| |
Transfusion Reactions
By Dr. Becky Van Ells
Ask the Blood Bank
Patient name, MRN, location and phone number
Call the floor nurse
Has the transfusion been stopped
What was the blood product
What were the reaction symptoms
o Exactly how much did the
temperature increase or blood pressure change etc.
o Does the patient have another
condition that could cause fever and/or
has the patient been febrile previously
What time frame during the transfusion did the reaction
occur
What are the vitals now
Have the patients symptoms improved
Has the blood product been returned to the Blood Bank
Refer to Table 2-1 etc. and get a differential on what type of reaction you
believe occurred
If considering an AHTR refer to AHTR section
(differential diagnosis)
o Make sure the Blood Bank has done
the appropriate clerical checks
o Post-transfusion DAT - use a purple
top tube may need to call back floor nurse
if this has not been sent
o Look for hemolysis in the plasma
If considering bacterial contamination refer to Bacterial
Contamination section
o Do a stat Gram stain
o Can do culture or can wait and do
culture later
If hives part of the reaction see Allergic Reaction section
If ruled out other causes of fever go to FNHTR section
If respiratory distress a major symptom consider TRALI
section
Consider anaphylaxis for hypotension, respiratory distress
(laryngeal edema),
angioedema, NO FEVER
CALL ATTENDING IF YOU HAVE ANY QUESTIONS OR IF IT SOUNDS LIKE A SEVERE REACTION
Reaction Types
Acute Hemolytic Transfusion
Reaction (Back)
Causes: ABO incompatibility (clerical error); other
circulating complement fixing antibody (IgM)
Signs/Symptoms:
FEVER
(primary sign)
Tachycardia
Back/chest
pain
Chills
Flushing
Hemoglobinemia/-uria
Hypotension
Nausea
Decreased UOP
Consequences: shock, DIC, ARF
Labs: +DAT (if most cells already hemolysed DAT may be
negative); hemolysis in plasma
Differential diagnosis
o Thermal injury inappropriately
warmed or cooled
o Outdated blood may cause
hemoglobinuria
o Hypotonic solution or drugs given
with the blood
o Forcing blood through a filter or
small needle especially if high hematocrit
What to do:
o Ask blood bank: clerical check
performed; post-transfusion DAT/hemolysis in plasma
o If post-transfusion +DAT:
Compare
with pre-transfusion result (if + DAT pre-transfusion -
may be autoimmune or due
to drugs)
Repeat ABO/Rh
type, antibody screen, and cross match if turned positive after transfusion
o Notify attending then patients
clinician
Recommend
clinician keep patient well hydrated and follow these labs qd x 5d:
haptoglobin, plasma free hemoglobin, H/H, hemoglobinuria (UA), indirect
bilirubin.
o Find what caused the hemolysis to
determine future blood products
Is there a
new antibody present that was not found previously
Do an
elution and screen against a cell panel to find the antibody
Febrile Non-hemolytic Transfusion Reaction
(Back)
>90% of transfusion reactions
Causes: recipient antibody against donor lymphocytes
(pt. Increased exposure-multiple
pregnancies or transfusions);
endogenous progeny release
Signs/Symptoms: fever (1C or more), chills, maybe N/V or
back/chest pain
o ASSUME HEMOLYTIC TRANSFUSION
REACTION UNTIL PROVEN OTHERWISE
Labs: DAT and no hemolysis in plasma
Differential diagnosis:
o Co-morbid condition causing fever
(hem/onc patient)
o AHTR, TRALI, bacterial
contamination see table 2-1
What to do
o Once other causes of fever ruled
out:
make sure
patient is receiving Tylenol for fever
recommend
continue pre-medication with Tylenol in the future.
o Can release more blood products if
needed
Bacterial
Contamination (Back)
Causes: may be due to Gram positive or Gram negative
bacteria
Signs/Symptoms: (within 0-30minutes) high fever (>2°C),
chills, H/A, vomiting, diarrhea
Consequences: shock. DIC, death
Products affected (in order of decreasing frequency):
platelets, RBC, FFP, cry
What to do:
o Stat Gram stain (done in Fast Flow
after hours
culture on
blood product bag
broad
spectrum antibiotics
o Call blood bank and make sure they
have pulled the other half if it was a divided unit
EVEN IF STAT
GRAM STAIN WAS NEGATIVE
Allergic
Transfusion Reaction
(Back)
Second most common transfusion complication
Causes: recipient antibody to donor plasma protein
(including Riga-may lead to anaphylaxis)
Signs/Symptoms: hives/rash, itching, fever
o Watch for signs of anaphylaxis:
flushing, hypotension, angioedema
respiratory
distress (laryngeal edema) NO FEVER
Consequences: allergic reactions are benign
What to do:
o If hives only may give more
Benadryl and proceed slowly with remaining product.
Make sure
clinician is aware of reaction to give corticosteroids if hives to not resolve.
o Future transfusions for benign
allergic reaction:
can release
more blood;
increase
premedication dose of Benadryl or
add an
additional dose halfway through transfusion.
o Anaphylactic reaction:
epinephrine/corticosteroids.
May have been
due to an anti-IgA.
May need
future blood products to be IgA free.
Transfusion Related Acute Lung Injury
(Back)
Cause: Usually due to WBCs.
Capillary
damage ---> vascular damage ----> pulmonary edema
Signs/Symptoms: (2-4 hrs after transfusion)
marked respiratory distress,
hypotension, hypoxemia,
fever, bilateral pulmonary
infiltrates without cardiac changes
o Must differentiate these symptoms
from fluid overload (cardiac changes)
Consequences: may need O2 or ventilator
Products affected: typically FFP or platelets
What to do:
o Clinicians will be treating
respiratory issues
TRALI
typically resolves spontaneously
o Look for HLA or granulocyte
specific antibody in donor or patients blood
Delayed Hemolytic Transfusion Reaction
(Back)
Causes: non-complement fixing IgG causes extravascular
hemolysis.
Antibody may have been at an
undetectable level causing a negative antibody screen (esp. Kidd)
Signs/Symptoms: (days to weeks post transfusion) fever,
anemia,
jaundice (increased indirect bilirubin)
Consequences: usually gradual and not serious.
May cause hypotension, shock, DIC,
ARF
Labs: +DAT due to unexpected antibody in serum
What to do
o Have clinician follow the same labs
for acute hemolytic transfusion reaction
o Do eluent to look for a new or
previously undetected antibody
o Usually no treatment necessary.
Transfuse with compatible blood products
based on new antibody screen.
Refractoriness to
Platelets (Back)
Due to chronic platelet transfusions (usually hem/onc
patient)
o Develop HLA antibody to Class I HLA
on platelets
What to do
o If patient not responding to
platelets have clinician order a Quick-screen
(gives a
percentage of HLA reactivity)
If 0-5%:
not responding, platelet refractoriness due to another cause
(sepsis, DIC, drugs
etc.)
If 5-95%:
must have future platelets cross matched at the Red Cross
send purple top tube to Red Cross
|