Acute Transfusion Reactions (<24 Hr)

• Mild allergic reaction:
  • Histamine-mediated hypersensitivity reaction to foreign protein in donor blood
  • Can occur before, during, or after transfusion
  • Can vary from urticaria, edema, pruritic, and progress to anaphylaxis
  • Mild symptoms can be managed with diphenhydramine, and slower rate of transfusion
• Anaphylaxis:
  • Generalized flushing, urticaria, angioedema, bronchospasm, profound hypotension, shock, or cardiac arrest
  • Usually seen in IgA-deficiency
  • Premedication with diphenhydramine, washing of cellular products or receiving products from IgA-deficient donors can help prevent recurrence of severe allergic/anaphylactic reactions
• FNHTR:
  • Most common but diagnosis of exclusion
  • Temperature increases ≥1 °C with chills within 6 hr
  • Caused by cytokines generated in the storage process of blood
  • Usually mild
  • Occurs more often with multiparous women or multiple transfusions
  • Recurs in 15% of patients
  • Acetaminophen to treat fever or it may be used prophylactically; its use as premedication is controversial, though not harmful
• AHTR:
  • Occurs immediately from incompatibility between donor RBC and recipient (ie, ABO or other antigen incompatibility)
  • Cytokine-mediated inflammatory response resulting in intravascular or extravascular hemolysis causing activation of coagulation system, leading to inflammation, shock, and DIC
  • Cytokines cause release of endothelin in kidneys, and free hemoglobin in lungs causing vasoconstriction leading to renal and pulmonary failure (ARDS)
  • Clinically may see chills, fever, hypotension, hemoglobinuria, back pain, and DIC
  • Mortality and morbidity correlate with amount of incompatible blood transfused (symptoms can occur with exposure to as little as 5–20 mL)
  • Usually due to lab/clerical error
• TACO:
  • Acute onset of respiratory distress during or within 6–12 hr of receiving a transfusion of any blood component due to increased circulating volume
  • Required criteria: Acute or exacerbation of respiratory distress, and/or clinical or radiologic evidence of pulmonary edema within 12 hr of transfusion
  • Additional criteria: Evidence of unexplained cardiovascular changes (eg, tachycardia, hypertension, JVD, elevated CVP, enlarged cardiac silhouette, and/or peripheral edema), evidence of fluid overload (eg, positive fluid balance, improvement with diuresis), supportive relevant biomarker (eg, BNP or NT-pro BNP greater than 1.5× pretransfusion level)
  • Leading cause of transfusion-related mortality and morbidity, accounting for around 20% of serious acute transfusion reactions
  • Increased risk of TACO for patients with CHF, severe aortic stenosis, chronic diuretic use, severe anemia
  • Treatment mimics that of heart failure exacerbation including positive pressure ventilator support (ie, NIPPV) and diuretics
• TRALI:
  • Acute onset of dyspnea with hypoxia and bilateral infiltrates within 6 hr of transfusion in the absence of circulatory overload 6 hr of transfusion
  • Difficult to distinguish from ARDS and TACO; often misdiagnosed and underreported
  • Categorized as TRALI type I and II:
    • Type I: Patients who have no risk factors for ARDS and meet the following criteria: Acute onset, hypoxemia (P/F of <300, SpO₂ <90% on room air), clear evidence of bilateral pulmonary edema on imaging, no evidence of left atrial hypertension (LAH); onset during/within 6 hr of transfusion; no temporal relationship or alternative risk factor for ARDS
    • Type II: Patients who have risk factors for but not diagnosed with ARDS or who have existing mild ARDS (P/F of 200–300), but whose respiratory status deteriorates due to transfusion based on type I criteria, and stable respiratory status in 12 hr before transfusion
  • Disease is typically self-limited within 96 hr
  • Mortality is 5–10%
  • Provide supportive care, including intubation/mechanical ventilation as needed
  • Diuretics contraindicated

Delayed Transfusion Reactions

• Infection:
  • HIV, hepatitis B, hepatitis C:
    • Blood screened for viruses
    • Blood treated to inactivate viruses
    • Blood donors with recent history of travel or poor health are deferred from donating
  • Bacterial:
    • 5 deaths in 2015
    • S. aureus most common pathogen
• Delayed extravascular hemolytic reaction:
  • Occurs 7–10 d after transfusion
  • Antigen–antibody reaction that develops after transfusion
  • Coombs test positive
  • Usually asymptomatic, but can present with low-grade fever or jaundice
  • Blood bank analysis detects antibody
• Iron overload
• Electrolyte imbalance:
  • Hypocalcemia: Calcium binds to citrate
  • Hyper/hypokalemia: Citrate metabolized to bicarbonate, which drives potassium intracellularly; prolonged storage of blood may cause hemolysis and hyperkalemia
• Transfusion-related graft vs host disease (TR-GVHD):
  • Rare but fatal in >90%
  • Immunologically competent donor lymphocytes recognize their new host as foreign and attack recipient’s tissues and engraft, wherein the recipient is unable to destroy the donor’s WBCs
  • At risk:
    • Severely immunocompromised
    • Congenital immunodeficiency affecting T-cells
    • Hodgkin lymphoma
    • High-dose chemotherapy or radiotherapy
    • Immunocompetent recipient of cellular products from blood relatives, or being transfused in a donor population with little HLA diversity

Pediatric Considerations

Blood can be transfused through 22G peripheral catheter under pressure (but <300 mm Hg) with minimal hemolysis