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H54 Hematology
Blood Products and Transfusions Toronto Notes 2019
Acute Blood Transfusion Reactions
IMMUNE
Acute Hemolytic Transfusion Reactions
• ABOincompatibilityresultinginintravascularhemolysissecondarytocomplementactivation,occurs
DDx of Post-Transfusion Fever
• Acute hemolytic transfusion reaction
• Febrile non-hemolytic transfusion reaction • Bacterial contamination
• Allergy
DDx of Post-Transfusion Dyspnea
• Transfusion-associated circulatory overload (TACO)
• Transfusion-related acute lung injury (TRALI)
• Allergy (bronchospasm/anaphylaxis)
• • • • •
immediately after transfusion mostcommonlyduetoincorrectpatientidentification riskperunitofbloodis<1in40,000 presentation:fever,chills,hypotension,backorflankpain,dyspnea,hemoglobinuria acuterenalfailure(<24h)andDIC
treatment
■ stop transfusion
■ notify blood bank and check for clerical error
■ maintain BP with vigorous IV fluids ± inotropes
■ maintain urine output with diuretics, crystalloids, dopamine
Febrile Nonhemolytic Transfusion Reactions
• duetoalloantibodiestoWBC,plateletsorotherdonorplasmaantigens,andreleaseofcytokinesfrom blood product cells
• occurswithin0-6hoftransfusion
• riskperunitofbloodis1in100(minor),1in10,000to40,000(severe)
• presentswithfever±rigors,facialflushing,headache,myalgia,hypotension
• treatment
■ rule out hemolytic reaction or infection
■ if temperature <38oC, continue with transfusion but decrease rate and give antipyretics ■ if temperature >38oC, stop transfusion, give antipyretics and anti-histamine
Allergic Nonhemolytic Transfusion Reactions
• alloantibodies(IgE)toproteinsindonorplasmaresultinmastcellactivationandreleaseofhistamine • occursmainlyinthosewithhistoryofmultipletransfusionsormultiparouswomen
• riskperunitofbloodis1in100
• presentsmainlyasurticariaandoccasionallywithfever
• canpresentasanaphylactoidreactionwithbronchospasm,laryngealedema,andhypotension,butthis occurs mainly in IgA deficient patients that have anti-IgA antibodies
• treatment
■ mild: slow transfusion rate and give diphenhydramine
■ moderate to severe: stop transfusion, give IV diphenydramine, steroids, epinephrine, IV fluids, and
bronchodilators
Transfusion-Related Acute Lung Injury
• new-onsetacutelunginjurythatoccursduringtransfusionorwithin6hoftransfusioncompletion ■ insidious, acute onset of pulmonary insufficiency
■ profound hypoxemia (PaO2/FiO2 <300 mmHg)
■ bilateral pulmonary edema on CXR
■ pulmonary artery wedge pressure <18 mmHg
■ no clinical evidence of left atrial hypertension
• pathogenesisuncertain;perhapsduetobindingofdonorantibodiestoWBCofrecipientandreleaseof
mediators that increase capillary permeability in the lungs
• typicallyoccurs2-4hposttransfusionandresolvesin24-72h
• riskperunitofbloodis1in10,000
■ is currently the leading cause of transfusion-related morbidity and mortality
• treatment:supportivetherapy(oxygen)
• informbloodbank;patientanddonortestingwillbearranged
NONIMMUNE
Transfusion-Associated Circulatory Overload
• duetoimpairedcardiacfunctionand/orexcessiverapidtransfusion
• presentation:dyspnea,orthopnea,hypotension,tachycardia,cracklesatbaseoflung,andincreased
venous pressure
• incidence:1in700andisbecomingmorecommon
• treatment:transfuseatlowerrate,givediureticsandoxygen
Bacterial Infection
• Gram-positive:S.aureus,S.epidermidis,Bacilluscereus
• Gram-negative: Klebsiella, Serratia, Pseudomonas, Yersinia
• overallriskis1in100,000forRBCand1in10,000forplatelets • neverstoreblood>4hafterbaghasleftbloodbank
• treatment:stoptransfusion,bloodcultures,IVantibiotics,fluids