Transfusion. Reactions. (adverse effects of transfusion) EBMT Geneva Monica Braisch RBSZ St. Gallen
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1 Transfusion Reactions (adverse effects of transfusion) Monica Braisch RBSZ St. Gallen
2 Recognition Evaluation and therapy of suspected TR Reporting
3 Febrile nonhemolytic TR Hemolytic TR, acute or delayed Septic TR TRALI Allergic and/or anaphylactic reactions Hemolytic TR Fever Rash Dyspnea Shock Acute hemolytic TR Anaphylaxis Fluid overload TRALI Acute hemolytic TR (intravascular hemolysis) Anaphylactic reaction Sepsis TRALI
4 Actions to be taken immediately whenever a TR is suspected include: STOP transfusion and evaluate the patient, maintain iv, monitor VS Report reaction to blood bank Return bag with all tubing attached Send posttransfusion bloodsample
5 Any adverse reaction to blood components should be reported to transfusion medicine personnel A transfusion medicine physician should be consulted for: Clinical evaluation of patients Laboratory investigation Selection of appropriate blood components for future transfusion Donor look back, as needed Reporting to the national Haemovigilance (Swissmedic for Switzerland)
6 Types of TR 1. Immunologic: Hemolytic TR acute: within 24 hours of transfusion (most intravascular) delayed: more than 24 hours after transfusion (1-28 days) (most extravascular) Febrile nonhemolytic TR( FHNTR) Allergic reaction mild (urticarial) anaphylactoid anaphylaxis Alloimmunisation (red cell antigens, platelet specific antigens, HLA antigens, neutrophil specific antigens) Post-Transfusion-Purpura (PTP) Transfusion-related graft-vs-host disease
7 2. Transfusion-transmitted infections (TTI): Viral infections (HIV, HTLV, HBV, HCV, WNV) Bacterial contamination (septic TR) Parasitic TTI (Malaria, T. cruzi) Prion infection (vcjd) Prevention: donor history questionnaire and donor testing antiseptic and inspection of phlebotomy site predonation pouch pathogen inactivation with INTERCEPT (Cerus) for platelet units (since in Switzerland)
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11 3. Other: Transfusion associated circulatory overlaod (TACO) Transfusion-related acute lung injury (TRALI) Febrile nonhemolytic TR (FNHTR) Transfusion-associated dyspnea (TAD: is characterised by respiratory distress within 24 h of transfusion that does not meet the criteria of TRALI, TACO or allergic reaction) Hypotensive TR Transfusion related iron-overload (20-25 g iron/rbc unit)
12 Massive transfusion hyperkalemia hypocalcemia (citrate: chills, muscle cramps and fasciculations, depressed cardiac function) hypothermia (ventricular arrhythmias, impaired hemostasis) Incorrect blood component transfused (IBCT: this category comprises all reported episodes where a patient was transfused with a blood component that was intended for another patient or which was incorrect in terms of its specification). 4. Near miss: A near miss event refers to any error which, if undetected, could result in the determination of a wrong blood group or transfusion of an incorrect component, but was recognised before the transfusion took place.
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15 Hemolytic TR- intravascular Causes ABO or certain other blood group incompatibilities Use of improperly stored or warmed blood Symptoms Hemoglobinemia and hemoglobinuria Fever, chills, chest pain, flank pain Dyspnea,anxiety, shock,oliguria =>anuria Burning at site of infusion DIC Evaluation Clerical check: match between unit, patient, sample ABO/Rh type,dat,antibodyscreen,crossmatch:pre-and posttransfusion samples Visual check for hemolysis Acute hemolysis: plasma free Hb,haptoglobin,hemoglobinuria,LDH,bilirubin (I>D) Culture on unit and patient
16 Hemolytic TR- extravascular Causes Blood group incompatibility, where antibodies do not fully activate complement Symptoms Fever, jaundice Elevated indirect bilirubin Falling hematocrit Evaluation Clerical check: match between unit, patient, sample ABO/Rh type,dat,antibodyscreen,crossmatch:preand posttransfusion samples Visual check for hemolysis Acute hemolysis: plasma free Hb,haptoglobin,hemoglobinuria,LDH,bilirubin (I>D) Culture on unit and patient
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18 FNHTR Causes Antibody mediated (HLA,HPA) Inflamatory mediators (cytokines in stored components) Symptoms Chills,Fever ( 1 C increase in body temperature in the 4 h after transfusion) Rigors in severe reactions Evaluation Clerical check: match between unit, patient, sample ABO/Rh type,dat,antibodyscreen,crossmatch:preand posttransfusion samples Exclude hemolysis Culture on unit and patient
19 Allergic Reaction Causes Presumed allergy to a soluble substance in donor plasma IgA-deficient patients (Anti-IgA) Symptoms Localized or generalized urticaria (hives) Laryngeal or facial edema Hypotension Anaphylactic shock: bronchospasm,flushing,chills,gicramps,nausea,vomiting,unconsciousness Evaluation No evaluation for mild reaction Exclude other TR IgA-deficiency Anti-IgA
20 Hypotensive reactions Causes Risk factors: ACE inhibitors, critically ill Symptoms Severe hypotension (>30 mmhg) within minutes of a transfusion Evaluation Rapid resolution of symptoms after stopping transfusion Hold ACE inhibitors 24h for patients undergoing HPC collection, therapeutic apheresis
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22 TRALI Causes Donor lymphocyte antibodies (HLA, HNA) Lipid activators of neutrophils in the donor plasma Symptoms Acute onset < 6 hours Hypoxia:O 2 <90%,PaO 2 /FiO 2 300mmHg Dyspnea,fever,chills,hypotension Pulmonary vascular congestion and/or pulmonary edema on chest X-ray but without cardiomegaly Evaluation Anti-HLA/-HNA in donor blood Positive crossmatch with recipientgranulocytes Switzerland adopted transfusion of FFP only from male donors
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25 TACO Causes Blood volume too large or infusion too fast for compromised cardiovascular system Symptoms Acute onset :during the transfusion or within 6h Dyspnea,orthopnea,tachycardia,hypertension Cardiomegaly and pulmonary congestion on chest X-ray Peripheral edema Evaluation Consider comparing pretransfusion BNP (B-type natriuretic peptide) with posttransfusion BNP (BNP>100pg/ml with 1.5-fold increase suggests volume overload)
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27 PTP Causes Antibody to platelet antigen in antigennegative recipient Symptoms Severe thrombocytopenia about 1 week after transfusion Evaluation HPA-antibodies (Anti-HPA-1a) Cross-match
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29 TA-GvHD Causes Infusion of immunocompetent donor lymphocytes in an immunosuppressed recipient An immunocompetent recipient shares HLA-haplotype with an HLA-homozygous donor Symptoms Fever,skin rash (desquamative) Hepatitis, diarrhea Marrow suppression Infection High mortality Evaluation Histology (skin-and liver-biopsy) HLA-typing Gamma-irradiate cellular blood components for immunosuppressed Irradiate all cellular components from HLAmatched or related donors
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31 Treatment of transfusion reactions Acute HTR: Closely monitor patient Fluid and O 2 - support Maintain renal function ± iv steroids Monitor/treat DIC FNHTR: STOP transfusion Administer antipyretic
32 Allergic reactions Mild: Antihistamine ± restart transfusion: Severity of symptoms Clinical status of patient Clinical decision Severe/ anaphylactic: Fluid and O 2 - support Antihistamine ± H 2 blocker Steroid Epinephrine DO NOT RESTART TRANSFUSION
33 TRALI: Oxygenation ± ventilation BP support TACO: Oxygen Diuresis
34 Hypotensive TR: STOP the transfusion Fluid and O 2 - support Symptoms should resolve after stopping transfusion Bacterial contamination: STOP the transfusion Fluid and O 2 - support IV antibiotics Transfusion = max. 4 hours Monitor /treat DIC
35 Swissmedic Reporting In Switzerland, all transfusion related adverse events and reactions, irrespective of their grade of severity, are eligible for reporting severity of TR imputability of TR Grade 1: without life threat Grade 2: permanent injury Grade 3: life-threatening Grade 4: death of the recipient Excluded/unlikely Possible Likely Certain
36 Donor adverse event reporting
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52 Take home message Assume that an adverse reaction temporaly related to a transfusion to be a transfusion reaction until proven otherwise
53 Thank you for your attention!
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