Module 6: Complications of blood transfusion

Transfusion Training WorkshopKKM 2012

Complications of blood transfusion Early Acute transfusion reactions

Major life-threatening Haemolysis (ABO incompatibility) Gram-negative Bacteremia Anaphylaxis/ Acute Hypotension

Minor Urticaria Febrile non-haemolytic

transfusion reaction

Transfusion-associated acute lung injury (TRALI)

Delayed/ Late Delayed haemolytic

transfusion reaction Transfusion-

associated graft vs. host disease (TA-GVHD)

Transfusion-transmitted infections (TTI)

Iron overload

Minor acute reactions

Minor transfusion reactions

1. Febrile non-haemolytic transfusion reaction

Commonest type of transfusion reaction Especially frequent in multi-transfused

patients

2. Urticarial reaction

Case 1

30 year old man Known to have a peptic ulcer Presented with severe epigastric pain

OGDS done immediately Forrest 1b ulcer noted Admitted for observation

Day 6, noted Hb dropped to 7 g/dL 2 pint PRBC were requested

Case 1

45 minutes into 1st PRBC

T 38.30C

BP 145/88

HR 95/min

1. Febrile reactions- what to do? Sudden rise in

temperature >1oC ± rigors

No fall in BP Occur during or

within 4 hours of transfusion

Temporarily stop blood Check for clerical error Give paracetamol 1 g po

Review 30 minutes Continue transfusion

slowly If symptoms do not settle

or recur once transfusion resumed, contact the BB

If in doubt, treat/ investigate as a major reaction

Febrile reactions

Antibodies against donor leucocytes in PRBC

Cytokines that accumulate in PRBC with storage

Usually in multiply transfused patients Can be reduced or prevented by

leuko-depletion at collection centre

Case 2

56 year old lady Known to have Myelodysplastic

Syndrome Was regularly transfused for the last 1

year Presented with petechiae and gum

bleeding PLT noted 7 x 109/L

Case 2

4 units of platelets was requested During the 3rd unit of platelet

transfusion, patient c/o rash and itchiness

BP 134/70 HR 86/min

2. Urticarial reaction – what to do? Temporarily stop

blood Give IV piriton 10 mg

± IV hydrocortisone 50-100 mg (repeat 4 – 6 hourly)

Review 30 minutes Continue transfusion

if settling

(Allergic) Urticarial reaction

Generally mild reaction Pre-existing IgE antibody against donor

plasma proteins in platelets or FFP Primed mast cells degranulate and

release chemical mediators including histamine

Major acute reactions

Major transfusion reactions

1. Acute Haemolysis (ABO incompatibility)

2. Gram-negative bacteremic shock

3. Anaphylaxis

Case 3

28 year-old lady

G3 P2, came in labour

Noted Hb 7.5 post-delivery

GXM 2 PC

Case 3 – cont’d

1st PC transfused uneventful

10 minutes into the 2nd PC

c/o severe back pain

BP 80/50 PR 110 T 400C

1. Acute Haemolysis (ABO incompatibility)2. Gram-negative bacteremic shock Suspect if ≥1 are

present: Shortness of breath/

chest pain not due to cardiac problems or pulmonary oedema

Back pain/ loin tenderness

Profound hypotension

Disconnect blood & giving set ; put up saline infusion

Check for clerical error Report to blood bank + specialist Take essential samples:

EDTA: FBC EDTA/plain: 10 mLs for re-GXM,

Coomb’s test and antibody screen DIC screen Renal Profile, serum bilirubin Blood culture First urine passed for

haemoglobinuria Send samples to transfusion lab

with unit giving set + all previous units + completed transfusion reaction form

Acute Haemolysis (ABO incompatibility)= Acute Haemolytic Transfusion Reaction (AHTR) Recipients antibody against donor red cells ABO antibodies are good complement binders Activation of complement results in

intravascular haemolysis and cytokine release Haemoglobinuria (vs. bacteremic shock), renal

failure

Bacterial sepsis

Bacterial contamination of donor blood inadequate aseptic technique during collection coring of the skin with the venipuncture needle transient asymptomatic donor bacteremia chronic low grade donor infection improper refrigeration of RBCs during storage or

transportation contamination during the processing of pooled

products contamination by infected water baths during

thawing of frozen components defects in blood bags

Bacteremic shock

More frequent in platelet transfusion – stored at room temperature

Both gram positive or negative contamination can occur

Symptoms appear during or immediately after blood transfusion

Symptoms of septicaemia, may result in hypotension and shock esp. with gram negative bacteremia

Inappropriate & unnecessary (I&U) transfusion has lead to a major transfusion reaction and mortality!

Inappropriate transfusion to correct iron deficiency anaemia

3. Anaphylaxis (Acute hypotension) Rare Immediate generalised

hypersensitivity reaction Recipient IgE to serum

proteins/ drugs/ in donor blood

IgG antibodies to IgA in patients with congenital IgA deficiency

Clinical features: Acute bronchospasm Oedema Circulatory collapse

Stop blood Maintain venous access

with 0.9% saline Oxygen by mask Adrenaline 1:1000 0.5 or

1.0 ml i/m repeated every 10 min as necessary

Piriton 10-20 mg IV slowly Disconnect blood and

investigate as for 1 & 2 Also investigate for congenital

IgA deficiency

Case 4

35 years old Chinese man

PRCA, transfusion-dependent

Hb 5.1, GXM 4 units PC over 2 days

3 units – no complication

After 120 mLs of 4th unit

c/o headache & SOB

Case 4 – cont’d

BP 60/40 > un-recordable feeble pulse

Resuscitated with i/m adrenaline and fluids

Cardiac monitoring – sinus tachycardia, no acute changes

BP 100/60 PR 93/min

Admitted to ICU for observation

Acute Hypotensive Transfusion Reaction

Looking back

4th PC, nurse decided to use bedside filter

15 minutes later, hypotensive shock

Patient on ARB (valsartan) for cardiomyopathy

Acute Hypotensive Transfusion Reaction Contact activation on negative charged

surface (blood filters)

Bradykinin release from HMWK

Acts on B2 receptors on endothelium

Releases prostaglandins, NO and proinflammatory cytokines

Vasodilatation and acute hypotension

Acute hypotension with ACE-I

1st reported in 1996

ACE hydrolyses bradykinin

ACE-I prevents breakdown of bradykinin

Has also been reported with ARB

Other complications

Case 5

40 year-old man with Paroxysmal Nocturnal Haemoglobinuria (PNH)

Transfused 2 PC for anaemia Hb 8.5

4 h later developed SOB

T 38.50C BP 130/80 PR 100

Transfusion-related acute lung injury (TRALI) (non-cardiogenic pulmonary oedema) During or within 6 hours of a transfusion Usually with WB or FFP Rapid onset of dyspnea and tachypnea Fever, cyanosis, and hypotension Respiratory distress and pulmonary crackles may be

present CXR bilateral pulmonary oedema with bilateral

patchy infiltrates Indistinguishable from Acute Respiratory Distress

Syndrome (ARDS)

TRALI - pathophysiology

Infusion of donor antibodies directed against recipient leukocytes anti-HLA (human leukocyte antigens) anti-HNA (human neutrophil antigens) cause complement activation, neutrophil

activation and release of cytotoxic agents Causing endothelial damage and capillary

leak Treatment: supportive Prevention: exclude donor from registry

Case 6

30 year-old Nigerian lady

Known sickle cell disease

Last crisis 20 years ago

G1P0 @ 14 weeks

Hb 7.0 in private hospital

GXM 2PC requested and transfused

Case 6 – cont’d

10 days later, presented with lower abdominal pain, dyspnoea and back pain

Referred to Ampang hospital on 1st day of CNY

GCS deteriorated

Pale+++ Jaundice++ Haemoglobinuria

Hb 2.0 Bil ID 400 LDH 2300

Normal plasma

Patient’s icteric plasma 10 days later

Group OcDe/cDe = R0R0

Antibodies detected:Anti-E, anti-Jkb and anti-Fya

Case 6 – cont’d

Delay getting matched blood

Exchange transfusion performed after 24 hours

Patient died 8 hours later

Cause of death: Delayed haemolytic transfusion reaction

Delayed haemolytic transfusion reaction (DHTR) Exposure to certain red cell antigens Development of alloantibodies and titres

may diminish with time Re-exposure results in amnestic response Especially with Kidd (anti-Jka and anti-Jkb)

and Duffy (anti-Fya and anti-Fyb) antigens Haemolysis occurs within hours, days or

weeks (typically 10 – 14 days)

Patients at risk for DHTR

Patients at risk for allo-immunization Sickle cell disease Thalassaemia AIHA Patients requiring repeated transfusions

How to prevent? Request for red cell phenotyping before

transfusion Talk to your blood bank specialist Transfuse phenotype-matched blood

Rare complications

Transfusion-associated GVHD

Transfused T lymphocytes can mount an immune reaction towards an immuno-compromised recipient

Can occur if donor and recipient has shared HLA antigens

Higher risk in patients receiving lympholytic chemotherapy e.g. Fludarabine and following BM transplant

High mortality – almost 100% Prevention : Gamma irradiation 2500 cGy (lowest dose

delivered to any portion of the canister should be 1500 cGy)

Indications for irradiated PRBC or platelets Premature babies Intrauterine/ neonatal exchange transfusions Congenital immuno-deficiencies Recipients receiving blood from directed donors

(blood relatives) Recipients with lymphomas esp. Hodgkin’s

Lymphomas Recipients receiving lympholytic therapy (e.g.

fludarabine, cladribine, clofarabine, campath) Recipients undergoing autologous or allogenic stem

cell transplants

Case 7

28 year-old lawyer c/o fever x 4 days Hb 12.5 Hct 36 Plt 18 No evidence of plasma leakage Having her menses Diagnosis: Dengue fever Transfused 4 units random platelets

(I&U)

Case 7 – cont’d

6 months later… Medical check-up Found to be HIV positive No risk factors

Transfusion-transmitted infections Risk of TTI:

HIV 1:2 million donations HCV 1:2 million donations HBV 1: 200,000 - 500,000 donations

Susan L, Arch Pathol Lab ed 2007

Blood is never 100% safe

Always a risk of transmission of virus and bacteria

Inappropriate & unnecessary (I&U) transfusion has lead to transmission of an infectious disease and its consequences

The next time you decide to transfuse

Stop, think and ask yourself …

Is it really necessary?

The end