blood transfusion reactions haemovigilance serious hazards of transfusion ( shot )

Blood Transfusion ReactionsBlood Transfusion Reactions

Col.Dr.Mohamed H Khalaf,MDCol.Dr.Mohamed H Khalaf,MDHead, Department of HaematologyHead, Department of Haematology

Maadi A F Medical CompoundMaadi A F Medical Compound

Blood Transfusion ReactionsBlood Transfusion Reactions

HaemovigilanceHaemovigilanceSerious Hazards of Transfusion Serious Hazards of Transfusion

( SHOT )( SHOT )

Blood Transfusion ReactionsBlood Transfusion Reactions Haemovigilance Haemovigilance

Serious Hazards of Transfusion ( SHOT )Serious Hazards of Transfusion ( SHOT )

65% Incorrect Blood Component65% Incorrect Blood Component10% Acute Transfusion Reaction10% Acute Transfusion Reaction10% Delayed Transfusion Reaction10% Delayed Transfusion Reaction5% Transfusion Lung Injury5% Transfusion Lung Injury3% Post-transfusion purpura3% Post-transfusion purpura3% Transfusion Transmitted Infection3% Transfusion Transmitted Infection1% Transfusion-GVHD1% Transfusion-GVHD

Blood Transfusion: Blood Transfusion: ImmediateImmediate ReactionsReactions

1. Acute Haemolytic Transfusion Reactions

2. Febrile Non-Haemolytic Transfusion Reactions

3. Allergic Reactions:

1. Anaphylaxis

2. Skin Reaction

4. Transfusion-related Acute Lung Injury

5. Bacterial Contamination

6. Circulatory Overload

7. Citrate Intoxication

Blood Transfusion: Blood Transfusion: DelayedDelayed Reactions Reactions

1. Delayed Haemolytic Transfusion Reactions

2. Post- transfusion Purpura

3. Infection Transmission

4. Transfusion-related Graft-versus-Host Disease

5. Immune Modulation

6. Iron Overload

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Haemolytic Transfusion Acute Haemolytic Transfusion ReactionsReactions

• Intra-vascular

• Extra-vascular

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Intra-vascular Haemolytic Acute Intra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions

• Trigger: ABO antigens on transfused red cells Not shared by the Recipient

• Reactor: Anti-A or Anti-B of Ig M type

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Intra-vascular Acute Intra-vascular Haemolytic Transfusion Haemolytic Transfusion

ReactionsReactions Pathophysiology

Full Complement cascade Activation

1. Complement Components C3a,C5a

2. Cytokines: IL-1, IL-6,IL-8, TNF

3. Free Haemoglobin – ATN

4. DIC

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Intra-vascular Haemolytic Acute Intra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions

Clinical Picture• Fever, Flushing, Rigors• Headache• Heat or pain at cannulated vein• Restlessness• Bronchospasm• Hypotension• Back or loin pain• Oozing in the surgical field• Red urine ( haemoglobinuria )• Oliguria or anuria

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Intra-vascular Haemolytic Acute Intra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions

Diagnosis• Clinical picture

• Transfusion Mistake

• Red urine

• Red plasma

• Lab Confirmation

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Intra-vascular Haemolytic Acute Intra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions

Laboratory Workup• Obtain Blood and urine samples, inspect color• Check paper work• Repeat cross Match• CBC• Direct Coombs’ test• DIC screen: PT,PTT, Fibrinogen• BUN, Cr, electrolytes• Haemolysis screen: LDH, Haptoglobin• Blood culture if sepsis is suspected

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Intra-vascular Haemolytic Acute Intra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions

Management• Stop transfusion Immediately• Replace giving set, keep IV line with Normal saline• Check patient ID against donor unit• Cardio-pulmonary support• Insert urine cath. And start Forced Diuresis

( ensure 100 ml/h for 24 h to get rid of free Hb and prevent renal VC)

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Intra-vascular Haemolytic Acute Intra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions

ManagementSaline Diuresis

• If urine < 1.5 ml/kg/h + Low CVP: More Fluid• If urine < 1.5 ml/kg/h + Normal CVP: – Fluid Challenge + 80 -120 mg Frusemide

+ Renal dose Dopamine ( 1-2 ug/kg/min)• If No response: Consult Nephrologist

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Intra-vascular Haemolytic Acute Intra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions

Outcome

Mortality ~ 10 %

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Extra-vascular Haemolytic Acute Extra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions

Trigger: Rh antigens not shared by the patient

Reactor: Anti-Rh antibodies of Ig G type

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Extra-vascular Haemolytic Acute Extra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions

Response: Pathophysiology

• Incomplete complement activation

Coating of transfused red cells with C3b

• Extravascular phagocytosis by RES

• Cytokines from activated RES

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Extra-vascular Haemolytic Acute Extra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions

Clinical Features• Less severe, may be no signs• Onset > I hour• Fever• + Jaundice• Rarely Haemoglobinuria or renal dysfunction

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Extra-vascular Haemolytic Acute Extra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions

Laboratory

• Anti-complementary Coombs positive

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Extra-vascular Haemolytic Acute Extra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions

Managment

• Stop Transfusion

• Supportive

• Mortality very rare

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Febrile Non-Haemolytic Transfusion Febrile Non-Haemolytic Transfusion Reaction ( FNHTR)Reaction ( FNHTR)

Trigger: Leucocyte antigens on infused blood not shared by the patient

Reactors: Leuco-agglutinins in the patient from previous exposure

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Febrile Non-Haemolytic Transfusion Febrile Non-Haemolytic Transfusion Reaction ( FNHTR)Reaction ( FNHTR)

Pathophysiology• Cytokine released from the transfused activated

leucocytes

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Febrile Non-Haemolytic Transfusion Febrile Non-Haemolytic Transfusion Reaction ( FNHTR)Reaction ( FNHTR)

Clinical Features• Fever after 30-90 min• + Rigors• + Headache• No Hypotension• No Bronchospasm• No flank pain• No haemoglobinaemia• No Haemoglobinuria

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Febrile Non-Haemolytic Transfusion Febrile Non-Haemolytic Transfusion Reaction ( FNHTR)Reaction ( FNHTR)

Management• If Temp < 40 + Stable patient:

– Stop transfusion– Antipyretics ( No rule of Anti-histamines )– Check the bag and cross match– Exclude red urine or red plasma– Resume transfusion at a slower rate– If recurrent: Leucodepleted transfusion in the future

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Febrile Non-Haemolytic Transfusion Febrile Non-Haemolytic Transfusion Reaction ( FNHTR)Reaction ( FNHTR)

Management• If Temp 40 or more + Unstable patient:– Stop transfusion– Manage as possible acute haemolytic

reaction till lab. Confirmation or exclusion

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Transfusion- Related Acute Lung Transfusion- Related Acute Lung Injury ( TRALI)Injury ( TRALI)

Sudden onset of acute respiratory distress within 6 hours( u. 1-2h) of

transfusion

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Transfusion- Related Acute Lung Transfusion- Related Acute Lung Injury ( TRALI)Injury ( TRALI)

Rare: 1/5000 transfusions

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Transfusion- Related Acute Lung Transfusion- Related Acute Lung Injury ( TRALI)Injury ( TRALI)

Pathophysiology• Trigger: Leucoagglutinins in the bag

against patient’s leucocytes• Reactors: Patient leucocytes• Result: massive Leucocyte activation Cytokine storm

Pulmonary Endothelial and Epithelial Injury

ARDS

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Transfusion- Related Acute Lung Transfusion- Related Acute Lung Injury ( TRALI)Injury ( TRALI)

Clinical Features• Fever, chills• Acute Respiratory Distress• Normal CVP• CXR: Pulmonary Infiltrate

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Transfusion- Related Acute Lung Transfusion- Related Acute Lung Injury ( TRALI)Injury ( TRALI)

Management

• Cardio-Pulmonary Support• Steroids• Diuretics of No value

MortalityHigh

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Allergic Acute Transfusion Allergic Acute Transfusion ReactionsReactions

Pathophysiology• Trigger: Plasma proteins in the transfused blood• Reactors: Patient antibodies of IgE type• Response:

– Mast cell degranulation– + Complement Activation– + Cytokines

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Allergic Acute Transfusion Allergic Acute Transfusion ReactionsReactions

Clinical Features• Mild / Skin-restricted ( common: 1%):

– Pruritus, Uerticaria, No fever or Hypotension

• Severe / Systemic ( Anaphylaxis):– As above +– Fever– Hypotension– Bronchospasm, Angio-edema

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Allergic Acute Transfusion Allergic Acute Transfusion ReactionsReactions

Management• Mild / Skin-restricted :

– Stop transfusion temporary– Anti-histamines– Resume Transfusion

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Allergic Acute Transfusion Allergic Acute Transfusion ReactionsReactions

Management• Severe / Systemic ( Anaphylaxis):

– Stop transfusion – Anti-histamines ( H1+H2 blockers)– Epinephrine: 1 ml of 1/1000 IM– Hydrocortisone 100 mg IV– Cardio-pulmonary support

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Pyrogenic Transfusion Acute Pyrogenic Transfusion ReactionsReactions

Pathophysiology• Trigger: Bacterial Pyrogens/Endotoxins in the

transfused blood contaminated with cold-growing organisms as:– Psudomonas– Yersinia– Some Staph

• Reactors: Patient Mono-nuclear cells• Response:

– Cytokine Storm

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Pyrogenic Transfusion Acute Pyrogenic Transfusion ReactionsReactions

Clinical FeaturesLike :

• Acute Haemolytic reaction BUT:– No Hemoglobinuria– No Hemoglobinaemia

• FNHTR BUT More Severe

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Pyrogenic Transfusion Acute Pyrogenic Transfusion ReactionsReactions

Management

• As Acute Haemolytic reaction

BUT

Add Broad- spectrum Antibiotics

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Circulatory Overload Acute Circulatory Overload

• Acute cardiogenic pulmonary edema• In rapidly transfused, non-bleeding ( euovolemic)

patiens• More in infants, elderly or cardiac patients

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Circulatory Overload Acute Circulatory Overload

D.D. from other Acute transfusion reactions:• No Fever ( DD from TRALI, FNHTR)• No red urine or plasma and Negative Coombs

( DD from Acute haemolytic reaction)

Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:

Acute Circulatory Overload Acute Circulatory OverloadPrevention

• Never exceed 2-3 ml/kg/hour Unless Bleeding• Pre-medicate with Diuretics in Cardiac or severely

anemic patients

Management• Diuretics• + Inotropics• Consider Haemodialysis• Supportive

Other Immediate Blood Transfusion Other Immediate Blood Transfusion Reactions: Reactions:

• Hypothermia

• Citrate Intoxication

Delayed Blood Transfusion Delayed Blood Transfusion ReactionsReactions

1. Delayed Haemolytic transfusion reactions

2. Post-transfusion Purpura

3. Infection transmission

4. Transfusion GVHD

5. Iron Overload

6. Immune Modulation

Massive Blood TransfusionMassive Blood Transfusion

Massive Blood Transfusion Massive Blood Transfusion

Definition

Transfusion of Blood ~ Blood Volume within 24 hours

•20 units whole blood

•10 units packed cells

Massive Blood Transfusion Massive Blood Transfusion

Complications

• Dilutional Thrombocytopenia

•Dilutional Coagulopathy

•Metabolic

•Hypothermia

Massive Blood Transfusion Massive Blood Transfusion

Complications

• Dilutional Thrombocytopenia

•Common after 10 units

•Severe after 20 units

•Give platelet transfusion if < 80,000 + bleeding

Massive Blood Transfusion Massive Blood Transfusion

Complications

•Dilutional Coagulopathy

•Particularily if blood stored > 2 weeks

•Monitor Coagulation profile

•FFP if Abnormal lab

•DIC is Rare

Massive Blood Transfusion Massive Blood Transfusion

Complications

•Metabolic: Citrate Intoxication

•Acidosis, Hypocalacemia, Hyperkalaemia

•Rare Except in Infants or Hepatic patients