Acute transfusion reaction: Difference between revisions

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==Background==
==Background==
#For all reactions:
*If concern for fluid overload, may need to transfuse as split pRBCs to tranfuse as slow as 1mL/kg/hr
##Stop the transfusion (at least temporaily)
*Sepsis is most commonly due to [[yersinia]], which is able to grow easily in refrigerated blood
##Call the blood bank
##Draw a new type + screen


== Acute ==
{{Transfusion risk}}
===Intravascular Hemolytic Tranfusion Reaction===
#Occurs due to ABO incompatibility
#Diagnosis
##Back pain, headache, hypotension, dyspnea, pulmonary edema, bleeding, renal failure
##Labs c/w hemolysis
#Treatment
##Stop transfusion
###Risk of death is proportional to amount of incompatible blood received
##Maintain urine output with IVF, mannitol, and furosemide as needed
##Treat shock with volume and vasopressors
##Treat coagulopathy w/ FFP
===Febrile Nonhemolytic Tranfusion Reaction===
#Occurs in 20% of pts due to recipient Ab against donor leukocytes
#Diagnosis
##Fever, HA, myalgias, tachycardia, dyspnea, chest pain
#Treatment
##Stop tranfusion pending rule-out of hemolytic transfusion reaction
##Give antipyretic
##Restart transfusion once hemolytic transfusion reaction is ruled-out
===Allergic Tranfusion Reaction===
#Occurs due to immune response to plasma proteins
#Diagnosis
##Symptoms range from urticaria/pruritus to bronchospasm, wheezing, anaphylaxis (rare)
#Treatment
##Stop transfusion until able to evaluate severity of allergic reaction
##Give diphenhydramine
##Restart transfusion if symptoms are mild
===Transfusion-associated circulatory overload (TACO)===
#Often confused with TRALI
#Associated with a rapid rise in blood pressure, not hypotension
#Diagnosis
##Dyspnea, orthopnea, peripheral edema, rapid rise in BP
#Treatment
##O2, supportive care, diuretics
===Transfusion-Related Acute Lung Injury (TRALI)===
#Due to granulocyte recruitment and degranulation within the lung
#More common with FFP and plt transfusions (extremely rare with pRBC transfusion alone)
##pRBCs do contain residual plasma and can have TRALI
#Time Frame: abrupt to within 6 hours of transfusion initiation
#Diagnosis
##ARDS-like symptoms
##B/l pulmonary infiltrates due to noncardiogenic pulmonary edema w/in 6h of transfusion
#Treatment
##Strop transfusion
##Treat like ARDS
##Avoid diuresis


===Fluid Overload===
==Clinical Features==
#Split pRBCs to tranfuse more slowly (as slow as 1mL/kg/hr)
*Etiology specific, see ddx below
===Sepsis===
#Most commonly due to yersinia which is able to grow easily in refrigerated blood
== Delayed ==
===Extravascular Hemolytic Tranfusion Reaction===
#Occurs days to weeks after transfusion
#Hemolysis occurs in spleen, liver, and bone marrow
#Diagnosis
##Hyperbilirubinemia
##Poor response to transfusion
#Treatment
##None necessary; rarely fatal
===Graft-vs-Host Disease===
*Acute vs Chronic
**Acute: 1-12 weeks post graft
**Chronic: >12 weeks
#Transplanted graft with immunologically competent cells stimulated by host antigens and host is incapable of mounting an effective immunologic response
#Occurs in leukemia/lymphoma or immunocompromised
#Diagnosis
##Nonspecific rash, mucositis, fever, and diarrhea
##LFT abnormalities, pancytopenia
#Treatment
##Glucocorticoids


== Transfusion Risk Ratios ==
==Differential Diagnosis==
#1:10 Febrile non-hemolytic transfusion reaction per pool of 5 donor units of platelets (1 pack)
{{Transfusion reaction types}}
#1:100 Minor allergic reactions (urticaria)
 
#1:300 Febrile non-hemolytic transfusion reaction per unit of RBC (1 pack)
{{Acute Allergic DDX}}
#1:700 Transfusion-associated circulatory overload per transfusion  episode
 
#1:5000 Transfusion-related acute lung injury (TRALI)
==Evaluation==
#1:7000 Delayed hemolytic transfusion reaction
*Workup of hemolytic reaction
#1:10,000 Symptomatic bacterial sepsis per pool of 5 donor units of platelets
**CBC with microscopy differential
#1:40,000 Death from bacterial sepsis per pool of 5 donor units of platelets
**Formal urinalysis with bilirubin
#1:40,000 ABO-incompatible transfusion per RBC transfusion episode
**Haptoglobin, LDH, free hemoglobin
#1:40,000 Serious allergic reaction per unit of component
**Serum total and direct bilirubin
#1: 82,000 Transmission of hepatitis B virus per unit of component
**Coombs test of pre-transfusion and post-transfusion blood
#1:100,000 Symptomatic bacterial sepsis per unit of RBC
[[File:Coombs.png|thumbnail]]
#1:500,000 Death from bacterial sepsis per unit of RBC
*Consider CXR to help differentiate anaphylaxis, TRALI, TACO
#1:1,000,000 Transmission of West Nile Virus
{{TRALI vs TACO}}
#1:3,000,000 Transmission of HTLV per unit of component
 
#1:3,100,000 Transmission of hepatitis C virus per unit of component
==Management==
#1:4,700,000 Transmission of HIV per unit of component
*For all reactions:
**Stop the transfusion (at least temporarily)
**Call the blood bank
**Draw a new type + screen
 
==Disposition==


==See Also==
==See Also==
[[Transfusions]]
{{Transfusion reactions see also}}


== Source  ==
==References==
*Tintinalli
<references/>
*Canadian Blood Services (Public Health Agency of Canada)


[[Category:Heme/Onc]]
[[Category:Heme/Onc]]

Latest revision as of 14:25, 19 September 2017

Background

  • If concern for fluid overload, may need to transfuse as split pRBCs to tranfuse as slow as 1mL/kg/hr
  • Sepsis is most commonly due to yersinia, which is able to grow easily in refrigerated blood

Transfusion Risk Ratios[1]

Rate Complication
1:10 Febrile non-hemolytic transfusion reaction per pool of 5 donor units of platelets (1 pack)
1:100 Minor allergic reactions (urticaria)
1:300 Febrile non-hemolytic transfusion reaction per unit of RBC (1 pack)
1:700 Transfusion-associated circulatory overload per transfusion episode
1:5,000 Transfusion-related acute lung injury (TRALI)
1:7,000 Delayed hemolytic transfusion reaction
1:10,000 Symptomatic bacterial sepsis per pool of 5 donor units of platelets
1:40,000 Death from bacterial sepsis per pool of 5 donor units of platelets
1:40,000 ABO-incompatible transfusion per RBC transfusion episode
1:40,000 Serious allergic reaction per unit of component
1:82,000 Transmission of hepatitis B virus per unit of component
1:100,000 Symptomatic bacterial sepsis per unit of RBC
1:500,000 Death from bacterial sepsis per unit of RBC
1:1,000,000 Transmission of West Nile Virus
1:3,000,000 Transmission of HTLV per unit of component
1:3,100,000 Transmission of hepatitis C virus per unit of component
1:4,700,000 Transmission of HIV per unit of component

Clinical Features

  • Etiology specific, see ddx below

Differential Diagnosis

Transfusion Reaction Types

Acute allergic reaction

Evaluation

  • Workup of hemolytic reaction
    • CBC with microscopy differential
    • Formal urinalysis with bilirubin
    • Haptoglobin, LDH, free hemoglobin
    • Serum total and direct bilirubin
    • Coombs test of pre-transfusion and post-transfusion blood
Coombs.png
  • Consider CXR to help differentiate anaphylaxis, TRALI, TACO

TRALI vs TACO

TRALI TACO
Onset Acute, within 6hrs Often more gradual
BP Low High
Temp Febrile Normal
JVD/pedal edema Unlikely Likely
CVP/PAWP Normal Elevated
BNP Normal Elevated
Resp Dyspneic Dyspneic
CXR B/l infiltrates B/l infiltrates

Management

  • For all reactions:
    • Stop the transfusion (at least temporarily)
    • Call the blood bank
    • Draw a new type + screen

Disposition

See Also

References

  1. ↑ Wagner, L. Why Should Clinicians Be Concerned about Blood Conservation? ITACCS. 2005 PDF
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