Transfusion Reactions
(adverse effects of transfusion)
EBMT 2012- Geneva
Monica Braisch
RBSZ St. Gallen
Recognition
Evaluation and therapy of suspected TR
Reporting
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• Acute hemolytic TR (intravascular hemolysis)
• Anaphylactic reaction
• Sepsis
• TRALI
• Acute hemolytic TR
• Anaphylaxis
• Fluid overload
• TRALI
• Allergic and/or anaphylactic reactions
• Hemolytic TR
• Febrile nonhemolytic TR
• Hemolytic TR, acute or delayed
• Septic TR
• TRALI
Fever Rash
Shock Dyspnea
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• Actions to be taken immediately whenever
a TR is suspected include:
STOP transfusion and evaluate the patient,
maintain iv, monitor VS
Report reaction to blood bank
Return bag with all tubing attached
Send posttransfusion bloodsample
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• Any adverse reaction to blood components should be reported to
transfusion medicine personnel
• A transfusion medicine physician should be consulted for:
Clinical evaluation of patients
Laboratory investigation
Selection of appropriate blood components for future transfusion
Donor look back, as needed
Reporting to the national Haemovigilance (Swissmedic for Switzerland)
EBMT 2012- Geneva
Types of TR
1. Immunologic:
Hemolytic TR acute: within 24 hours of transfusion (most intravascular)
delayed: more than 24 hours after transfusion (1- 28 days)
(most extravascular)
Febrile nonhemolytic TR( FHNTR)
Allergic reaction mild (urticarial)
anaphylactoid
anaphylaxis
Alloimmunisation (red cell antigens, platelet specific antigens, HLA antigens,
neutrophil specific antigens)
Post-Transfusion-Purpura (PTP)
Transfusion-related graft-vs-host disease
EBMT 2012- Geneva
EBMT 2012- Geneva
2. Transfusion-transmitted infections (TTI):
Viral infections (HIV, HTLV, HBV, HCV, WNV)
Bacterial contamination (septic TR)
Parasitic TTI (Malaria, T. cruzi)
Prion infection (vCJD)
Prevention:
donor history questionnaire and donor testing
antiseptic and inspection of phlebotomy site
predonation pouch
pathogen inactivation with INTERCEPT (Cerus)
for platelet units (since 01.07.2011 in Switzerland)
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EBMT 2012- Geneva
EBMT 2012- Geneva
3. Other:
Transfusion associated circulatory overlaod (TACO)
Transfusion-related acute lung injury (TRALI)
Febrile nonhemolytic TR (FNHTR)
Transfusion-associated dyspnea (TAD: is characterised by respiratory
distress within 24 h of transfusion that does not meet the criteria of
TRALI, TACO or allergic reaction)
Hypotensive TR
Transfusion related iron-overload (20-25 g iron/RBC unit)
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4. Near miss:
A near miss event refers to any error which, if undetected, could result in
the determination of a wrong blood group or transfusion of an incorrect
component, but was recognised before the transfusion took place.
Massive transfusion hyperkalemia
hypocalcemia (citrate: chills, muscle cramps and
fasciculations, depressed cardiac function)
hypothermia (ventricular arrhythmias, impaired
hemostasis)
Incorrect blood component transfused (IBCT: this category comprises all reported
episodes where a patient was transfused with a blood component that was
intended for another patient or which was incorrect in terms of its
specification).
EBMT 2012- Geneva
EBMT 2012- Geneva
EBMT 2012- Geneva
• ABO or certain other blood group incompatibilities
• Use of improperly stored or warmed blood Causes
• Hemoglobinemia and hemoglobinuria
• Fever, chills, chest pain, flank pain
• Dyspnea,anxiety, shock,oliguria =>anuria
• Burning at site of infusion
• DIC
Symptoms
• Clerical check: match between unit, patient, sample
• ABO/Rh type,DAT,Antibodyscreen,crossmatch:pre-and posttransfusion samples
• Visual check for hemolysis
• Acute hemolysis: plasma free Hb,haptoglobin,hemoglobinuria,LDH,bilirubin (I>D)
• Culture on unit and patient
Evaluation
Hemolytic TR- intravascular
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• Blood group incompatibility, where antibodies do not fully activate complement Causes
• Fever, jaundice
• Elevated indirect bilirubin
• Falling hematocrit Symptoms
• Clerical check: match between unit, patient, sample
• ABO/Rh type,DAT,Antibodyscreen,crossmatch:pre-and posttransfusion samples
• Visual check for hemolysis
• Acute hemolysis: plasma free Hb,haptoglobin,hemoglobinuria,LDH,bilirubin (I>D)
• Culture on unit and patient
Evaluation
Hemolytic TR- extravascular
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EBMT 2012- Geneva
• Antibody mediated (HLA,HPA)
• Inflamatory mediators (cytokines in stored components)
Causes
• Chills,Fever (≥ 1°C increase in body temperature in the 4 h after transfusion)
• Rigors in severe reactions Symptoms
• Clerical check: match between unit, patient, sample
• ABO/Rh type,DAT,Antibodyscreen,crossmatch:pre-and posttransfusion samples
• Exclude hemolysis
• Culture on unit and patient
Evaluation
FNHTR
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• Presumed allergy to a soluble substance in donor plasma
• IgA-deficient patients (Anti-IgA) Causes
• Localized or generalized urticaria (hives)
• Laryngeal or facial edema
• Hypotension
• Anaphylactic shock: bronchospasm,flushing,chills,GI-cramps,nausea,vomiting,unconsciousness
Symptoms
• No evaluation for mild reaction
• Exclude other TR
• IgA-deficiency
• Anti-IgA
Evaluation
Allergic Reaction
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• Risk factors: ACE inhibitors, critically ill Causes
• Severe hypotension (>30 mmHg) within minutes of a transfusion
Symptoms
• Rapid resolution of symptoms after stopping transfusion
• Hold ACE inhibitors 24h for patients undergoing HPC collection, therapeutic apheresis
Evaluation
Hypotensive reactions
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EBMT 2012- Geneva
• Donor lymphocyte antibodies (HLA, HNA)
• Lipid activators of neutrophils in the donor plasma
Causes
• Acute onset < 6 hours
• Hypoxia:O2<90%,PaO2/FiO2≤300mmHg
• Dyspnea,fever,chills,hypotension
• Pulmonary vascular congestion and/or pulmonary edema on chest X-ray but without cardiomegaly
Symptoms
• Anti-HLA/-HNA in donor blood
• Positive crossmatch with recipient-granulocytes
• Switzerland adopted transfusion of FFP only from male donors
Evaluation
TRALI
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EBMT 2012- Geneva
EBMT 2012- Geneva
• Blood volume too large or infusion too fast for compromised cardiovascular system Causes
• Acute onset :during the transfusion or within 6h
• Dyspnea,orthopnea,tachycardia,hypertension
• Cardiomegaly and pulmonary congestion on chest X-ray
• Peripheral edema
Symptoms
• Consider comparing pretransfusion BNP (B-type natriuretic peptide) with posttransfusion BNP (BNP>100pg/ml with 1.5-fold increase suggests volume overload)
Evaluation
TACO
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EBMT 2012- Geneva
• Antibody to platelet antigen in antigen-negative recipient Causes
• Severe thrombocytopenia about 1 week after transfusion
Symptoms
• HPA-antibodies (Anti-HPA-1a)
• Cross-match Evaluation
PTP
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EBMT 2012- Geneva
• Infusion of immunocompetent donor lymphocytes in an immunosuppressed recipient
• An immunocompetent recipient shares HLA-haplotype with an HLA-homozygous donor
Causes
• Fever,skin rash (desquamative)
• Hepatitis, diarrhea
• Marrow suppression
• Infection
• High mortality
Symptoms
• Histology (skin-and liver-biopsy)
• HLA-typing
• Gamma-irradiate cellular blood components for immunosuppressed
• Irradiate all cellular components from HLA-matched or related donors
Evaluation
TA-GvHD
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EBMT 2012- Geneva
Treatment of transfusion reactions
• Acute HTR:
Closely monitor
patient
Fluid and O2- support
Maintain renal
function
± iv steroids
Monitor/treat DIC
• FNHTR:
STOP transfusion
Administer antipyretic
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Allergic reactions
• Mild:
Antihistamine
± restart transfusion:
Severity of symptoms
Clinical status of
patient
Clinical decision
• Severe/ anaphylactic:
Fluid and O2- support
Antihistamine
± H2 blocker
Steroid
Epinephrine
DO NOT RESTART
TRANSFUSION
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• TRALI:
Oxygenation ±
ventilation
BP support
• TACO:
Oxygen
Diuresis
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• Hypotensive TR:
STOP the transfusion
Fluid and O2- support
Symptoms should
resolve after stopping
transfusion
• Bacterial
contamination:
STOP the transfusion
Fluid and O2- support
IV antibiotics
Monitor /treat DIC
EBMT 2012- Geneva
Transfusion
= max. 4
hours
In Switzerland, all transfusion related adverse events and reactions,
irrespective of their grade of severity, are eligible for reporting
severity of TR Grade 1: without life threat
Grade 2: permanent injury
Grade 3: life-threatening
Grade 4: death of the recipient
imputability of TR Excluded/unlikely
Possible
Likely
Certain
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Swissmedic Reporting
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Donor adverse event reporting
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Severity
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Imputability
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Take home message
Assume that an adverse reaction
temporaly related to a transfusion
to be a transfusion reaction until
proven otherwise
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Thank you for your attention!
EBMT 2012- Geneva