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        o Outdated blood – may cause hemoglobinuria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 patient’s 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 WBC’s.
            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
 

Copyright © 2005 Madory Consulting
Last modified: 03/05/06

Copyright © 2005 Madory Consulting
Last modified: 03/05/06