Serious Hazards of Transfusion

8/10/2019 Serious Hazards of Transfusion

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Serious hazards of transfusion

Dr Kenneth S Charles

MB.BS (UWI), FRCP (UK), FRCPath(UK)

Senior Lecturer in Haematology


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Introduction

Case study

Definition of adverse effect

Classification Pathophysiology

Management

Prevention


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Red cell concentrate

Cryoprecipitate Fresh frozen

plasma

Platelet concentrate


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Case study

26 year old man

Relapsed Hodgkins Lymphoma

Chemotherapy Sepsis/Disseminated Intravascular

Coagulation

2 U RBC, 6 U platelets, 6 U FFP 6 hours later, dyspnoea, hypoxia


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Adverse reaction

Any untoward event occurring within a few

hours, weeks or months of and as a direct

result of administration of a blood

component


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Classification

Immediate/Delayed

Infectious/Non-infectious

Immune/Non-immune Clinical presentation


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Adverse reactions classified by

clinical presentation

Febrile

Haemolysis

Acute haemolytic transfusion reactionDelayed haemolytic transfusion reaction

Sepsis

Bacterial contamination of componentAntileucocyte antibodies


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Dyspnoeic

Transfusion related acute lung injury

Congestive cardiac failureAnaphylaxis caused by IgA deficiency


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Urticarial

Allergy to plasma proteins


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OtherIron overload

Transfusion Transmissible infectionsHIV

HBV

HCV

Syphilis

HTLV1

Graft versus host disease

Posttransfusion purpura


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FEBRILE


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Acute Haemolytic Febrile Transfusion

Reaction (AHFTR)

As little as 20 mls incompatible RBCs

1 in 7 000 transfusions

Mortality 10% Anti-A, anti-B, anti-Kell, anti-Kidd, anti-

Duffy, anti-Lewis


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AHFTR contd

Abs in recipients serum activate

complement to initiate intravascular lysis

Catecholamines and kinins released

DIC in 30-50%

Fever, chills, nausea, pain at IV site,

chest and back pains (intravascularocclusion by agglutinated red

cells),hypotension, dark urine

Nephrotoxic effects of anti-red cell stroma


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AHFTR

Stop transfusion

IV hydration - Normal Saline to systolic BP

> 100 mmHg, UO > 100 ml/hr

Diuresis - +/- IV Frusemide or mannitol

Appropriate samples to blood bench


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Conditions mimicking AFHTR

Improperly warmed blood

Blood piggy-backed


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(D)Some technical aspects of the

administration of blood and blood

components: blood warming

Rarely indicated

Only with specifically designed blood warmers

with visible thermometer and audible warningNOT hot water bath, microwave, radiator.

Massive transfusions in adults, exchangetransfusions in neonates, clinically

significant cold agglutinins

BCSH, 1998


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Bacterial contamination

Especially platelet concentrate

Sourcesdonor bacteraemia, donor arm,

contamination during processing

Fever, chills, shock, ARF, DIC

G- and G+ bacteria

Mortality 26%


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Fate of unused red cells

25

1

Domestic refrigerator

Returned to Blood

Bench


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(B) Collection of blood or blood components from

the hospital blood bank or blood transfusion issue

refrigerator and its delivery to the ward or operatingtheatre

The transfusion of blood and blood components should

begin as soon as possible after delivery to the ward oroperating theatre. If not possible, return to bloodtransfusion refrigerator. If > 30 mins return to hospitalblood bank for disposal (risk of bacterial infection)

If the ward or operating room does not have a

refrigerator that is approved for storing blood, theblood should not be released from the blood bankuntil immediately before transfusion

BCSH, 1999


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Wastage: Blood returned from

wards


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DYSPNOEIC


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Non-haemolytic febrile

transfusion reactions (NHFTR)

Most common type of transfusion reaction

Granulocyte and HLA-specificantileucocyte Abs develop in recipient by

pregnancy, previous transfusion Lysis of donor WBCs and release of

cytokines

1 in 200-500 transfusions


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Leucocyte antigens

HLA Class I and II

Neutrophil specific antigensNA-1, NA-2,NB


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HLA Antigens


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Febrile Non-haemolytic Transfusion

Reaction (FNHTR)

Fever, otherwise well

Stop transfusion

Exclude haemolysis, bacterialcontamination

Acetominophen 650 mg

Resume transfusion If recurs, leucocyte filter


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Non-cardiogenic pulmonary oedema

(TRALI)

1 in 5 000 transfusions

Donor antileucocyte Abs (previous

transfusions, pregnancy) passively

transfused to recipient

Any blood component

Ag/Ab complexes trapped in pulmonary

vasculature

Dyspnoea, hypoxia, chills, fever


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TRALI


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TRALI


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Congestive Cardiac Failure

(CCF)

Safe rate for 1U RBCs 2-3 hrs


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Anaphylaxis

Hereditary IgA deficiency 1 in 700 in USA

Complement-fixing IgG anti-IgA through

pregnancy or transfusion

Dyspnoea, chest pain, nausea, abdo

cramps, hypotension

IV epinephrine, methylprednisolone

Washed red cells, IgA deficient donors


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URTICARIAL


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Urticaria

Allergic reaction to plasma proteins

Usually FFP but any component

Skin rash, pruritis Antihistamine and continue transfusion


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OTHER


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Infective risks of blood transfusion

Risk factor Estimated frequency

Hepatitis A 1 in 1 000 000

Hepatitis B 1/30 000-1/250 000

Hepatitis C 1/30 0001/150 000

HIV 1/200 0001/2 000 000

HTLV1 1/250 000-1/2000 000


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Centralized screening for TTIs

HTLV1, Chagas

Syphilis,HCV

HIV, HBsAg


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0

50

100

150

200

250

300

350

Voluntary Replacement Paid

Risk of HIV seropositivity per 100,000 donors

WHO,2002


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Serological markers NBTS

Year Sample

(no)

HIV HBsAg HTLV1 HCV TP Chagas

200014 882 0.19 0.83 0.94 0.37 0.55 ND

2004 13742 0.21 0.58 1.46 0.77 2.16 0.05


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1866

11275

78

1808

11817

66

1551

18055

165

1322

19589

106

2707

19209

95

2908

19867

95

0

5000

10000

15000

20000

25000

NUMBER

2004 2005 2006 2007 2008 2009

YEAR

ANNUAL DONATIONS BY TYPE

AUTOLOGOUS

REPLACEMENT

VOLUNTARY


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TTIs 2009

HIV HBV HCV SYPH HTLV CHAGAS ALL

REPLACEMENT 43(0.21) 68(0.33) 41(0.20) 275(1.3) 195(0.97) 11(0.05) 633(3.2)

VOLUNTARY 3(0.14) 1(0.05) 5(0.23) 5(0.23) 14(0.64) 0(0) 28(1.3)


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0

0.2

0.4

0.6

0.8

1

1.2

2005 2006 2007 2008 2009

JA

TR

CU

0

0.1

0.2

0.3

0.40.5

0.6

0.7

0.8

0.9

1

2005 2006 2007 2008 2009

BAR

JAMTRT

CUR

Voluntary donor % HIV in donors

%

HBsAg in donors %HCV in donors

%


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Window period/days

Virus ELISA NAT (PCR)

HCV 88 23

HBV 56 31

HIV 22 12

VIP Blood Screening LATAM meeting, Pleasanton, CA, Oct 2007

Blood donation rate per 10 000 inhabitants and


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Blood donation rate per 10,000 inhabitants and

proportion of units reactive/positive for

infectious markers in 2005

Country Donation rate % TTI markers

Jamaica 83.6 5.0

Trinidad and Tobago 104.4 4.69

Curacao 368.6 0.03

From : PAHO, CD 48/11 Annex

A

W t S iti it f


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Wastage: Seropositive units for

discard

T f i A i t d G ft


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Transfusion Associated Graft

Versus Host Disease

Engraftment of donor lymphocytes in the

blood of patients with impaired cellular

immunity

Congenital SCID, organ transplantrecipients, Intrauterine Transfusions,

Hodgkins Disease, purine analogues

7-10 days. Skin, gut, liver, pancytopaenia

90% mortality. No effective Rx

15 Gy irradiation of blood components


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Post Transfusion Purpura (PTP)

Middle aged, multiparous

PlA1 negative

Severe thrombocytopenia 7-10 days after

transfusion

AlloAb to PlA1 destroys transfused and

recipient platelets

Rx - IVIg


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Iron overload

IU red cells contains 250 mg iron

No iron excretion mechanism

Skin, joints, liver, heart, endocrine glands

Iron chelationintravenous, s/c

- oral

thalassaemia major patients


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Case study

26 year old man

Relapsed Hodgkins Lymphoma

Salvage chemotherapy

Sepsis/Disseminated Intravascular

Coagulation

2 U RBC, 6 U platelets, 6 U FFP 6 hours later, dyspnoea, hypoxia


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Case study

TRALI

IPPV

Later succumbed to malignancy

Female donor anti NA-1 Abs


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Summary

Case study

Definition of adverse effect

Classification

Pathophysiology

Management

Prevention

When do patients require


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When do patients require

transfusion?

Red cellsHb < 7.0 or acute blood loss

- Hb < 9.0 pre-op

Platelets- Active bleeding + platelets < 50

- Prophylactic/ platelets < 10 Fresh frozen plasmaprolonged PT and/or

APTT + active

bleedingor planned procedure

Cryoprecipitateno response to FFP


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Serious Hazards of Transfusion