Transfusion Reactions, Slides of Physiology

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Transfusion Reactions

June 2015 https://www.medicine.uci.edu/residency/powerpoint/Inpatient%20Mini%20Lecture/Transfusion%20Rxn.pptx 4/25/19, 3E36 PM

Objectives

• Be able to recognize the more common transfusion reactions
• Learn about treatment and prevention of transfusion reactions https://www.medicine.uci.edu/residency/powerpoint/Inpatient%20Mini%20Lecture/Transfusion%20Rxn.pptx 4/25/19, 3E36 PM

Case 1

• Mr Red is a 17 year old male is brought to the ER after a motor vehicle accident. He is in pain, tachycardic to 100s, but normotensive.
• Given his acute blood loss, transfusion of 2u PRBC is initiated (after appropriate type and cross-matching revealing no antibodies, and compatibility with donor blood).
• During transfusion, he develops a fever but otherwise has no new signs or symptoms.
• What is the diagnosis? https://www.medicine.uci.edu/residency/powerpoint/Inpatient%20Mini%20Lecture/Transfusion%20Rxn.pptx 4/25/19, 3E36 PM

Febrile Nonhemolytic Transfusion

Reaction

• Fevers are common during transfusion
• Pathophysiology: likely involves recipient-derived leukoreactive antibodies + donor-derived cytokines
• Workup/Treatment: stop the transfusion!
  • Must r/o acute hemolytic transfusion reaction (AHTR)
  • Consider non-transfusion causes of fevers
  • Once AHTR is ruled out, may continue transfusion with antipyretics
• Prevention: antipyretics or leukoreduction of blood products https://www.medicine.uci.edu/residency/powerpoint/Inpatient%20Mini%20Lecture/Transfusion%20Rxn.pptx 4/25/19, 3E36 PM

Delayed Hemolytic

Transfusion Reaction

• Onset of symptoms: 5-10 days after RBC transfusion
• S/S: hemolytic anemia, jaundice, fever (can also be asymptomatic)
• Life-threatening complications are rare
• Confirmation: repeat type and screen to detect alloantibody
• Treatment: supportive
  • Abrupt onset of S/S
  • S/S: intravascular hemolysis, hypotension, fevers, AKI, pain at the infusion site, DIC, pink plasma or urine
  • Treatment: stop the transfusion!
    • Send blood back to blood bank to check for incompatibility, hemolysis
    • Supportive treatment with IVF, pressors, diuresis

Acute Hemolytic

Transfusion Reaction

http://arimmuneresponseassignment.weebly.com/report.html https://www.medicine.uci.edu/residency/powerpoint/Inpatient%20Mini%20Lecture/Transfusion%20Rxn.pptx 4/25/19, 3E36 PM

Case 1 (continued)

• Mr Red is now 78 years old. Since we last saw him, he has been diagnosed with diabetes, complicated by ESRD 2/2 diabetic nephropathy for which he is dialyzed three times per week.
• He is admitted for a suspected GI bleed for which he is transfused 2 units PRBC. An hour after transfusion, he starts to complain of shortness of breath and chest tightness. HR 120s, BP 180/90, an S3 gallop is noted, and new bibasilar crackles are heard on pulmonary exam. Post-transfusion CXR is shown (was previously normal).
• What is the diagnosis? https://www.med-ed.virginia.edu/courses/ rad/cxr/pathology2chest.html https://www.medicine.uci.edu/residency/powerpoint/Inpatient%20Mini%20Lecture/Transfusion%20Rxn.pptx 4/25/19, 3E36 PM

Case 2

• Mr Red’s hospital roommate also happens to be a 78 year old male admitted for likely GI bleed. He also underwent transfusion with 2 units PRBC 1 hour ago and reports shortness of breath.
• He is febrile to 38.5C, HR 120s, BP 70/ 4 0, SpO2 is 85% on RA. New bibasilar crackles are heard on pulmonary exam. Post-transfusion CXR is shown (was normal previously).
• What is the diagnosis? https://www.med-ed.virginia.edu/courses/ rad/cxr/pathology2chest.html https://www.medicine.uci.edu/residency/powerpoint/Inpatient%20Mini%20Lecture/Transfusion%20Rxn.pptx 4/25/19, 3E36 PM

Transfusion-Related Acute Lung

Injury (TRALI)

• Onset: during or within 6 hours of transfusion
• S/S: hypoxia, dyspnea, fevers, hypotension, pulmonary edema
• Treatment: stop the transfusion!
  • Supportive (may need intubation), O
• Prevention: notify blood bank of reaction thelancet.com https://www.medicine.uci.edu/residency/powerpoint/Inpatient%20Mini%20Lecture/Transfusion%20Rxn.pptx 4/25/19, 3E36 PM

Back to Mr Red…

• Mr Red is now 80 years old and is admitted after a fall during which he sustained a left hip fracture. Following surgery, he requires 1 unit PRBC. He is appropriately type and crossmatched, pretreated with acetaminophen, and a slow transfusion is initiated during dialysis. During the transfusion, he develops diffuse urticaria but is otherwise stable.
• What is the diagnosis? umm.edu https://www.medicine.uci.edu/residency/powerpoint/Inpatient%20Mini%20Lecture/Transfusion%20Rxn.pptx 4/25/19, 3E36 PM

Allergic Reactions and

Anaphylaxis

• Mild allergic reactions (urticaria) are common, especially in pts who have undergone multiple transfusions
  • Prevention: pretreat with anti histamines, or wash blood products to remove plasma proteins
• Severe anaphylaxis is rare
  • Mechanism: recipient who is IgA deficient and has anti-IgA antibodies reacts to IgA in donor blood
  • Prevention: wash all subsequent blood products to remove plasma proteins
    • If IgA deficient, then only give blood products from IgA deficient donors https://www.medicine.uci.edu/residency/powerpoint/Inpatient%20Mini%20Lecture/Transfusion%20Rxn.pptx 4/25/19, 3E36 PM

https://www.medicine.uci.edu/residency/powerpoint/Inpatient%20Mini%20Lecture/Transfusion%20Rxn.pptx 4/25/19, 3E36 PM

References

• Kim J, Na S. Transfusion-related acute lung injury; clinical perspectives. Korean J Anesthesiol. 2015 Apr;68(2):101-5.
• MKSAP 16
• UpToDate https://www.medicine.uci.edu/residency/powerpoint/Inpatient%20Mini%20Lecture/Transfusion%20Rxn.pptx 4/25/19, 3E36 PM