T9 - Adverse Transfusion Reactions

Question 1

Adverse Donation Events

Answer 1

Vasovagal (immediate/delayed)
Haematoma
Nerve irritation/injury/arm pain
Allergy
Fe deficiency
Apheresis
- citrate toxicity
- haemolysis
- transfusion transmitted diseases
- air bubble embolism
- depletion of clotting factors

Question 2

Adverse Transfusion Reactions

Answer 2

Immune
- acute
- delayed
- allergic
- transfusion-related acute lung injury (TRALI)
- febrile non-haemolytic transfusion reaction (FNHTR)
- transfusion-associated graft vs host disease (TA-GvHD)
Non-immune
- transfused-associated circulatory overload (TACO)
- infections

Question 3

Acute Haemolytic Reaction - Symptoms

Answer 3

Systemic
- chills
- fever
Increased heart rate
Chest pain
Hypotension
Uncontrollable bleeding
Lumbar pain
Urinary
- hemoglobinuria
- hyperbilirubinemia

Question 4

Acute Haemolytic Transfusion Rxn

Answer 4

1:40k-80k transfusions, fatal in 1:1.8 million transfusions
Occur soon after transfusion starts (minutes to hours)
Usually ABO incompatibilities
e.g. complement-mediated intravascular haemolysis
- complement activation → C3a and C5a release → mast cell activation → histamine and serotonin release
- factor XII activation → bradykinin production → vasodilation and ↑ EC permeability → hypotension
- EC activation and damage → TF exposure → DIC

Question 5

Delayed Haemolytic Transfusion Rxn’s

Answer 5

Occurs in 1:2.5k-11k transfusions
Haemolysis occurring > 24 hrs after transfusion
Extravascular haemolysis in RE system
After secondary exposure to antigen
- aby “missed” on pre transfusion screen
Anti-Jka, Rh, Kell, Duffy antibodies
Haemolysis is usually not fatal
- Hb doesn’t rise to expected level, fever, jaundice, haemoglobinuria
`

Question 6

Infections

Answer 6

Bacterial, viral, parasitic bacterial risk – 1:75k (platelets) to 1:500k (RBCs)
Symptoms
- fever, chills, vomiting, hypotension, dyspnoea, tachycardia, shock, renal failure, DIC
Bacterial sources
- donor (skin or bacteraemia)
- contamination during component preparation (inc water bath)
Proprionibacterium sp., Staphylococcus sp., Bacillus sp., Yersinia enterocolitica

Question 7

Allergic Transfusion Rxn’s

Answer 7

Range from mild (1:100) to severe (1:20k-50k)
Symptoms:
- urticaria (hives), erythema, itching, hypotension, nausea, vomiting, diarrhoea, respiratory distress
Can be fatal
Due to:
- hypersensitivity to allergens or plasma proteins in donor unit
- IgA ↓ patients with anti-IgA antibody

Question 8

Transfusion-Related Acute Lung Injury (TRALI)

Answer 8

Occurs in ~1:10k transfusions, the major cause of transfusion-related fatality
Symptoms begin within 2-6 hours of transfusion completion
Fever, chills, respiratory problems, hypotension, hypoxemia, → respiratory failure
Pathophysiology
- aby’s in donor plasma bind to HLA/HNA’s on recipients’ granulocytes → granulocyte activation
- → basement membrane destruction
- → increased permeability of the pulmonary circulation
- → leakage of high-protein fluid into the lungs
- → pulmonary oedema

Question 9

Prevention of Transfusion-Related Acute Lung Injury

Answer 9

Anti-HNA/HLA aby’s are more common in women who have previously been pregnant
AABB recommended that:
- only male plasma is collected
- if collecting plasma from females who have previously been pregnant, it should be tested for anti-HLA/HNA aby’s and only aby neg plasma transfused

Question 10

Transfusion-Associated Circulatory Overload (TACO)

Answer 10

Occurs in < 1% of transfusions
Dyspnoea (shortness of breath), orthopnea (shortness of breath when lying down), cyanosis, tachycardia, pulmonary oedema, hypertension within 1-2 hrs of transfusion
Elderly, paediatric, and anaemic patients
Often confused with TRALI
- patients with TRALI rarely have hypertension
- different findings on chest X-ray
- distended neck veins and peripheral oedema in TACO
Treatment - O2, diuretics
Prevention - administer transfusion slowly

Question 11

Febrile Non-Haemolytic Transfusion Reactions (FNHTR)

Answer 11

Occurs in 0.1-1% of transfusions (esp platelets)
Symptoms
- unexpected temp. increase shortly after transfusion, chills, ↑ respiration, headache
Similar presentation to TRALI, sepsis, HTR
- FNHTR if these have been ruled out
Pathophysiology
- cytokine release from donor leukocytes
- anti-HLA/HNA aby’s in recipient plasma binding to and activating leukocytes in donor units
Treatment - acetaminophen
Prevention - leukodepletion

Question 12

Transfusion-Associated Graft vs Host Disease

TA-GvHD

Answer 12

Very rare
Symptoms
- rash, fever, liver dysfunction, GI symptoms with recent transfusion history
Pathogenesis
- immunocompetent T lymphocytes in donor product are transfused into shared HLA (i.e. family) or immunocompromised recipient
- donor T-lymphocytes engraft and proliferate in recipient BM
- recipient HLA class II and/or minor histocompatibility Ag’s are presented to donor T-lymphocytes → activation
- cytokine release and cytolytic activity
Diagnosis - HLA typing
Results in bone marrow aplasia, usually fatal

Question 13

Steps to take when an Adverse Transfusion Reaction Occurs

Answer 13

Stop transfusion immediately and initiate appropriate therapy
Monitor vitals
Maintain IV access
Check AGAIN that the correct unit was given
If bacterial/viral reaction is suspected, contact ARCBS
Send the following to the lab:
- transfusion reaction investigation request
- remainder of the component being transfused, empty transfusion bags, infusion set
- post-transfusion blood sample
- first post-transfusion urine sample

Question 14

Infections - Treatment and Prevention

Answer 14

Treatment/further testing
- broad spectrum antibiotics
- remainder of the unit is sent to lab for culture and gram stain
- notify ARCBS
Prevention
- diversion pouch
- platelets are cultured 24 hours after manufacture