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)

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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

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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).

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• 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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• 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

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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