Download Transfusion

Blood Transfusion Reactions
Col.Dr.Mohamed H Khalaf,MD
Head, Department of Haematology
Maadi A F Medical Compound
Blood Transfusion Reactions
Haemovigilance
Serious Hazards of Transfusion
( SHOT )
Blood Transfusion Reactions
Haemovigilance
Serious Hazards of Transfusion ( SHOT )
65% Incorrect Blood Component
10% Acute Transfusion Reaction
10% Delayed Transfusion Reaction
5% Transfusion Lung Injury
3% Post-transfusion purpura
3% Transfusion Transmitted Infection
1% Transfusion-GVHD
Blood Transfusion:
Immediate
Reactions
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:
Delayed
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:
Acute Haemolytic Transfusion
Reactions
•
Intra-vascular
•
Extra-vascular
Immediate Blood Transfusion Reactions:
Acute Intra-vascular Haemolytic
Transfusion Reactions
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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:
Acute Intra-vascular
Haemolytic Transfusion
Reactions
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:
Acute Intra-vascular Haemolytic
Transfusion Reactions
Clinical Picture
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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:
Acute Intra-vascular Haemolytic
Transfusion Reactions
Diagnosis
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Clinical picture
Transfusion Mistake
Red urine
Red plasma
Lab Confirmation
Immediate Blood Transfusion Reactions:
Acute Intra-vascular Haemolytic
Transfusion Reactions
Laboratory Workup
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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:
Acute Intra-vascular Haemolytic
Transfusion 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:
Acute Intra-vascular Haemolytic
Transfusion Reactions
Management
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•
Saline 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:
Acute Intra-vascular Haemolytic
Transfusion Reactions
Outcome
Mortality ~ 10 %
Immediate Blood Transfusion Reactions:
Acute Extra-vascular Haemolytic
Transfusion Reactions
Trigger: Rh antigens not shared by the
patient
Reactor: Anti-Rh antibodies of Ig G type
Immediate Blood Transfusion Reactions:
Acute Extra-vascular Haemolytic
Transfusion 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:
Acute Extra-vascular Haemolytic
Transfusion Reactions
Clinical Features
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Less severe, may be no signs
Onset > I hour
Fever
+ Jaundice
Rarely Haemoglobinuria or renal dysfunction
Immediate Blood Transfusion Reactions:
Acute Extra-vascular Haemolytic
Transfusion Reactions
•
Laboratory
Anti-complementary Coombs positive
Immediate Blood Transfusion Reactions:
Acute Extra-vascular Haemolytic
Transfusion Reactions
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Managment
Stop Transfusion
Supportive
Mortality very rare
Immediate Blood Transfusion Reactions:
Febrile Non-Haemolytic Transfusion
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:
Febrile Non-Haemolytic Transfusion
Reaction ( FNHTR)
Pathophysiology
•
Cytokine released from the transfused activated
leucocytes
Immediate Blood Transfusion Reactions:
Febrile Non-Haemolytic Transfusion
Reaction ( FNHTR)
Clinical Features
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Fever after 30-90 min
+ Rigors
+ Headache
No Hypotension
No Bronchospasm
No flank pain
No haemoglobinaemia
No Haemoglobinuria
Immediate Blood Transfusion Reactions:
Febrile Non-Haemolytic Transfusion
Reaction ( FNHTR)
•
Management
If Temp < 40 + Stable patient:
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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:
Febrile Non-Haemolytic Transfusion
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:
Transfusion- Related Acute Lung
Injury ( TRALI)
Sudden onset of acute respiratory
distress within 6 hours( u. 1-2h) of
transfusion
Immediate Blood Transfusion Reactions:
Transfusion- Related Acute Lung
Injury ( TRALI)
Rare: 1/5000 transfusions
Immediate Blood Transfusion Reactions:
Transfusion- Related Acute Lung
Injury ( TRALI)
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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:
Transfusion- Related Acute Lung
Injury ( TRALI)
Clinical Features
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Fever, chills
Acute Respiratory Distress
Normal CVP
CXR: Pulmonary Infiltrate
Immediate Blood Transfusion Reactions:
Transfusion- Related Acute Lung
Injury ( TRALI)
Management
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Cardio-Pulmonary Support
Steroids
Diuretics of No value
Mortality
High
Immediate Blood Transfusion Reactions:
Allergic Acute Transfusion
Reactions
Pathophysiology
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Trigger: Plasma proteins in the transfused blood
Reactors: Patient antibodies of IgE type
Response:
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Mast cell degranulation
+ Complement Activation
+ Cytokines
Immediate Blood Transfusion Reactions:
Allergic Acute Transfusion
Reactions
Clinical Features
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Mild / Skin-restricted ( common: 1%):
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Pruritus, Uerticaria, No fever or Hypotension
Severe / Systemic ( Anaphylaxis):
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As above +
Fever
Hypotension
Bronchospasm, Angio-edema
Immediate Blood Transfusion Reactions:
Allergic Acute Transfusion
Reactions
Management
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Mild / Skin-restricted :
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Stop transfusion temporary
Anti-histamines
Resume Transfusion
Immediate Blood Transfusion Reactions:
Allergic Acute Transfusion
Reactions
Management
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Severe / Systemic ( Anaphylaxis):
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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:
Acute Pyrogenic Transfusion
Reactions
Pathophysiology
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Trigger: Bacterial Pyrogens/Endotoxins in the
transfused blood contaminated with cold-growing
organisms as:
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Psudomonas
Yersinia
Some Staph
Reactors: Patient Mono-nuclear cells
Response:
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Cytokine Storm
Immediate Blood Transfusion Reactions:
Acute Pyrogenic Transfusion
Reactions
Clinical Features
Like :
Acute Haemolytic reaction BUT:
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No Hemoglobinuria
No Hemoglobinaemia
FNHTR BUT More Severe
Immediate Blood Transfusion Reactions:
Acute Pyrogenic Transfusion
Reactions
Management
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As Acute Haemolytic reaction
BUT
Add Broad- spectrum Antibiotics
Immediate Blood Transfusion Reactions:
Acute Circulatory Overload
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Acute cardiogenic pulmonary edema
In rapidly transfused, non-bleeding ( euovolemic)
patiens
More in infants, elderly or cardiac patients
Immediate Blood Transfusion Reactions:
Acute Circulatory Overload
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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:
Acute Circulatory Overload
Prevention
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Never exceed 2-3 ml/kg/hour Unless Bleeding
Pre-medicate with Diuretics in Cardiac or severely
anemic patients
Management
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Diuretics
+ Inotropics
Consider Haemodialysis
Supportive
Other Immediate Blood Transfusion
Reactions:
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Hypothermia
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Citrate Intoxication
Delayed Blood Transfusion
Reactions
1. Delayed Haemolytic transfusion reactions
2. Post-transfusion Purpura
3. Infection transmission
4. Transfusion GVHD
5. Iron Overload
6. Immune Modulation
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
Complications
• Dilutional Thrombocytopenia
•Dilutional Coagulopathy
•Metabolic
•Hypothermia
Massive Blood Transfusion
Complications
• Dilutional Thrombocytopenia
•Common after 10 units
•Severe after 20 units
•Give platelet transfusion if < 80,000 +
bleeding
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
Complications
•Metabolic: Citrate Intoxication
•Acidosis, Hypocalacemia, Hyperkalaemia
•Rare Except in Infants or Hepatic
patients