Download blood transfusion reaction in pediatric age group

Suhailur Rehman
Arif SH, Mehdi G, Afzal K, Siddiqui S
Department of Pathology & Pediatrics, JN
Medical College, AMU, Aligarh
Types of transfusion reactions
Transfusion reactions may be acute or delayed:
 Acute transfusion reaction (within 24 hours).
 Delayed transfusion reaction (> 24hr upto months
and years)
 Acute transfusion reactions are further subdivided into
immunologic and non-immunologic reactions.
Immunologic Acute
Transfusion rxn
Non Immunologic
Acute Transfusion Rxn
Haemolytic transfusion
reactions
FNHTR
Transfusion associated
sepsis:
Circulatory overload
Allergic reactions
Non immune haemolysis
due to physical/ chemical
means
Hypocalcemia:
Anaphylactic reactions
Transfusion related acute Hyperkalemia
lung injury
Hypothermia
Immunological
Delayed transfusion
reaction
Non Immunological
Delayed transfusion
reaction
Alloimmunization to
RBC antigen and HLA
antigen
Delayed haemolytic
transfusion reaction
Transfusion induced
hemosiderosis
Transfusion associated
GVHD
Post transfusion purpura
Introduction
Pediatric transfusion concerns are usually divided into
two periods:
 Neonates from birth through 4months
 Older infants (>4 months) and children
Reason for considering neonates and infants separately:
 Small blood volume
 Decreased production of endogenous Erythropoietin
in the premature infant.
 Physiological anemia of infancy.
 They have immature immune and metabolic processes
Transfusion reaction in neonates and infants deferred
from adults for the similar reasons.
Objective of the study
 It was seen in my pediatric posting during internship
that ,a large number transfusion reactions in neonates
and infants occurred as compared to adults.
 When I searched the literature, we found very few
studies in pediatric age group to the best of my effort.
 So, I decided to perform this study during my post
graduate study and I found a very alarming results.
Aim of the study:
 To analyse the type of transfusion reaction seen in
pediatric age group due to different components.
 To analyse most common type of transfusion reaction.
 To find the probable reason associated with them.
Materials and methods
 The study was conducted on 500 patients admitted
to pediatric ward of JN Medical College, AMU,
Aligarh, India
 Pt. who were given transfusion of any of the
component were evaluated for transfusion
reactions accordingly.
Transfusion reactions that occurred in the course of
study were evaluated under following heads:
 Clinical profile of the patients was assessed before
and after transfusion.
 Blood grouping and cross matching was done by
standard techniques (Gel Technology, Diamed
GmbH Cressier FR Switzerland) .
 Component transfused.
 Volume transfused.
 Time taken for transfusion.
 Signs and symptoms that developed after reaction if
any.
 To find the reason for the reaction to develop.
If there is any reaction it will be examined according to
the same protocol as that of adult –
 History of patient.
 Pre & post transfusion clinical profile.
 Volume of the component transfused.
 Any previous transfusion.
 Sample required for investigations are
1. Pre & post transfusion blood sample
2. Urine samples
 Condition of the blood bag and its contents like colour
of plasma, any supernatant etc.
 Re-cross match (using gel technique) and
Agglutination test (direct and indirect) was done in
every case of transfusion reaction.
 Urine was examined for its color or any
hemoglobinuria.
Observation and results
 Males were more common than females, who required
blood transfusion.
 M:F ratio of 1.55:1 was found .
Blood group
B+ve
O+ve
A+ve
AB+ve
B-ve
O-ve
AB-ve
A-ve
Rh Positivity
Percentage
36.2%
32.4
19.2%
6.6%
3.2%
1.4%
0.6%
0.4%
94.4%
DIAGNOSIS
Sepsis
Malaria
Pancytopenia
Thalassemia
Hepatitis
Dengue
DIC
Trauma/surgery
Iron def anemia
HDN
NO. OF CASES (%)
119 (23.8%)
71( 14.2%)
39 (7.8%)
35 (7%)
29 (5.8%)
26 (5.2%)
23 (4.6%)
23 (4.6%)
18 (3.6%)
18 (3.6%)
DIAGNOSIS
Leukemia
Severe pneumonia
Cyanotic CHD
Megalobl anemia
ITP
Meningitis
Burns
H. Spheroctosis
Others
Total
Diagnosis of Total no. of cases
NO. OF CASES (%)
17 (3.4%)
14 (2.8%)
9 (1.8%)
8 (1.6%)
8 (1.6%)
6 (1.2%)
3 (0.6%)
3 (0.6%)
31 (6.2%)
500 (100%)
 Sepsis/Infection was one of the common disease for
which the transfusion was given, especially FFP.
However, it was not an approved indication for
transfusion.
 Malaria with features of hemolysis and
thrombocytopenia was the 2nd most common
encountered disease, due to endemecity in an around
Aligarh.
Acute Transfusion Reaction
Sign &Symp
(Reaction)
PRBC
(n=287)
FFP
(n=116)
Platelet
(n=102)
WB
(n=52)
Total
(n=557)
CHF
Chills
Cyanosis
Resp. Distress
Fever (FNHTR)
Hemoglobinuria
Pain at inf. site
Rashes
Tachycardia
Trali
Vomiting
Total
5 (1.7%)
6 (2.1%)
1 (0.3%)
7 (2.4%)
4 (1.4%)
4 (1.4%)
7 (2.4%)
2 (0.7%)
1 (0.3%)
37
(12.9%)
2 (1.7%)
1 (0.9%)
2 (1.7%)
1 (0.9%)
5 (4.3%)
11
(9.5%)
5 (4.9%)
3 (2.9%)
8
(7.8%)
4 (7.7%)
3 (5.8%)
5 (9.6%)
1 (1.9%)
1 (1.9%)
14
(26.9%)
9 (1.6%)
11 (2%)
1
3
18 (3.2%)
4
4
16 (2.8%)
2
1
1
70
(12.57%)
Acute transfusion reaction
 Acute transfusion reaction was seen in 12.57% of the
cases.
 PRBC (12.9%)was the most common component
associated with reaction followed by FFP (9.5%).
 FNHTR (3.2%)was the most common transfusion
reaction encountered in pediatric age group.
 FNHTR was most commonly seen in WB
(9.6%)followed by platelet transfusion (4.9%).
 2nd most common transfusion reaction seen was
allergic rashes (2.8%).
 Most common component responsible was FFP (4.3%)
 3rd most common reaction seen was Chills (2%).
 Most commonly seen in WB and PRBC.
 However, in most of the cases chills was associated
with fever.
Delayed transfusion reactions
 Due to loss of follow up, delayed transfusion
reactions could not be traced properly.
 However, FNHTR was seen followed by rashes in some
of the cases returned to OPD.
 Platelet transfusion and WB transfusion were the
component responsible.
Delayed transfusion reactions
Sign
&Symptoms
(Reaction)
WB
(n=52)
Fever
4
2
-
2
8
Rashes
1
1
-
-
2
Total
5 (9.6%)
PRBC
FFP Platelet
(n=287) (n=116) (n=102)
3 (1%)
-
Total
10
2 (1.9%)
(1.8%)
Discussion
 Acute transfusion reaction was seen in 12.57% cases.
 PRBC (12.9%)was the most common component
associated with reaction followed by FFP (9.5%) and
platelets (7.8%).
 In a study done by Pedrosaa et al [2013], a prevalence
of reactions of 3.8% was seen in paediatric age group.
None of the children who had a reaction were
neonates.
 Regarding the total number of transfusions, adverse
events occurred involving 1.1% of packed red blood
cells, 2.4% of platelet concentrate and 0.8% of
plasma. [Pedrosaa et al ,2013]
 Oakley et al [2015] found an incidence of 6.2 reactions
per 1000 transfusions within the paediatric (age <
21) population and an incidence of 2.4 reactions per
1000 transfusions within the adult population.
 Transfusion reactions were most commonly associated
with PLT, followed by RBC, and then plasma
transfusions. [Oakley et al. 2015]
 This was an alarming result seen during this study as
compared to other studies.
 The reasons could be: pediatric and neonatal age
group who are prone and susceptible to their low
blood volume and less erythropoietin production,
lower immunity status etc.
 Transfusion reactions like fever, rashes, chills and
pain at infusion sites which can be controlled
easily by medications, may be under reported in
other studies.
 FNHTR was most commonly seen in platelets
(4.9%)and whole blood (9.6%), the reason of which
are contaminating WBCs or by cytokines in the
plasma produced by the WBCs during storage.
 Yazer et al (2004) reported 0.33% of nonhemolytic immunological transfusion reaction in
red cell transfusions and 0.45% in platelet
transfusions.
 Allergic reactions were due to FFP (4.3%) , the
reason of which were A/b to donor plasma proteins.
The probable reason for higher transfusion reactions
found in this study were:
Fast transfusion of the blood bags.
Multiple transfusions in chronic programmes
like thallassemia.
Prolonged transfusion due to highly viscous PRBC
transfused through small bore needles in
pediatric age group .
Wrong indication.
Improper temperature maintenance of the bag
at the time of transfusion
 The disease itself acting as an aggravating factor.
 A detailed eye seeking observation done by my
side starting from the component preparation till
the end of the transfusion and upto 24 hrs more,
making detection of transfusion reaction easy,
hence increasing their frequency.
Precautions which should to be taken
 Use of standard protocol for transfusion led by the
transfusion committee should be followed strictly.
 Rate and volume of the blood product transfused
should be according to the weight and age of the
patient as they are more vulnerable to volume
overload, rapid change in temperature and have
immature and inexperienced cellular and humoral
immune system.
 Every transfusion must be carefully watched; pre
transfusion vitals must be checked and recorded
before starting transfusion and every 15-30 minutes
after starting of transfusion.
 Warming the blood bag to the body temperature
 If any symptoms related to transfusion reaction are seen,
transfusion must be stopped immediately and attempt for
starting the transfusion after a while can be taken.
 Slowing the rate of transfusion, if some initial symptoms
develops.
 Changing the IV catheter, if required.
 But, if reactions did occur again, then the blood bag with
all its content and urine should be send to the blood bank
of the hospital for evaluation according to the protocol.
 Some of the transfusion reactions can be
controlled by medications.
 Leukoreduced platelets/FFP/Whole blood.
 Irradiation should be done wherever required.
 Use of single donor platelets should be
encouraged in place of random donor platelets.
 Specific education of staff, residents in paediatric
transfusion practice is very important.
 The wearing and checking of patient identification
e.g. Wristbands is essential in the paediatric age group.
Donor exposure is reduced by using 'paedipacks‘(aliquots), where
multiple neonatal small-volume transfusions can be given from the
same donation up to the expiry date.
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