Transfusion Complications

Transfusion Complications is a topic covered in the 5-Minute Emergency Consult.

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  • Of 39 million hospital discharges in US, 5.8% (2.3 million) were associated with blood transfusions (2004).
  • In 2011 there were 30 deaths in US fully attributable to transfusion complications.
  • Some type of transfusion reaction occurs in 2% of units transfused within 24 hr of use.
  • Noninfectious complications:
    • Febrile nonhemolytic reaction: RBCs 1 in 500 transfusions, platelets 1 in 900
    • Allergic reaction (nonanaphylactic): 1 in 3 to 1 in 300
    • Anaphylaxis: 1 in 20,000 to 1 in 50,000
    • Acute hemolytic reaction: 1 in 38,000 to 1 in 70,000
    • Delayed hemolytic reaction: 1 in 4,000 to 1 in 11,000
    • Transfusion-associated circulatory overload (TACO): 1 in 100, but as high as 10% in susceptible populations
    • Alloimmunization: 1 in 10 to 1 in 100
    • Graft-versus-host disease: 1 in 400,000; rare but has >90% mortality.
    • Transfusion-related lung injury (TRALI): 1 in 5,000 to 1 in 190,000; represents 13% of reported transfusion-related deaths
    • Iron overload: Unknown incidence, depends on volume of blood, often occurs after >100 RBC units
    • Hypocalcemia: Unknown incidence
    • Hyperkalemia: Unknown incidence
  • Infectious complications:
    • Bacterial contamination: RBCs 1 in 65,000 to 1 in 500,000; platelets 1 in 1,000 to 1 in 10,000:
      • Most common bacterial agents: Yersinia enterocolitica, Pseudomonas spp, Serratia spp.
      • Leading cause of mortality among infectious complications; 17–22% of all cases
    • Hepatitis C: 1 in 1.6 million
    • Hepatitis B: 1 in 100,000 to 1 in 400,000
    • HTLV I and II: 1 in 500,000 to 1 in 3 million
    • HIV: 1 in 1.4 million to 1 in 4.7 million
    • HAV: 1 in 1,000,000
    • B19 parvovirus: 1 in 40,000; post-transfusion anemia rare with scattered case reports
    • Parasites: Babesia and malaria: <1 in 1 million
    • Parasites: Trypanosoma cruzi: 1 in 42,000
    • Case reports of Epstein–Barr virus, Lyme disease, brucellosis, human herpesvirus, Creutzfeldt–Jakob disease

Acute Intravascular Hemolytic Transfusion Reaction
  • Mortality and morbidity correlate with amount of incompatible blood transfused (symptoms can occur with exposure to as little as 5–20 mL)
  • Occurs immediately from:
    • ABO incompatibility
    • Blood type identification error
    • Incompatible transfused cells immediately destroyed by antibodies
  • Intravascular hemolysis causing activation of coagulation system, leading to inflammation, shock, and DIC
  • Mediators (cytokines) released during inflammatory response
  • Renal failure:
    • Cytokines cause local release of endothelin in kidney, causing vasoconstriction.
    • Leads to parenchymal ischemia and acute renal failure
  • Respiratory failure owing to pulmonary edema/adult ARDS:
    • Free hemoglobin (Hb) causes vasoconstriction in pulmonary vasculature.

Other Transfusion-related Complications
  • Hemolysis because of Rh incompatibility:
    • Mild, self-limiting
    • 1:200 U transfused
  • Febrile nonhemolytic transfusion reaction:
    • Most common transfusion reaction, diagnosis of exclusion.
    • Temperature increases at least 1°C with chills within 6 hr
    • Antigen–antibody reaction to transfused blood components (WBCs, platelets, plasma)
    • Usually mild
    • Occurs more often with multiparous women or multiple transfusions
    • Recurs in 15% of patients
    • Acetaminophen may be used prophylactically; its use as premedication is controversial, though not harmful.
  • Allergic transfusion reaction:
    • Occurs in 1% of transfusions
    • Usually seen with immunoglobulin A (IgA)–deficient patients
    • Urticaria alone is not a reason to stop transfusion.
    • Antihistamine may be used as therapy or prophylactically.
  • Premedicating with acetaminophen and diphenhydramine found to have no effect on incidence of transfusion reaction compared with placebo in some trials.

Delayed 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.
  • Delayed extravascular hemolytic reaction:
    • Occurs 7–10 days after transfusion
    • Antigen–antibody reaction that develops after transfusion
    • Coombs test positive
    • Usually asymptomatic
    • Blood bank analysis detects antibody
  • 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
  • Graft-versus-host disease:
    • Fatal in >90%
    • Immunologically competent lymphocytes transfused into immunocompetent host
    • Host unable to destroy new WBCs
    • Donor WBCs recognize host as foreign and attack host's tissues.
  • Anaphylactic reaction:
    • Can occur with <10 mL of exposure
    • Generalized flushing, urticaria, laryngeal edema, bronchospasm, profound hypotension, shock, or cardiac arrest.
    • Treat with subcutaneous epinephrine, supportive hemodynamic and respiratory care.
  • TRALI:
    • Symptoms typically begin with 6 hr of transfusion.
    • Acute onset of respiratory distress, bilateral pulmonary edema, fever, tachycardia, hypotension, with normal cardiac function
    • 3rd most common cause of fatal transfusion
    • Difficult to distinguish from ARDS and TACO; often misdiagnosed and underreported
    • Provide supportive care.
    • Disease is typically self-limited within 96 hr.
    • Mortality is 5–10%.
    • Diuretics contraindicated

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

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