Reaction Type

Symptoms

Cause

Frequency

Prevention

Acute Hemolytic Reaction

Fever, chills and fever, the feeling of heat along the vein in which the blood is being transfused, pain in the lumbar region, constricting pain in the chest, tachycardia, hypo-tension, and hemoglobinemia with subsequent hemoglo-binuria and hyperbilirubin-emia.

A "feeling of impending doom" is frequently reported by the patient as an early sign of this reaction.

In an unconscious or anesthe-tized patient: Uncontrollable bleeding due to disseminated intravascular coagulation may be the only sign of a hemolytic transfusion reaction

Human error such as mislabeled pretransfusion specimen; the transfusion of properly labeled blood to the wrong person, or clerical errors occurring within the Blood Bank

transfused red cells react with circulating antibody in the recipient with resultant intravascular hemolysis

Most likely to occur when a group O patient is mistakenly transfused with group A, B, or AB blood. Patients receiving a major ABO- incompatible marrow or stem cell transplant with sufficient red cell content will likely develop an acute hemolytic reaction

Rare

proper identification of patients, pretransfusion blood samples and blood components at the time of transfusion

DELAYED HEMOLYTIC REACTIONDelayed Hemolytic Reaction

Notify the Blood Bank at the time the reaction is suspected, to allow prompt investigation. Care must be taken that subsequently transfused red cells lack the antigen corresponding to the patient's antibody.

the most common signs are a falling hematocrit (due to extravascular destruction of the transfused red blood cells) and a positive direct antiglobulin (Coombs) test (DAT).

"delayed" hemolytic reactions commonly occurs about 4-8 days after blood transfusion, but may develop up to one month later. There may also be hemoglobinuria and a mild elevation of the serum bilirubin. . Symptomatic patients may manifest fever and leukocytosis thus appearing to have an occult infection.

Many delayed hemolytic reactions will go undetected because the red cell destruction occurs slowly

Delayed hemolytic reactions occur in patients who have developed antibodies from previous transfusion or pregnancy but, at the time of pretransfusion testing, the antibody in question is too weak to be detected by standard procedures. Subsequent transfusion with red cells having the corresponding antigen results in an anamnestic antibody response and hemolysis of transfused red cells.

Uncomon

Febrile

fever or chill fever A temperature rise of 1.8 F or 1.0 C from the baseline

Cytokines and antibodies to leukocyte antigens reacting with leukocytes or leukocyte fragments

1 in 8 transfusions

Allergic - urticaria

allergic reactions may be associated with laryngeal edema and bronchospasm.

If coupled with another sign, such as fever, evaluation for a hemolytic reaction may be indicated.

this reaction is caused by foreign plasma proteins

1% of recipients

Allergic - Anaphylaxis

anaphylactic or anaphylactoid Respiratory involvement with dyspnea or stridor may be more pronounced than is usually seen in typical allergic reactions.

Reactions manifest cardiovascular instability that includes hypotension, tachycardia, loss of consciousness, cardiac arrhythmia, shock and cardiac arrest.

may be due to anti-IgA

Rare

TRALI

abrupt onset of noncardiogenic pulmonary edema Severe cases may require assisted ventilation with high FIO2..

TRALI has been associated with the presence of antibodies in the donor plasma reactive to recipient leukocyte antigens or with the production of inflammatory mediators during storage of cellular blood components

TRALI is a rare though under recognized complication of transfusion

Most cases of TRALI resolve within 72 hours although fatalities may occur in approximately 10 percent of cases.

Volume Overlead

transfusion-related volume overload

Infuse smaller volumes more slowly

Bacterial Contamination

hypotension, shock, fever and chills, nausea and vomiting, and respiratory distress. Diagnosis is established by Gram stain and blood culture of both the blood component and the recipient.distress

Bacterial contamination occurs when a small number of bacteria enter a blood component during collection or processing.. During storage, bacteria may proliferate, resulting in a large number of organisms, and possible endotoxin, being given with the transfusion

rare but difficult to detect prior to transfusion Autologous blood may be contaminated with bacteria, particularly if the patient had an active infection at the time of donation.

Hypotension

A drop of at least 10 mm Hg in systolic or diastolic arterial blood pressure in the absence of signs or symptoms of other transfusion reactions

if the immediate pretransfusion blood pressure is elevated from the patient’s typical blood pressure, and the arterial pressure does not fall below the patient’s usual blood pressure, it should not be considered a hypotensive reaction. The onset of hypotension is during the transfusion, and resolves quickly with discontinuation of the transfusion.

If hypotension persists beyond 30 minutes after discontinuing the transfusion, another diagnosis should be strongly considered.

Some reactions have been associated with angiotensin converting enzyme (ACE) inhibitor drugs or the use of leukocyte reduction filters.

Hypotensive reactions have been associated with red cell and platelet transfusions.

Graft-vs-Host Disease GVHD

rash, fever, diarrhea, cytopenia and liver dysfunction 3-4 weeks after transfusion

viable T lymphocytes in blood components are transfused, engraft and react against the recipient's tissues and the recipient is unable to reject the donor lymphocytes because of immunodeficiency, severe immunosuppression, or shared HLA antigens

associated with bone marrow transplantation. Transfusion associated GVHD occurs. It typically. Transfusion associated GVHD carries a very poor prognosis.

Rare

Irradiation of cellular components

The Blood Bank must be apprised of the immune status, or diagnosis, of the patient so that cellular components intended for transfusion of immunocompromised patients and blood components from directed (designated) donors will be irradiated. Irradiation of blood red cell containing components decreases the red cell survival and increases the potassium of the component. There is no apparent effect on platelet survival. Fresh Frozen Plasma (FFP) and cryoprecipitated AHG (CRYO) need not be irradiated because these components do not contain enough viable lymphocytes to cause GVHD.

Non-immune Hemolysis

hemoglobinemia and hemoglobinuria Transient hemodynamic, pulmonary and renal impairment may occur. cardiac arrhythmia due to yyperkalemia may occur, particularly in patients with renal failure.

Lysis of red cells can occur due to improper storage, handling, or transfusion conditions.

mishandling or storage of blood components

the contents of the blood bags are available for study. The blood bag together with attached tubing and intravenous fluids should be saved for further investigations.

Rare

Post-transfusion purpura (PTP)

thrombocytopenia that is frequently profound, purpura, or bleeding

Febrile reactions have been reported retrospectively with the implicated transfusion

thrombocytopenia typically 7-48 days after transfusion

PTP must be differentiated from the far more common alloimmunization to platelet antigens. Consultation with a Blood Bank physician is recommended in evaluating such patients.

the patient makes an alloantibody in response to platelet antigens in the transfused blood that for a period of time causes destruction of autologous antigen negative platelets

Rare

Platelet transfusion is of very little value in PTP; however, therapeutic plasma exchange may be beneficial Since autologous platelets do not survive in circulation, there is no expectation that transfused platelets regardless of antigen matching will do any better.

Reserved platelet transfusion for patients with active bleeding.

Reaction Type

Treatment - Adult

Pediatric

Follow-up

Acute Hemolytic Reactions Acute Hemolytic Reactions

Diuretic therapy: Initially, give 40-80 mg Furosemide (Lasix) intravenously. This dose can be repeated once. Lack of response to furosemide in 2-3 hours indicates the presence of acute renal failure.

Pediatric dose: 1-2 mg/kg/dose. May repeat once at 2-4 mg/kg.

Treat shock and disseminated intravascular coagulation with appropriate measures if and when they appear.

Water loading: The patient should be hydrated to maintain urinary output of at least 100 mL/hr until urine is free of hemoglobin.

Infuse a loading dose of 0.9% sodium chloride or 5% dextrose in 0.45% sodium chloride. Chart hourly urine output. Maintain the urine output by administering intravenous fluid at 100 mL/hour until the urine is free of hemoglobin. If the patient's urinary output does not increase, with this hydration any additional fluids should be infused with caution.

Pediatric patients should receive a smaller loading volume of fluid in proportion to their body surface area.

Delayed Hemolytic Transfusion Reactions

Specific treatment generally is not necessary

Supplemental transfusion of blood lacking the antigen corresponding to the offending antibody may be necessary to compensate for the transfused cells that have been removed from the circulation.

Allergic Transfusion Reactions

Antihistamines(e.g., Benadryl). Give 50-100 mg orally or intravenously. If urticaria develops slowly, antihistamines may be given orally.

Pediatric dose: 1-2 mg/kg intramuscularly or intravenously for 25-50 mg per average dose.

Routine use of Benadryl as premedication for all transfusions, regardless of a history of allergic reactions, is discouraged.

Aminophylline for wheezing, at a dose of 125-250 mg intravenously slowly over a period of about five minutes

Pediatric dose: 3 mg/kg/dose in intravenous drip over of 20 minutes.

Epinephrine for severe, acute reactions including laryngeal edema or bronchospasm Give 0.1-0.5 mg (0.1-0.5 mL of a 1:1000 solution) subcutaneously. Subcutaneous dose may be repeated at 10-15 minute intervals. The total subcutaneous dose in a 24-hour period, with rare exception, should not exceed 5 mg.

Pediatric dose: 0.03 mL/M2 (0.03 mg/M2 of a 1:1000 solution) given subcutaneously. A single pediatric dose should not exceed 0.3 mg.

Febrile Transfusion

Reactions

Premedicate the patient with acetaminophen or other antipyretic agents when previous reactions have been extremely bothersome. Pediatric dose: 10 mg/kg to a maximum of 600 mg.

Aspirin will adversely affect the patient's platelet function, so non-aspirin antipyretic agents are preferable.

Severe shaking chills

(rigors) can be controlled by the sedative effect of Benadryl or Demerol (25-50 mg given intramuscularly or intravenously

Note: Demerol may cause acute respiratory arrest. An opiate antagonist (Narcan) should be immediately available.

Sepsis Due to Bacterial Contamination of Donor Blood

Treatment of septic shock includes: terminating the suspected transfusion immediately, cardio-vascular and respiratory support, blood culture of the patient, and administration of broad spectrum antibiotics including anti-pseudomonas coverage if the blood component involved is Red Blood Cells.