transfusion_reactions_and_their_management

1. NON INFECTIOUS
TRANSFUSION REACTIONS

2. CLASSIFICATION
Transfusion reaction
acute delayed
Immunologic Nonimmunologic Immunologic Nonimmunologic

3. A. Hemolytic transfusion
reactions (HTR)
 Accelerated clearance or lysis of red cells in the
transfusion recipient. Usually d/t immunological
incompatibility b/w blood donor and the recipient
A. C LASSIFICATION WITH RESPECT TO TIME OF
OCCURRENCE
 Acute (AHTRs )
During or within 24 hours of transfusion
 Delayed ( DHTRs )
After 24 hours of transfusion.( 5-7 days )

4. Signs and Symptoms of Acute HTR
Inder GA
•Hypotension
•Hemoglobinuria (This may be masked in patients
undergoing GU surgeries due to hematuria)
•Undue bleeding from surgical site
Abrupt onset Nausea, Vomiting
Anxiety Shock
Facial flushing Oliguria
Fever, chills Hemoglobinuria
Pain in back or flanks Bleeding
Dyspnoea
Under GA
Conscious patient

5. Complications of AHTRS
Renal failure :- 36 %
Thrombus formation in renal
arterioles
DIC :- 10 %

6. Immediate Mx of suspected
AHTRs
A. Action for nursing staff
In presence of fever > 38 0 C and / or any S/s
• Stop the transfusion
• Check the pt identity and unit transfused
• Save any urine the pt passes
• Monitor pulse, BP and temp at 15 min interval

7. Immediate Mx of suspected
AHTRs
B. Action for medical staff
1. Isolated fever / fever & shivering, stable
observations, correct unit given :-
FNHTR = Paracetemol 1 g orally ,
observe P, BP and T every 15 min for 1
hr, then hourly. If no improvement call
hematology medical staff

8. Immediate Mx of suspected
AHTRs
2. Fever with pruritis, urticaria :- Allergic
transfusion reaction = Chlorpheniramine 10
mg iv
3. Any other s/s, hypotension, incorrect unit :-
AHTR = discontinue transfusion, N saline to
maintain urine output 1ml /kg / h. full and
continuous monitoring

9. Mx of AHTRs
 Take immediate note and inform blood bank
 Seek help immediately from skilled anaesthetist or
emergency team
 Complete the transfusion reaction form and
appropriately record the following
• Type of transfusion reaction
• Time after the start of transfusion to the occurrence of
reaction
• Unit No. of component transfused
• Volume of the component transfused

10. 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
Investigation of suspected AHTRs

11. Other reactions characterized
by hemolysis
1. Pts with autoimmune hemolytic anemia
2. Donor units m/b hemolysed due to
• Bacterial contamination
• Excessive warming
• Erroneous freezing
• Addition of drugs or iv fluids
• Trauma from extracorporeal devices
• Red cell enzyme deficiency

12. Maintain adequate renal perfusion by
- Fluid challenges
- Frusemide infusion
- If hypovolumic – dopamine infusion
Transfer to high dependency area
Repeat coagulation and biochemistry screens ever
2- 4 hrly
If urinary output not maintained seek expert renal
advice
Hemofiltration or dialysis m/b required for acute
tubular necrosis
DIC development – component therapy may be
required
Mx of confirmed AHTRs

13. Due to secondary immune responses
following re-exposure to a given red
cell antigen
- Ab most commonly involved – Rh ,
Kidd, Duffy and Kell
- No clinical signs of red cell destruction
but positive DAT
- Rarely fatal
DELAYED HEMOLYTIC TRANSFUSION
REACTIONS

14. Sign and symptoms
- fever
- fall in Hb concentration
- Jaundice and hemoglobinuria
Mx
- Requires no Tt.
- Hypotension & renal failure – may
require expert medical advice
DELAYED HEMOLYTIC TRANSFUSION
REACTIONS

15. Diagnosis & Management
 Routine examination
 Stop Tx immediately
 Monitor vital signs, urine out put
 Verify identification of the patient
 IV line kept open with NS
 Evaluate for evidence of HTR, septic shock, anaphylaxis
TRALI other D/D fever
 Report and send transfusion set to B/B
Diagnosis of exclusion

16. Blood Bank:
• Recheck the records for clerical error
• check for identification error
• Visual check for hemolysis, appearance of returned unit
• Evidence of blood group incomparability
Pre Tx sample Post Tx sample
ABO,Rh group
DCT
ICT
Repeat CxM
•Gram stain, culture
•HLA, Plt, Granulocyte specific Abs in recipient

17. Treatment
 Antipyretics
acetaminophen ; 325-650mg orally
(adult) 10-15mg/kg (children)
 Meperiedine
severe chills - 25-50mg IV
contraindication: renal failure
Pts on MAO inhibitors
 Antihistaminics: not indicated
 Tx should not be restarted for 30 min.

18. D. URTICARIAL AND ANAPHYLACTIC
REACTIONS
- Usually mild allergic reactions
Treatment
- Non systemic reaction = focal urticaria /
angioedema : Antihistamine
- Mild systemic = chest tightness,
generalized urticaria / angioedema :
Antihistamine, salbutamol and / or inhaled
steroid

19. URTICARIAL AND ANAPHYLACTIC
REACTIONS
Moderate systemic = wheeze /
breathlessness / obstructive laryngeal
oedema : All above including prednisolone
, consider adrenaline
Severe systemic = Severe breathing
difficulty, shock arrhythmias, loss of
consciousness : Adrenaline im and all
above

20. E. BACTERIAL CONTAMINATION
Most common microbiological
complication of transfusion
Higher incidence after platelet
transfusion

21. Apparent infrequency of clinical
events of bacterial contamination
Non pathogenic bacteria
- Insufficient no. of bacteria
- Premedication with steroides
- Pts already on antibiotics
- Immunosuppressed pts
underinvestigated

22. Clinical features
- usually appear immediately during
transfusion
- S/t symptoms delayed until after the end of
transfusion
- - fever ( inc > 2 o C )
- - chills / rigors
- Hypotension, collapse, shock
- Nausea, vomitting
- DIC, intravascular hemolysis, renal failure

23. Management
- Stop transfusion. Retain unit for
investigation
- Give general supportive Tt (iv fluids ,
inotropic agents , diuretics to maintain
urine output )
- Broad spectrum antibiotics until blood
culture report comes
- Assess need for intensive care bed

24. 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 Technical Error
Wrong Blood
Issued
Storage Error
Patient
Misidentification
Administrative
Error

25. Error Prevention in the Transfusion Services
 Adherence to Standard Operating Procedures (SOPs)
for pre-transfusion testing
 Antibody screen in patients at risk of alloimmunization;
preferably universal screen
 Antibody identification when required
 Appropriate storage and transfusion instructions on
labels
 Clerical checks prior to issue

26. Prevention of transfusion reaction
Education and training of nurses health care
assistants, doctors at every level
Proper communication at all level should be
appropriate, timely and effective.
Promoting the knowledge in hospital, raising
awareness by having more educational sessions and
poster available to hospital