blood transfusion reactions col.dr.mohamed h khalaf,md head, department of haematology maadi a f...

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


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


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



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



Diagnosis• Clinical picture

• Transfusion Mistake

• Red urine

• Red plasma

• Lab Confirmation



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



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)



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



Outcome

Mortality ~ 10 %


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



Response: Pathophysiology

• Incomplete complement activation

Coating of transfused red cells with C3b

• Extravascular phagocytosis by RES

• Cytokines from activated RES



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



Laboratory

• Anti-complementary Coombs positive



Managment

• Stop Transfusion

• Supportive

• Mortality very rare


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



Pathophysiology• Cytokine released from the transfused activated

leucocytes



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



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



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

reaction till lab. Confirmation or exclusion


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



Rare: 1/5000 transfusions



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



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



Management

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

MortalityHigh


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



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

– Pruritus, Uerticaria, No fever or Hypotension

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



Management• Mild / Skin-restricted :

– Stop transfusion temporary– Anti-histamines– Resume Transfusion



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


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



Clinical FeaturesLike :

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

• FNHTR BUT More Severe



Management

• As Acute Haemolytic reaction

BUT

Add Broad- spectrum Antibiotics


Acute Circulatory Overload Acute Circulatory Overload

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

patiens• More in infants, elderly or cardiac patients


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)


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


Complications

• Dilutional Thrombocytopenia

•Dilutional Coagulopathy

•Metabolic

•Hypothermia


Complications

• Dilutional Thrombocytopenia

•Common after 10 units

•Severe after 20 units

•Give platelet transfusion if < 80,000 + bleeding


Complications

•Dilutional Coagulopathy

•Particularily if blood stored > 2 weeks

•Monitor Coagulation profile

•FFP if Abnormal lab

•DIC is Rare


Complications

•Metabolic: Citrate Intoxication

•Acidosis, Hypocalacemia, Hyperkalaemia

•Rare Except in Infants or Hepatic patients

blood transfusion reactions col.dr.mohamed h khalaf,md head, department of haematology maadi a f...

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blood transfusion reactionscol

acute transfusion reaction

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posttransfusion purpura

incorrect blood component

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