Transfusion Reactions

Immune Mediated

Acute Hemolytic Transfusion Reaction

  • Most often d/t ABO incompatibility
  • Pre-existing IgM fixes complement -> rapid intravascular hemolysis
  • “Classic” triad: fever, flank pain, red/brown urine; also can present w/ DIC, venous oozing, pink plasma on blood draw
  • Can present as only fever so ddx includes FNHTR
  • Management:
    • Stop transfusion, save tubing and bags, alert blood bank
    • IVF to support renal function
    • Consider sepsis from transfusion
    • Coomb’s test
    • Follow renal function, coags/DIC labs, monitor for hyperK+
    • Supportive care including vasopressors if needed

Anaphylaxis

  • Generally caused by recipient antibodies to donor IgG or IgA, most common in recipients w/ IgA deficiency
  • Looks like anaphylaxis d/t any other reason and tx is stop transfusion then standard anaphylaxis management

Delayed Hemolytic Transfusion Reaction

  • Amnestic Ab response usually 3-30 d s/p transfusion (Rh, Kidd etc)
  • Usually gradual extravascular hemolysis
  • Fever, falling Hgb, slight elev. bili, spherocytosis

Febrile Non-hemolytic Transfusion Reaction

  • D/t cytokine accumulation in donor blood (less risk in leukoreduced blood)
  • Incidence: ~0.5% for non-reduced RBC’s, 0.1% in reduced RBC’s
  • Fever, mild dyspnea 1-6 hrs after start of transfusion
  • DDx includes acute hemolytic reaction so transfusion should be stopped blood should be sent to blood bank etc
  • APAP and diphenhydramine for symptomatic tx
  • 40% of pts will have recurrence, 1/4 w/ their next transfusion

Urticarial Reactions

  • Recipient IgE vs soluble substances in donor plasma
  • Incidence: 1-3%
  • Only reaction where transfusion does not need to be stopped (though may need to for severe reactions
  • Treat w/ diphenhydramine

Post-Transfusion Purpura

  • Delayed transfusion reaction to any platelet containing products
  • Most often seen in women
  • Can present w/ severe thrombocytopenia (e.g. Plt<20K)
  • Tx: High dose IVIG; possibly glucocorticoids or exchange transfusion

 

TRALI

  • 2-hit mechanism:
    • Neutrophil sequestration in lung microvasculature
    • Neutrophil activation
  • Sudden onset of hypoxic resp failure and non-cardiogenic pulm edema after transfusion of blood products (any kind of products including cryo)
  • Often w/in minutes, most w/in 1-2 hrs after transfusion but as late as 6 hrs
  • Fever in ~ 1/3
  • DDx includes TACO, cardiogenic pulm edema, PNA, hemolytic transfusion reaction
  • Management: Stop transfusion, supportive
  • Do not appear to be at increased risk of recurrence w/ future transfusions

 

Non-Immune Mediated

Bacterial contamination

  • Yersinia enterocolitica most likely
  • Need to consider if febrile reaction and sent BCx
  • Ceftri and Zosyn if concerned

TACO

  • Transfusion associated circulatory overload
  • HF after blood product transfusion

 

Transfusion associated GVHD

  • Irradiated blood for severely immunosuppressed patients

 

Fever During Transfusion

  • Defined of temp increase of at least 1 C during transfusion
  • Stop transfusion, remove tubing
  • NS Bolus
  • Send labs including direct Coombs and BCx
  • Send bag and tubing to pathology in lab bag (hand deliver)