TOC |  STAT | Heme TRANFUSION Reactions      RX of Reactions  | See also Tranfusions     

Practice guidelines for blood component therapy.  - Anesthesiology 1996 Mar; 84(3):732-47
A report by the American Society of Anesthesiologists Task Force on Blood Component Therapy.

Transfusion Adverse Reactions

Acute Reactions	Delayed Reactions
Immunologic
FNHTR = febrile, nonhemolytic transfusion reaction	Alloimmunization
Urticaria	Platelet refractoriness
TRALI = transfusion-related acute lung injury	Immune modulation/suppression
Acute hemolysis, Fatal acute hemolysis	Delayed hemolysis
Anaphylaxis	Graft-versus-host disease , Post-transfusion purpura
Nonimmunologic
Bacterial contamination, platelets	Hepatitis C, Hepatitis B, HTLV-I, HIV-1
Hypervolemia	Hemosiderosis (RBCs only)
Chemical effects, hypothermia, coagulopathy
Nonimmune hemolysis
Sepsis, RBCs

Febrile, nonhemolytic transfusion reaction is a diagnosis of exclusion. Fever, the most commonly observed adverse effect with transfusions of all types of components (occurring in 0.1 to 1% of cases), can be a mild symptom, easily treated by antipyretic medication, or it can signal the onset of serious consequences, including death, due to sepsis or hemolysis. Consequently, when fever occurs during transfusion of any blood component, it must be considered an ominous sign.  Transfusions must be stopped while investigation for possible hemolytic or septic reactions is undertaken. Prevention includes the use of  leukoreduction, either pre-storage or by bedside filtration & antipyretics /acetominophen.

Urticaria with No Other Signs or Symptoms.
The appearance of an itchy rash during component transfusion, frequently seen with transfusion of platelets or plasma, is a common occurrence. The mechanism is histamine release after degranulation of basophils or mast cells. Because local or generalized rash with itching can be relieved quickly by administration of antihistamine, typically 50 mg of diphenhydramine (Benadryl), this adverse effect should be managed symptomatically.  Once rash and/or itchiness has subsided, the transfusion can be safely continued to completion. This is the only acute adverse effect for which resumption of transfusion is considered to be safe, once symptoms have resolved.

Transfusion-Related Acute Lung Injury.
The abrupt onset, usually within 2 to 4 hours of a transfusion, of acute respiratory distress, hypotension, and fever with documented hypoxemia and bilateral pulmonary edema may signal the potentially life-threatening complication termed transfusion-related acute lung injury (TRALI). These symptoms define adult respiratory distress syndrome (ARDS).

Hemolysis
may be clinically silent, with only an unexplained hyperbilirubinemia or anemia,  particularly if no clinical signs alert the caregivers to its presence. However, it can also be severe and life-threatening when it is due to disseminated intravascular coagulation (DIC), shock, hypotension, or acute renal failure.
Classic SX: abrupt onset of acute flank pain, bright red urine, fever, and often a patient's complaint that "something is wrong."
Fever (body temperature elevation of greater than 1°C above normal) and chills are commonly seen. In anesthetized or comatose patients, the onset of unexplained oozing from venipuncture sites and the appearance of hemoglobinuria may be the only signs. In some patients, for reasons not fully understood, a very small volume (less than 25 mL) of incompatible RBCs can trigger a violent and fatal outcome, while others tolerate multiunit transfusions with no apparent clinical harm.

GENERAL MEASURES for acute transfusion reactions:

• Stop transfusion immediately upon first sign of reaction  & send the blood to blood bank for investigation.
• Substitute infusion with normal saline at 100-300 mL per hour if  indicated.
• Check patient writstband, ID, paperwork for any clerical error (usual cause of an ABO-incompatible transfusion)
• Monitor vital signs , Maintain systolic blood pressure above 100 mm Hg
• Maintain urine flow at 100 mL/hr for 6-8 hours or until hemoglobinuria clears
• Recognize and treat disseminated intravascular coagulation if it occurs.
• Lab: CBC, Coomb's test, BUN, Creat, UA, blood bilirubin, haptoglobin
• Posttransfusion blood sample and discontinued blood to blood bank for reaction investigation

Nonhemolytic transfusion reactions: fever, chills, or urticaria
are the most common adverse effects of RBC transfusion; they occur in approximately 1-5% of all transfusions.

Hemolytic reactions: hypotension, tachycardia, hemoglobinuria and microvascular bleeding
due to administration of ABO-incompatible blood transfusions can be life-threatening.

SIGNS AND SYMPTOMS of Hemolytic transfusion reactions:

1. Immediate (intravascular) hemolytic transfusion reaction:
   • Anxiety ,  Flushing ,  Tachycardia ,  Hypotension ,  Chest or back pain ,  Dyspnea ,  Fever ,  Chills
     Note: symptoms are masked in anesthetized patient
2. Delayed (extravascular) hemolytic transfusion reaction:
   • Fever ,  Anemia (2-14 days after transfusion) ,  Jaundice

CAUSES of Hemolytic transfusion reactions:

1. Immune reactions - incompatibility within ABO system
2. A nonhemolytic febrile reaction due to immune sensitivity to leukocytes, platelets, plasma constituents
3. Hemolytic reactions:
   • Transfusion of mismatched blood
   • Destruction of donor erythrocytes by recipient incompatible isoantibodies
   • Isosensitization by repeated transfusions
   • Isosensitization by prior pregnancies
   • Universal blood donor type considered dangerous unless thoroughly
   • checked for agglutination titer
   • Acquisition of B antigen by Group A individuals with colon cancer

RISK FACTORS of Hemolytic transfusion reactions:

• Multiple blood transfusions ,  Rh negative mother ,  Multiple pregnancies

DIFFERENTIAL DIAGNOSIS of Hemolytic transfusion reactions:

• Other causes of acute hemolysis
• Autoimmune diseases
• Hemoglobinopathies
• Red blood cell enzyme defects
• Bacterial contamination of stored blood

LABORATORY of Hemolytic transfusion reactions:

• Positive direct antiglobulin test (Coomb's)
• Plasma obtained 2-4 hours after lysis is red or pink, indicating free hemoglobin
• Increased BUN, creatinine
• Elevated serum bilirubin (mild)
• Wine-colored urine indicating hemoglobinuria
• Reduced serum haptoglobin

Common Infectious Agent Transmission from transfusions:

• Hepatitis C, hepatitis B, HIV, CMV, bacterial & parasitic agents.

Ref:
Practice guidelines for blood component therapy.  - Anesthesiology 1996 Mar; 84(3):732-47
      A report by the American Society of Anesthesiologists Task Force on Blood Component Therapy.
Dambro: Griffith's 5-Minute Clinical Consult, 1999
Rakel: Conn's Current Therapy 1999
Washington Manual of Medical Therapeutics, 29th ed.1998