated
window period is about 3 weeks.
 PCR for HIV RNA is able to reduce the window period to
approximately 1 week.

30. Human T- cell leukaemia viruses.
 HTLV 1 and II are related retroviruses.
 HTLV 1 is endemic in the caribbean, parts of Africa and
in Japan, 3 – 6 % of the population are seropositive.
 HTLV 1 is associated with tropical spastic paraparesis
and adult T cell – leukaemia.
 Importance of HTLV II is not clear.
 Both HTLV 1 and II are cell associated and not
transmitted in plasma.
 Currently available test include ELISA and gelatin
particle assay, but confirmation of positive result are
difficult due to cross reactivity with other retroviruses.

31. Investigation of
transfusion reactions.

32. Investigations of transfusion reaction are necessary for :
1. Diagnosis
2. Selection of appropriate therapy
3. Transfusion management
4. Prevention of future transfusion reaction.
Investigations should include correlations of clinical data with
laboratory result .
Important clinical data :
1. Diagnosis
2. Medical history of pregnancies, transplant, and previous
transfusion.
3. Current medication
4. Clinical signs and symptoms of the reaction.

33. 5. Question related to the transfusion:
Amount of blood transfused to cause the reaction.
How fast , how long ?
The use of blood warmer.
Any filter used ? Other solutions.
Any drugs given at the time of transfusion

34. Laboratory investigation outline of
transfusion reaction.
1.Immediate procedures
• Clerical checks.
• Visual inspection of serum and plasma for free
hemoglobin ( pre and post transfusion )
• Direct anti – globulin test. ( post transfusion EDTA
sample )

35. 2. As recquired procedures
•ABO grouping and RH typing, pre and post
transfusion
•Major compatibility testing , pre and post transfusion
•Antibody screening test , pre and post transfusion
•Alloantibody identification
•Antigen typings
•Free hemoglobin in first voidedurine post transfusion
•Unconjugated bilirubin 5 – 7 hours post transfusion.

36. 3. Extended procedures
•Gram stain and bacterial culture of unit
•Quantitative serum Hemoglobin.
•Serum Haptoglobin , pre and post transfusion
•Peripheral blood film.
•Coagulation and renal output study
•Urine hemosiderin

37. References:
1. Modern blood banking and transfusion practice. Denise
M. Harmening.
2. Post graduate haematology.

38. THE END
Thank you for your attention.