Adverse Reactions To Blood Transfusion1

Adverse reactions associated
with Blood Transfusion
Dr. Afshan Sumera

Haematologist (Pathologist)
Session outcomes
At the end of this session, you should be able
to
• List transfusion reactions
• Explain the differences between immunological and non-
immunological reactions in blood transfusion
• Differentiate between haemolytic and non-haemolytic
reactions
• Describe common transfusion reactions & actions to be
taken in the occurrence of a transfusion reactions
• Discuss the role of the transfusion committee in the
hospital
Immunologic Non-Immunologic Infectious
Alloimmunization Volume Overload Hepatitis

Haemolytic Transfusion Massive Transfusion: HIV
Reaction Metabolic,
Hypothermia,
Febrile Transfusion Dilutional, CMV, EBV
Reaction Pulmonary
Microembolism
TRALI Bacterial
Allergic Transfusion
Reaction
Syphilis
Transfusion
Immunosuppressive
Effects
Parasites
reactions
Acute (immediate) or
delayed
Haemolytic Transfusion Reactions (HTRs)
• RBC destruction, either of the transfused RBCs, the recipient's RBCs
Major incompatibility Minor incompatibility

• Recipient's antibodies • Donor's plasma antibodies
vs vs
• Donor's RBCs • Recipient's RBC antigens
antigens
Inter-donor incompatibility
• Donor's plasma antibodies vs
• with antigens on the RBCs of another donor
that meet each other in the recipient's blood
Frequency 1 in 600 to
1 per 250000
components infused
Death most
commonly associated
Acute with ABO
Haemolytic incompatible blood
Reactions
Haemolysis
Intravascular Extravascular
Both intravascular and

Acute Haemolytic extravascular haemolysis may
Reactions – occur within the same haemolytic
Clinical transfusion reaction episode
presentation
Fever, or fever with chills
Nausea, vomiting, chest pain, wheezing,

dyspnoea, back pain, restlessness
Most serious consequences
• hypotension, renal failure, and DIC
Clinical Cytokine generation is thought to play an

important role in the pathogenesis of
presentation haemolytic reactions
Acute Haemolytic Reactions
Laboratory Testing
• Done immediately if haemolytic reaction is suspected

1. Infusion must be stopped
2. Blood sample taken from patient for testing
3. Notification to blood bank or transfusion services
4. Clerical check to ensure that proper unit to proper patient
5. Repetition of ABO blood group type on pretransfusion and
posttransfusion blood sample
6. Direct antiglobulin test (DAT) for presence of Ig on RBC surface
7. Urine sample for presence of hemoglobin
8. Return blood unit to Blood Bank
Laboratory Testing (Additional Testing)
Repetition of cross-matching
Plasma free hemoglobin
Serum haptoglobin
Bilirubin
Lactate dehydrogenase (LDH) levels

Treatment
Stop Stop the transfusion.
Keep the intravenous line open with 0.9% normal

Keep saline.
Initiate symptomatic treatment to correct hypotension,

Initiate control bleeding, and prevent acute tubular necrosis.
Febrile nonhaemolytic reactions
Multiparous women
Multiple times transfused patients
Leukoreactive antibodies
During the storage of blood

• clinically significant quantities of cytokines are sometimes liberated from donor-derived
passenger leukocytes present in platelet and red cell products
IL-2, IL-6, IL-8, and tumour necrosis factor
Self-limited
Can administer subsequent transfusions without undue risk

Stop the transfusion and rule out
the possibility of a haemolytic
transfusion reaction
Additional tests are not done
Diagnosis is made on the absence

Febrile of evidence of haemolysis in
nonhaemolytic association with the clinical findings
reactions
Laboratory Testing
Febrile nonhaemolytic reactions
Treatment & Prevention
Mostly self-limited
Treated with orally administered antipyretics
Prevention
• Removing the WBCs from the blood product
• reactions are mostly associated with antibodies
against the transfused leukocytes
Development of pulmonary
infiltrates and non-cardiogenic
pulmonary oedema
Passively transferred donor

antibodies
• react against recipient leukocyte

antigens
Transfusion-related Uncommon adverse transfusion

acute lung injury event
(TRALI)
Fever, substernal chest pain,
dyspnoea, cyanosis, cough, blood-
tinged sputum, and hypoxemia 1
to 4 hours after transfusion
Heart size is normal
TRALI – Bilateral diffuse pulmonary

Clinical infiltrates are seen on chest
Presentation radiographs
TRALI – Treatment & Prevention
Patients may require respiratory support and
mechanical ventilation
Recovery usually occurs within 48 hours
Prevention
• Identification of donor with antibodies
• restricting future use of their blood
Allergic Reactions
Range from urticaria and pruritus to severe
anaphylactic reactions
Mild reactions may occur in as many as 1% to

3% of transfused patients
Severe reactions approximately 1 in 150,000

components transfused
Allergic Reactions – Lab testing
Urticaria is not a sign of haemolysis
Laboratory investigation for a transfusion reaction

is not necessary
Such reactions should be reported to the blood

bank
• Documentation, because recurrence of such reactions may
require changes in blood product
Allergic Reactions – Treatment &
Prevention
Hives (urticaria) are treated with

antihistamines
Patients with recurrent or severe urticarial

reactions
• should receive saline washed blood components (remove
plasma)
Anaphylactic • IgA deficient
transfusion • Extremely rare 1 in 150,000
components transfused
reactions
• Clinical S/S apprehension, a
feeling of doom, chest or
lumbar pain, facial and upper
body flushing, generalized
urticaria with pruritus,
laryngeal or facial oedema,
bronchospasm, wheezing,
dyspnoea, hypotension, loss
of consciousness, vomiting,
and diarrhoea
Anaphylactic transfusion
reactions
Treatment & Prevention
• Should be initiated promptly with

epinephrine and careful clinical
monitoring
• If subsequent transfusions are

required
• red cells and platelets should be
washed to remove plasma or
• from an IgA-deficient donor
Hypervolemia
• Most unrecognized complication
• Patients should be evaluated

carefully prior to transfusion for
• cardiac status
• state of hydration
• Patients at risk for hypervolemia

• Slow infusion, 4 hours for 1 unit
of blood
Nonimmune Haemolysis
• Rupture of transfused red cells

• osmotic or
• mechanical stress
• overheating occurs as a result
of a malfunctioning blood
warmer
• infusion pump injures red cells
Complications of massive transfusion
• Hypotension, tissue damage, and shock with concomitant complications
1. Bleeding complications
2. Hypocalcaemia
3. Hypokalaemia/hyperkalaemia
4. pH abnormalities
5. Hypothermia
6. Adult respiratory distress syndrome (40%)
Massive transfusion is replacement of a patient's total blood volume in less than

24 hours, or as the acute administration of more than half the patient's estimated
blood volume per hour.
• Haemostatic state should be done on
a periodic basis during massive
transfusion
• platelet count, prothrombin time
Complications of
(INR), partial thromboplastin time, massive
and fibrinogen levels transfusion
Laboratory
• Blood gas and electrolyte testing
determinations should also be
performed as needed
• Dilutional thrombocytopenia and
dilutional coagulopathy
• replacement of platelets,
coagulation factors, and fibrinogen
through transfusion of platelet
concentrates, FFP, and Complications of
cryoprecipitate respectively
massive
transfusion
• Metabolic abnormalities should be
treated appropriately when recognized. Treatment
• Blood warmers should be used in any

patient undergoing massive transfusion
in order to prevent hypothermia.
• Infrequent
• Important complication
• Both RBCs and platelet concentrates
associated with bacterial contamination
• Clinical presentation:
Bacterial Sepsis
• Chills or rigors often associated with
nausea, vomiting, lethargy, and fever
occur after infusion of 50 to 70 mL of
blood.
• Patients may complain of pain in the
abdomen or low back region or
along the infusion site
• Difficult to distinguish from a haemolytic
transfusion reaction
• Patient should be evaluated for
haemolytic transfusion reaction
• In addition,
• aliquot obtained from the remaining Bacterial Sepsis
component should be examined for Laboratory
bacteria by Gram stain and a
bacterial culture should be testing &
performed Treatment
• Broad-spectrum antibiotics
• Supportive measures
• Alloantibody-mediated red cell
destruction
• Generally secondary or anamnestic

responses
• manifest several days to 2 weeks after
transfusion
• Frequency of approximately 1 per 1,500 Delayed

to 8,000 units transfused Haemolytic
Reactions
• Usually mild
• Unexpected anaemia after recent

transfusion
• Fever (75%). Jaundice (67%) and oliguria

(17%)
• Rare complication
• viable lymphocytes in a blood
product react against host tissues
• Immunosuppressed patients
• 4 to 30 days after transfusion
• Patients develop fever, erythema, Post-transfusion
diarrhoea, liver function graft-versus-host
abnormalities, and bone marrow
suppression marked by disease
pancytopenia
• Hepatomegaly and jaundice are
common
• Diagnostic biopsy of the skin or
gastrointestinal tract
• DNA testing
• to determine that circulating
Post-transfusion
lymphocytes are non-patient types graft-versus-host
disease
• Treatment is usually unsuccessful, and
Lab testing &
mortality rates approach 90% Treatment
• Prevention
• Gamma irradiation of blood products
• Hepatitis
• HIV infection
• Cytomegalovirus (CMV)
• fetuses receiving intrauterine
transfusions
• premature infants
• Spirochete infection Transfusion-
• Syphilis is an unusual complication transmitted
• spirochetes are not viable after 24 Diseases
hours at 4°C storage
• still required on all donor units in the
United States
• Parasitic infections:
• Malaria
Transfusion-
• Babesiosis is a potentially fatal transmitted
complication when occurring in
immunocompromised, splenectomized, Diseases
or elderly patients
• Provide an active forum to facilitate
communication between those involved with
transfusion
• Recommend or perform practice audits
Role of Hospital
• Monitor transfusion practice compared to
institutional, national or international Transfusion
benchmarks Committee
• Provide education to effect change in
practice
• Ten minutes after starting a new infusion of
PRBCs, you suspect an acute hemolytic
transfusion reaction. You stop the blood
infusion, and keep the vein open with NS and
new IV tubing. You also obtain vital signs, notify
the MD and the blood bank. In addition to the
above, what else is important for you to follow-
up on?
A. Ask the MD for an order to administer
an anticoagulant
B. Call the family and ask if they want to
alter the advance directive
C. Send the blood bag and IV tubing back
to the blood bank for testing
D. Assess for new signs and symptoms of
deep vein thrombosis (DVT)
• If a hemolytic blood transfusion is suspected,
the blood bank will ask the RN to send:
A. Nasal swab culture.
B. Medication and allergy list.
C. The original MD order for the blood
product.
D. A new blood specimen & first voided
urine specimen.
• A haemolytic blood transfusion reaction is
highly dangerous and is the result of:
A. Decreased RBC production.
B. Contamination of the blood product.
C. Incompatible ABO or Rh blood type.
D. Antibodies react against donor white
blood cells or platelets.
Thanks

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Adverse reactions associated

with Blood Transfusion

Dr. Afshan Sumera

Alloimmunization Volume Overload Hepatitis

• RBC destruction, either of the transfused RBCs, the recipient's RBCs

Major incompatibility Minor incompatibility

Both intravascular and

Nausea, vomiting, chest pain, wheezing,

Most serious consequences

• hypotension, renal failure, and DIC

Clinical Cytokine generation is thought to play an

• Done immediately if haemolytic reaction is suspected

Plasma free hemoglobin

Lactate dehydrogenase (LDH) levels

Stop Stop the transfusion.

Keep the intravenous line open with 0.9% normal

Initiate symptomatic treatment to correct hypotension,

Multiple times transfused patients

During the storage of blood

IL-2, IL-6, IL-8, and tumour necrosis factor

Can administer subsequent transfusions without undue risk

Additional tests are not done

Diagnosis is made on the absence

Treated with orally administered antipyretics

Passively transferred donor

• react against recipient leukocyte

Transfusion-related Uncommon adverse transfusion

TRALI – Bilateral diffuse pulmonary

Recovery usually occurs within 48 hours

Mild reactions may occur in as many as 1% to

Severe reactions approximately 1 in 150,000

Urticaria is not a sign of haemolysis

Laboratory investigation for a transfusion reaction

Such reactions should be reported to the blood

Hives (urticaria) are treated with

Patients with recurrent or severe urticarial

• Should be initiated promptly with

• If subsequent transfusions are

• Most unrecognized complication

• Patients should be evaluated

• Patients at risk for hypervolemia

• Rupture of transfused red cells

Massive transfusion is replacement of a patient's total blood volume in less than

• Blood warmers should be used in any

• Generally secondary or anamnestic

• Frequency of approximately 1 per 1,500 Delayed

• Unexpected anaemia after recent

• Fever (75%). Jaundice (67%) and oliguria

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