module 6: complications of blood transfusion
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Module 6: Complications of blood transfusion. Transfusion Training Workshop KKM 2012. Complications of blood transfusion. Early Acute transfusion reactions Major life-threatening Haemolysis (ABO incompatibility) Gram-negative Bacteremia Anaphylaxis/ Acute Hypotension Minor Urticaria - PowerPoint PPT PresentationTRANSCRIPT
Module 6: Complications of blood transfusion
Transfusion Training WorkshopKKM 2012
Complications of blood transfusion Early Acute transfusion reactions
Major life-threatening Haemolysis (ABO incompatibility) Gram-negative Bacteremia Anaphylaxis/ Acute Hypotension
Minor Urticaria Febrile non-haemolytic
transfusion reaction
Transfusion-associated acute lung injury (TRALI)
Delayed/ Late Delayed haemolytic
transfusion reaction Transfusion-
associated graft vs. host disease (TA-GVHD)
Transfusion-transmitted infections (TTI)
Iron overload
Minor acute reactions
Minor transfusion reactions
1. Febrile non-haemolytic transfusion reaction
Commonest type of transfusion reaction Especially frequent in multi-transfused
patients
2. Urticarial reaction
Case 1
30 year old man Known to have a peptic ulcer Presented with severe epigastric pain
OGDS done immediately Forrest 1b ulcer noted Admitted for observation
Day 6, noted Hb dropped to 7 g/dL 2 pint PRBC were requested
Case 1
45 minutes into 1st PRBC
T 38.30C
BP 145/88
HR 95/min
1. Febrile reactions- what to do? Sudden rise in
temperature >1oC ± rigors
No fall in BP Occur during or
within 4 hours of transfusion
Temporarily stop blood Check for clerical error Give paracetamol 1 g po
Review 30 minutes Continue transfusion
slowly If symptoms do not settle
or recur once transfusion resumed, contact the BB
If in doubt, treat/ investigate as a major reaction
Febrile reactions
Antibodies against donor leucocytes in PRBC
Cytokines that accumulate in PRBC with storage
Usually in multiply transfused patients Can be reduced or prevented by
leuko-depletion at collection centre
Case 2
56 year old lady Known to have Myelodysplastic
Syndrome Was regularly transfused for the last 1
year Presented with petechiae and gum
bleeding PLT noted 7 x 109/L
Case 2
4 units of platelets was requested During the 3rd unit of platelet
transfusion, patient c/o rash and itchiness
BP 134/70 HR 86/min
2. Urticarial reaction – what to do? Temporarily stop
blood Give IV piriton 10 mg
± IV hydrocortisone 50-100 mg (repeat 4 – 6 hourly)
Review 30 minutes Continue transfusion
if settling
(Allergic) Urticarial reaction
Generally mild reaction Pre-existing IgE antibody against donor
plasma proteins in platelets or FFP Primed mast cells degranulate and
release chemical mediators including histamine
Major acute reactions
Major transfusion reactions
1. Acute Haemolysis (ABO incompatibility)
2. Gram-negative bacteremic shock
3. Anaphylaxis
Case 3
28 year-old lady
G3 P2, came in labour
Noted Hb 7.5 post-delivery
GXM 2 PC
Case 3 – cont’d
1st PC transfused uneventful
10 minutes into the 2nd PC
c/o severe back pain
BP 80/50 PR 110 T 400C
1. Acute Haemolysis (ABO incompatibility)2. Gram-negative bacteremic shock Suspect if ≥1 are
present: Shortness of breath/
chest pain not due to cardiac problems or pulmonary oedema
Back pain/ loin tenderness
Profound hypotension
Disconnect blood & giving set ; put up saline infusion
Check for clerical error Report to blood bank + specialist Take essential samples:
EDTA: FBC EDTA/plain: 10 mLs for re-GXM,
Coomb’s test and antibody screen DIC screen Renal Profile, serum bilirubin Blood culture First urine passed for
haemoglobinuria Send samples to transfusion lab
with unit giving set + all previous units + completed transfusion reaction form
Acute Haemolysis (ABO incompatibility)= Acute Haemolytic Transfusion Reaction (AHTR) Recipients antibody against donor red cells ABO antibodies are good complement binders Activation of complement results in
intravascular haemolysis and cytokine release Haemoglobinuria (vs. bacteremic shock), renal
failure
Bacterial sepsis
Bacterial contamination of donor blood inadequate aseptic technique during collection coring of the skin with the venipuncture needle transient asymptomatic donor bacteremia chronic low grade donor infection improper refrigeration of RBCs during storage or
transportation contamination during the processing of pooled
products contamination by infected water baths during
thawing of frozen components defects in blood bags
Bacteremic shock
More frequent in platelet transfusion – stored at room temperature
Both gram positive or negative contamination can occur
Symptoms appear during or immediately after blood transfusion
Symptoms of septicaemia, may result in hypotension and shock esp. with gram negative bacteremia
Inappropriate & unnecessary (I&U) transfusion has lead to a major transfusion reaction and mortality!
Inappropriate transfusion to correct iron deficiency anaemia
3. Anaphylaxis (Acute hypotension) Rare Immediate generalised
hypersensitivity reaction Recipient IgE to serum
proteins/ drugs/ in donor blood
IgG antibodies to IgA in patients with congenital IgA deficiency
Clinical features: Acute bronchospasm Oedema Circulatory collapse
Stop blood Maintain venous access
with 0.9% saline Oxygen by mask Adrenaline 1:1000 0.5 or
1.0 ml i/m repeated every 10 min as necessary
Piriton 10-20 mg IV slowly Disconnect blood and
investigate as for 1 & 2 Also investigate for congenital
IgA deficiency
Case 4
35 years old Chinese man
PRCA, transfusion-dependent
Hb 5.1, GXM 4 units PC over 2 days
3 units – no complication
After 120 mLs of 4th unit
c/o headache & SOB
Case 4 – cont’d
BP 60/40 > un-recordable feeble pulse
Resuscitated with i/m adrenaline and fluids
Cardiac monitoring – sinus tachycardia, no acute changes
BP 100/60 PR 93/min
Admitted to ICU for observation
Acute Hypotensive Transfusion Reaction
Looking back
4th PC, nurse decided to use bedside filter
15 minutes later, hypotensive shock
Patient on ARB (valsartan) for cardiomyopathy
Acute Hypotensive Transfusion Reaction Contact activation on negative charged
surface (blood filters)
Bradykinin release from HMWK
Acts on B2 receptors on endothelium
Releases prostaglandins, NO and proinflammatory cytokines
Vasodilatation and acute hypotension
Acute hypotension with ACE-I
1st reported in 1996
ACE hydrolyses bradykinin
ACE-I prevents breakdown of bradykinin
Has also been reported with ARB
Other complications
Case 5
40 year-old man with Paroxysmal Nocturnal Haemoglobinuria (PNH)
Transfused 2 PC for anaemia Hb 8.5
4 h later developed SOB
T 38.50C BP 130/80 PR 100
Transfusion-related acute lung injury (TRALI) (non-cardiogenic pulmonary oedema) During or within 6 hours of a transfusion Usually with WB or FFP Rapid onset of dyspnea and tachypnea Fever, cyanosis, and hypotension Respiratory distress and pulmonary crackles may be
present CXR bilateral pulmonary oedema with bilateral
patchy infiltrates Indistinguishable from Acute Respiratory Distress
Syndrome (ARDS)
TRALI - pathophysiology
Infusion of donor antibodies directed against recipient leukocytes anti-HLA (human leukocyte antigens) anti-HNA (human neutrophil antigens) cause complement activation, neutrophil
activation and release of cytotoxic agents Causing endothelial damage and capillary
leak Treatment: supportive Prevention: exclude donor from registry
Case 6
30 year-old Nigerian lady
Known sickle cell disease
Last crisis 20 years ago
G1P0 @ 14 weeks
Hb 7.0 in private hospital
GXM 2PC requested and transfused
Case 6 – cont’d
10 days later, presented with lower abdominal pain, dyspnoea and back pain
Referred to Ampang hospital on 1st day of CNY
GCS deteriorated
Pale+++ Jaundice++ Haemoglobinuria
Hb 2.0 Bil ID 400 LDH 2300
Normal plasma
Patient’s icteric plasma 10 days later
Group OcDe/cDe = R0R0
Antibodies detected:Anti-E, anti-Jkb and anti-Fya
Case 6 – cont’d
Delay getting matched blood
Exchange transfusion performed after 24 hours
Patient died 8 hours later
Cause of death: Delayed haemolytic transfusion reaction
Delayed haemolytic transfusion reaction (DHTR) Exposure to certain red cell antigens Development of alloantibodies and titres
may diminish with time Re-exposure results in amnestic response Especially with Kidd (anti-Jka and anti-Jkb)
and Duffy (anti-Fya and anti-Fyb) antigens Haemolysis occurs within hours, days or
weeks (typically 10 – 14 days)
Patients at risk for DHTR
Patients at risk for allo-immunization Sickle cell disease Thalassaemia AIHA Patients requiring repeated transfusions
How to prevent? Request for red cell phenotyping before
transfusion Talk to your blood bank specialist Transfuse phenotype-matched blood
Rare complications
Transfusion-associated GVHD
Transfused T lymphocytes can mount an immune reaction towards an immuno-compromised recipient
Can occur if donor and recipient has shared HLA antigens
Higher risk in patients receiving lympholytic chemotherapy e.g. Fludarabine and following BM transplant
High mortality – almost 100% Prevention : Gamma irradiation 2500 cGy (lowest dose
delivered to any portion of the canister should be 1500 cGy)
Indications for irradiated PRBC or platelets Premature babies Intrauterine/ neonatal exchange transfusions Congenital immuno-deficiencies Recipients receiving blood from directed donors
(blood relatives) Recipients with lymphomas esp. Hodgkin’s
Lymphomas Recipients receiving lympholytic therapy (e.g.
fludarabine, cladribine, clofarabine, campath) Recipients undergoing autologous or allogenic stem
cell transplants
Case 7
28 year-old lawyer c/o fever x 4 days Hb 12.5 Hct 36 Plt 18 No evidence of plasma leakage Having her menses Diagnosis: Dengue fever Transfused 4 units random platelets
(I&U)
Case 7 – cont’d
6 months later… Medical check-up Found to be HIV positive No risk factors
Transfusion-transmitted infections Risk of TTI:
HIV 1:2 million donations HCV 1:2 million donations HBV 1: 200,000 - 500,000 donations
Susan L, Arch Pathol Lab ed 2007
Blood is never 100% safe
Always a risk of transmission of virus and bacteria
Inappropriate & unnecessary (I&U) transfusion has lead to transmission of an infectious disease and its consequences
The next time you decide to transfuse
Stop, think and ask yourself …
Is it really necessary?
The end