Blood Transfusion Reactions

Seconds-minutes

  • Anaphylaxis
    • IgE-mediated hypersensitivity
    • Rash, angioedema, wheezing, hypotension
    • Management: Intramuscular epinephrine injection + steroids

Minutes-hours

  • Acute Hemolytic Reaction
    • Recipient antibodies to donor RBC antigens (usually ABO antigens), as a result of improper cross-matching prior to administration
    • Fever, chills, flank pain, hemoglobinuria, potentially progressing to renal failure and DIC
    • High unconjugated bilirubin, high LDH, low haptoglobin, Coombs-positive
    • Management: STOP transfusion, give normal saline (not LR, LR has calcium which can coagulate any blood remaining in the IV), at recommended rate 1 ml/kg/hr to prevent hypotension and renal injury . Can supplement with blood products as needed if patient is in DIC. (1-2)

~1-6 hours

  • Febrile Non-Hemolytic Reaction
    • When donor blood is in storage, residual WBCs release cytokines. These cytokines cause a fever when introduced to the patient
    • Fever with normal LDH, haptoglobin, and bilirubin
    • Management: STOP transfusion, give antipyretics. Use leukoreduced blood products in the future
  • TACO (Transfusion-Associated Circulatory Overload)
    • Volume overload in the setting of blood product administration
    • Dyspnea, bilateral pulmonary infiltrates seen on CXR (similar to TRALI)
    • No fever, +JVD, hypertensive, elevated BNP, good response to diuretics
    • Management: Diuresis
  • TRALI (Transfusion-Associated Lung Injury)
    • Two-hit hypothesis (3)
      • 1st: Sequestration/priming of neutrophils and endothlium from an inflammatory state (such as sepsis, malignancy, etc.) in the pulmonary endothelium prior to transfusion
      • 2nd: Various substances in the transfused blood activate the neutrophils and endothelium, causing inflammation and fluid leakage in the pulmonary vasculature
    • Dyspnea, bilateral pulmonary infiltrates seen on CXR (similar to TACO)
    • +Fever, no JVD, hypotensive, normal BNP, unreliable response to diuretics
    • Management: Treat as ARDS (see ARDS section) with essentially supportive treatment and lung-protective ventilation

Days-Weeks

  • Delayed Hemolytic Reaction
    • Immune system reaction to RBC antigen that it is has previously been exposed to (e.g. pregnancy, prior reaction), usually minor antigens (i.e. Rh) (4)
    • May be asymptomatic or have symptoms of anemia (fatigue, lightheadedness, etc.)
    • High unconjugated bilirubin, high LDH, low haptoglobin, Coombs-positive
    • Management: Supportive: close monitoring of hemoglobin levels and renal function. +/- antipyretics if febrile (5)

What to Do When Issues are Encountered with Blood Transfusion

  • Stop blood transfusion
  • Get IM epinephrine ready and consider having IV methylprednisolone or diphenhydramine ready
  • Look for wheezing, angioedema, rash (if present, likely anaphylaxis and epinephrine would be indicated)
  • Assess oxygenation saturation (consider CXR if inadequate oxygen saturation to eval for TACO vs TRALI)
  • If none of the above are present, start normal saline 1 mg/kg/hr for an acute hemolytic reaction and give antipyretics as needed and continue to monitor
  • Check labs (CBC with dif, CMP, LDH, haptoglobin) in the meantime to differentiate acute hemolytic reaction from febrile nonhemolytic reaction
  • Close monitoring of hemoglobin levels

References

  1. Singh, S. (2020, December 05). Ringer’s lactate. Retrieved February 05, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK500033/
  2. Harewood, J. (2020, August 16). Hemolytic transfusion reaction. Retrieved February 05, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK448158/#_article-22740_s7_
  3. Kim, J., & Na, S. (2015, April). Transfusion-related acute lung injury; clinical perspectives. Retrieved February 05, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4384395/
  4. Zerra, P., & Josephson, C. (2018, September 14). Delayed hemolytic transfusion reactions. Retrieved February 05, 2021, from https://www.sciencedirect.com/science/article/pii/B9780128137260000647
  5. Strobel, E. (2008). Hemolytic transfusion reactions. Retrieved February 05, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3076326/

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