Transfusion Reactions

Question 1

Presentation of febrile non-hemolytic transfusion reaction

Answer 1

Isolated fever, no systemic symptoms

Question 2

AHTR presentation

Answer 2

Fever, hypotension, chills, flank pain, hematuria, nausea/vomiting, and oozing from intravenous sites, “feeling of impending doom”.

Question 3

How does a urticarial transfusion reaction (UTR) present?

Answer 3

Hives but no other allergic findings (ie, no wheezing, angioedema, hypotension)

Question 4

Definition of massive transfusion

Answer 4

• 10 units of blood in 24 hours or less

- transfusion of 4 units in 1 hour or less

Question 5

Transfusion goals with massive transfusion

Answer 5

Platelets greater than 50k

Fibrinogen greater than 100

Question 6

Transfusion goal with FFP

Answer 6

PT or PTT less than 1.5x mean

Question 7

Complications of massive transfusion

Answer 7

• hypothermia (blood products stored at cold temperatures)
• hypocalcemia (large volume of citrate in blood components)
• bleeding, coagulopathy (dilutional coagulopathy)
• acidosis

Question 8

Evidence-based relative components of massive transfusion

Answer 8

1:1:2 (PRBC’s)

Question 9

Pathophys + how AHTR typically happens

Answer 9

ABO mismatch (clerical error, nurse or someone else misidentifies blood sample and or misidentifies the patient)

Question 10

Most severe transfusion reaction

Answer 10

• acute hemolytic transfusion reaction

Question 11

AHTR mechanism

Answer 11

• PRBCs coated with antibody activate complement system, leading to hemolysis and active coagulation and fibrinolytic system

Question 12

AHTR management

Answer 12

• stop transfusion
• aggressive IV hydration w/ NS w/ added bicarb (renal protection)
• Titrate to urine output >100cc/hr
• alkalinize urine
• Trend UA → goal urine pH > 7.5
• Lasix
• DIC labs

Question 13

Febrile non hemolytic transfusion reaction mechanism

Answer 13

• patient with anti-WBC antibodies

- OR cytokine accumulation

Question 14

Febrile non hemolytic transfusion reaction presentation

Answer 14

fever/chills, myalgias, tachycardia, headache

Question 15

most common transfusion reactions

Answer 15

• allergic

- febrile nonhemolytic

Question 16

mechanism of urticarial reaction

Answer 16

antibody in patient reacts with donor plasma proteins

OR antibod in donor plasma reacts with patient plasma proteins

Question 17

management of urticarial reaction + can you rechallenge?

Answer 17

Benadryl
+/- steroids
IF symptoms resolve → resume transfusion at slower rate

Question 18

mechanism of anaphylactic transfusion reactions

Answer 18

Antibodies to IgA in IgA deficient recipients

Question 19

TRALI mechanism

Answer 19

• antibodies in donor plasma against patient WBC and or priming lipids

Question 20

TRALI natural course

Answer 20

Resolves in 24-48 but severe cases can be fatal

Question 21

TRALI diagnosis

Answer 21

Onset within 6 hours of transfusion + hypoxemia + bilateral infiltrates on CXR + no evidence of volume overload

Question 22

when delayed hemolytic transfusion reactions typically occur

Answer 22

1-2 weeks after pRBC transfusion

Question 23

RBC antigens most commonly responsible for DHTRs

Answer 23

kidd or Rh system

Question 24

Unique lab finding of delayed hemolytic transfusion reaction

Answer 24

• reticulocytopenia (unknown why thought to be peripheral consumption?)

Question 25

Antigen on RBC's that parvovirus binds to

Answer 25

P antigen

Question 26

pathophysiology of acute allergic reaction

Answer 26

antibody reacts with donor plasma proteins - transfused blood contains IgE that binds to antigen from recipients blood or patient's IgE binds to antigen in blood product, leading to histamine release from mast cells

Question 27

Febrile nonhemolytic transfusion reaction pathophys

Answer 27

- antibodies directed against white blood cells HLA in donor blood OR cytokine release

Question 28

pathophys of TRALI

Answer 28

- antibodies in donor plasma against a patients white blood cells

Question 29

Leading cause of transfusion-related mortality in the US

Answer 29

TRALI

Question 30

mechanism of delayed hemolytic transfusion reaction

Answer 30

- low level antibody to RBC antigen (typically non-ABO)

Question 31

Cause of platelet refractoriness from alloimmunization

Answer 31

- Antibodies to a donors antigens of the HLA system

Question 32

Antigen antibody is directed against in post-transfusion purpura

Answer 32

HPA-1a

Question 33

Most common alloantibody outside of the ABO and Rh group system

Answer 33

Anti-Kell

Question 34

pathophys of passenger lymphocyte syndrome

Answer 34

Minor mismatch between donor and recipient in ABO system

Question 35

Definition of major ABO incompatibility in transplant

Answer 35

- naturally occurring antibody in the recipient (eg recipient 0, donor A or B OR recipient A, donor AB)

Question 36

Definition of minor ABO incompatibility in transplant

Answer 36

- naturally occurring antibody in the donor (recipient A, donor O)

Question 37

Typical blood groups of mom and baby in hemolytic disease of the newborn

Answer 37

- Group A or B neonates of group O mothers (group O individuals make predominantly IgG (rather than IgM) anti-A and anti-B isohemagglutinins, which can cross the placenta. IgM does not cross the placenta.

Question 38

Why patients on purine analogues need irradiated blood

Answer 38

- purine analogues induce profound lymphopenia with low CD4 counts, which may persistent for several years after treatment

Question 39

What are the purine analogues

Answer 39

- fludarabine, cladribine