Acute transfusion reaction

Background

• For all reactions:
  • 1. Stop the transfusion (at least temporaily)
  • 2. Call the blood bank
  • 3. Draw a new type + screen

Acute

1. Intravascular Hemolytic Tranfusion Reaction
   1. Occurs due to ABO incompatibility
   2. Diagnosis
      1. Back pain, headache, hypotension, dyspnea, pulmonary edema, bleeding, renal failure
      2. Labs c/w hemolysis
   3. Treatment
      1. Stop transfusion
         1. Risk of death is proportional to amount of incompatible blood received
      2. Maintain urine output with IVF, mannitol, and furosemide as needed
      3. Treat shock with volume and vasopressors
      4. Treat coagulopathy w/ FFP
2. Febrile Nonhemolytic Tranfusion Reaction
   1. Occurs in 20% of pts due to recipient Ab against donor leukocytes
   2. Diagnosis
      1. Fever, HA, myalgias, tachycardia, dyspnea, chest pain
   3. Treatment
      1. Stop tranfusion pending rule-out of hemolytic transfusion reaction
      2. Give antipyretic
      3. Restart transfusion once hemolytic transfusion reaction is ruled-out
3. Allergic Tranfusion Reaction
   1. Occurs due to immune response to plasma proteins
   2. Diagnosis
      1. Symptoms range from urticaria/pruritus to bronchospasm, wheezing, anaphylaxis (rare)
   3. Treatment
      1. Stop transfusion until able to evaluate severity of allergic reaction
      2. Give diphenhydramine
      3. Restart transfusion if symptoms are mild
4. Transfusion-Related Acute Lung Injury (TRALI)
   1. Due to granulocyte recruitment and degranulation within the lung
   2. More common with FFP and plt tranfusions (extremely rare with pRBC transfusion alone)
   3. Diagnosis
      1. ARDS-like symptoms
      2. B/l pulmonary infiltrates due to noncardiogenic pulmonary edema w/in 6h of transfusion
   4. Treatment
      1. Strop transfusion
      2. Treat like ARDS
      3. Avoid diuresis
5. Fluid Overload
   1. Split pRBCs to tranfuse more slowly (as slow as 1mL/kg/hr)
6. Sepsis
   1. Most commonly due to yersinia which is able to grow easily in refrigerated blood

Delayed

1. Extravascular Hemolytic Tranfusion Reaction
   1. Occurs days to weeks after transfusion
   2. Hemolysis occurs in spleen, liver, and bone marrow
   3. Diagnosis
      1. Hyperbilirubinemia
      2. Poor response to transfusion
   4. Treatment
      1. None necessary; rarely fatal
2. Graft-vs-Host
   1. Occurs in leukemia/lymphoma or immunocompromised
   2. Diagnosis
      1. Fever, rash, N/V
      2. LFT abnormalities, pancytopenia
   3. Treatment
      1. Glucocorticoids
3. Hemosiderosis

Transfusion Risk Ratios

1. 1:10 Febrile non-hemolytic transfusion reaction per pool of 5 donor units of platelets (1 pack)
2. 1:100 Minor allergic reactions (urticaria)
3. 1:300 Febrile non-hemolytic transfusion reaction per unit of RBC (1 pack)
4. 1:700 Transfusion-associated circulatory overload per transfusion episode
5. 1:5000 Transfusion-related acute lung injury (TRALI)
6. 1:7000 Delayed hemolytic transfusion reaction
7. 1:10,000 Symptomatic bacterial sepsis per pool of 5 donor units of platelets
8. 1:40,000 Death from bacterial sepsis per pool of 5 donor units of platelets
9. 1:40,000 ABO-incompatible transfusion per RBC transfusion episode
10. 1:40,000 Serious allergic reaction per unit of component
11. 1: 82,000 Transmission of hepatitis B virus per unit of component
12. 1:100,000 Symptomatic bacterial sepsis per unit of RBC
13. 1:500,000 Death from bacterial sepsis per unit of RBC
14. 1:1,000,000 Transmission of West Nile Virus
15. 1:3,000,000 Transmission of HTLV per unit of component
16. 1:3,100,000 Transmission of hepatitis C virus per unit of component
17. 1:4,700,000 Transmission of HIV per unit of component

Source

1. 2/18/06 DONALDSON (adapted from Rosen)
2. Canadian Blood Services (Public Health Agency of Canada)