blood transfusion reactions col.dr.mohamed h khalaf,md head, department of haematology maadi a f...
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Blood Transfusion ReactionsBlood Transfusion Reactions
Col.Dr.Mohamed H Khalaf,MDCol.Dr.Mohamed H Khalaf,MDHead, Department of HaematologyHead, Department of Haematology
Maadi A F Medical CompoundMaadi A F Medical Compound
Blood Transfusion ReactionsBlood Transfusion Reactions
HaemovigilanceHaemovigilanceSerious Hazards of Transfusion Serious Hazards of Transfusion
( SHOT )( SHOT )
Blood Transfusion ReactionsBlood Transfusion Reactions Haemovigilance Haemovigilance
Serious Hazards of Transfusion ( SHOT )Serious Hazards of Transfusion ( SHOT )
65% Incorrect Blood Component65% Incorrect Blood Component10% Acute Transfusion Reaction10% Acute Transfusion Reaction10% Delayed Transfusion Reaction10% Delayed Transfusion Reaction5% Transfusion Lung Injury5% Transfusion Lung Injury3% Post-transfusion purpura3% Post-transfusion purpura3% Transfusion Transmitted Infection3% Transfusion Transmitted Infection1% Transfusion-GVHD1% Transfusion-GVHD
Blood Transfusion: Blood Transfusion: ImmediateImmediate ReactionsReactions
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: Blood Transfusion: DelayedDelayed Reactions 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: Immediate Blood Transfusion Reactions:
Acute Haemolytic Transfusion Acute Haemolytic Transfusion ReactionsReactions
• Intra-vascular
• Extra-vascular
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Acute Intra-vascular Haemolytic Acute Intra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions
• 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: Immediate Blood Transfusion Reactions:
Acute Intra-vascular Acute Intra-vascular Haemolytic Transfusion Haemolytic Transfusion
ReactionsReactions 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: Immediate Blood Transfusion Reactions:
Acute Intra-vascular Haemolytic Acute Intra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions
Clinical Picture• 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: Immediate Blood Transfusion Reactions:
Acute Intra-vascular Haemolytic Acute Intra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions
Diagnosis• Clinical picture
• Transfusion Mistake
• Red urine
• Red plasma
• Lab Confirmation
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Acute Intra-vascular Haemolytic Acute Intra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions
Laboratory Workup• 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: Immediate Blood Transfusion Reactions:
Acute Intra-vascular Haemolytic Acute Intra-vascular Haemolytic Transfusion ReactionsTransfusion 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: Immediate Blood Transfusion Reactions:
Acute Intra-vascular Haemolytic Acute Intra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions
ManagementSaline 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: Immediate Blood Transfusion Reactions:
Acute Intra-vascular Haemolytic Acute Intra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions
Outcome
Mortality ~ 10 %
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Acute Extra-vascular Haemolytic Acute Extra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions
Trigger: Rh antigens not shared by the patient
Reactor: Anti-Rh antibodies of Ig G type
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Acute Extra-vascular Haemolytic Acute Extra-vascular Haemolytic Transfusion ReactionsTransfusion 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: Immediate Blood Transfusion Reactions:
Acute Extra-vascular Haemolytic Acute Extra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions
Clinical Features• Less severe, may be no signs• Onset > I hour• Fever• + Jaundice• Rarely Haemoglobinuria or renal dysfunction
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Acute Extra-vascular Haemolytic Acute Extra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions
Laboratory
• Anti-complementary Coombs positive
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Acute Extra-vascular Haemolytic Acute Extra-vascular Haemolytic Transfusion ReactionsTransfusion Reactions
Managment
• Stop Transfusion
• Supportive
• Mortality very rare
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Febrile Non-Haemolytic Transfusion Febrile Non-Haemolytic Transfusion Reaction ( FNHTR)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: Immediate Blood Transfusion Reactions:
Febrile Non-Haemolytic Transfusion Febrile Non-Haemolytic Transfusion Reaction ( FNHTR)Reaction ( FNHTR)
Pathophysiology• Cytokine released from the transfused activated
leucocytes
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Febrile Non-Haemolytic Transfusion Febrile Non-Haemolytic Transfusion Reaction ( FNHTR)Reaction ( FNHTR)
Clinical Features• Fever after 30-90 min• + Rigors• + Headache• No Hypotension• No Bronchospasm• No flank pain• No haemoglobinaemia• No Haemoglobinuria
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Febrile Non-Haemolytic Transfusion Febrile Non-Haemolytic Transfusion Reaction ( FNHTR)Reaction ( FNHTR)
Management• If Temp < 40 + Stable patient:
– 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: Immediate Blood Transfusion Reactions:
Febrile Non-Haemolytic Transfusion Febrile Non-Haemolytic Transfusion Reaction ( FNHTR)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: Immediate Blood Transfusion Reactions:
Transfusion- Related Acute Lung Transfusion- Related Acute Lung Injury ( TRALI)Injury ( TRALI)
Sudden onset of acute respiratory distress within 6 hours( u. 1-2h) of
transfusion
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Transfusion- Related Acute Lung Transfusion- Related Acute Lung Injury ( TRALI)Injury ( TRALI)
Rare: 1/5000 transfusions
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Transfusion- Related Acute Lung Transfusion- Related Acute Lung Injury ( TRALI)Injury ( TRALI)
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: Immediate Blood Transfusion Reactions:
Transfusion- Related Acute Lung Transfusion- Related Acute Lung Injury ( TRALI)Injury ( TRALI)
Clinical Features• Fever, chills• Acute Respiratory Distress• Normal CVP• CXR: Pulmonary Infiltrate
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Transfusion- Related Acute Lung Transfusion- Related Acute Lung Injury ( TRALI)Injury ( TRALI)
Management
• Cardio-Pulmonary Support• Steroids• Diuretics of No value
MortalityHigh
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Allergic Acute Transfusion Allergic Acute Transfusion ReactionsReactions
Pathophysiology• Trigger: Plasma proteins in the transfused blood• Reactors: Patient antibodies of IgE type• Response:
– Mast cell degranulation– + Complement Activation– + Cytokines
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Allergic Acute Transfusion Allergic Acute Transfusion ReactionsReactions
Clinical Features• Mild / Skin-restricted ( common: 1%):
– Pruritus, Uerticaria, No fever or Hypotension
• Severe / Systemic ( Anaphylaxis):– As above +– Fever– Hypotension– Bronchospasm, Angio-edema
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Allergic Acute Transfusion Allergic Acute Transfusion ReactionsReactions
Management• Mild / Skin-restricted :
– Stop transfusion temporary– Anti-histamines– Resume Transfusion
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Allergic Acute Transfusion Allergic Acute Transfusion ReactionsReactions
Management• Severe / Systemic ( Anaphylaxis):
– 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: Immediate Blood Transfusion Reactions:
Acute Pyrogenic Transfusion Acute Pyrogenic Transfusion ReactionsReactions
Pathophysiology• Trigger: Bacterial Pyrogens/Endotoxins in the
transfused blood contaminated with cold-growing organisms as:– Psudomonas– Yersinia– Some Staph
• Reactors: Patient Mono-nuclear cells• Response:
– Cytokine Storm
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Acute Pyrogenic Transfusion Acute Pyrogenic Transfusion ReactionsReactions
Clinical FeaturesLike :
• Acute Haemolytic reaction BUT:– No Hemoglobinuria– No Hemoglobinaemia
• FNHTR BUT More Severe
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Acute Pyrogenic Transfusion Acute Pyrogenic Transfusion ReactionsReactions
Management
• As Acute Haemolytic reaction
BUT
Add Broad- spectrum Antibiotics
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Acute Circulatory Overload Acute Circulatory Overload
• Acute cardiogenic pulmonary edema• In rapidly transfused, non-bleeding ( euovolemic)
patiens• More in infants, elderly or cardiac patients
Immediate Blood Transfusion Reactions: Immediate Blood Transfusion Reactions:
Acute Circulatory Overload Acute Circulatory Overload
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: Immediate Blood Transfusion Reactions:
Acute Circulatory Overload Acute Circulatory OverloadPrevention
• Never exceed 2-3 ml/kg/hour Unless Bleeding• Pre-medicate with Diuretics in Cardiac or severely
anemic patients
Management• Diuretics• + Inotropics• Consider Haemodialysis• Supportive
Other Immediate Blood Transfusion Other Immediate Blood Transfusion Reactions: Reactions:
• Hypothermia
• Citrate Intoxication
Delayed Blood Transfusion Delayed Blood Transfusion ReactionsReactions
1. Delayed Haemolytic transfusion reactions
2. Post-transfusion Purpura
3. Infection transmission
4. Transfusion GVHD
5. Iron Overload
6. Immune Modulation
Massive Blood TransfusionMassive Blood Transfusion
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 Massive Blood Transfusion
Complications
• Dilutional Thrombocytopenia
•Dilutional Coagulopathy
•Metabolic
•Hypothermia
Massive Blood Transfusion Massive Blood Transfusion
Complications
• Dilutional Thrombocytopenia
•Common after 10 units
•Severe after 20 units
•Give platelet transfusion if < 80,000 + bleeding
Massive Blood Transfusion 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 Massive Blood Transfusion
Complications
•Metabolic: Citrate Intoxication
•Acidosis, Hypocalacemia, Hyperkalaemia
•Rare Except in Infants or Hepatic patients