Blood Transfusion Reactions

Nanda Nair, D.O.

Chief Rounds, July 19, 2010
The Blundell Gravitator
 Case # 1
80yro male h/o HTN, CKD and Anemia due
to CKD, prostate cancer p/w shortness of
breath and fatigue to his oncologist office.
Blood work showed hemoglobin of 6.5 and
he was sent in for PRBC transfusion
He was transfused 2 units of PRBC
As he was getting 2nd unit, he developed
shortness of breath and dyspnea.
 Case # 1
VS: T 99.4F, BP 95/58, HR 76, RR 30, 76%
on RA
Physical Exam
Gen: In mild-mod respiratory distress. He is
using accessory muscles
CV: tachycardic. No JVD. No S3
Lungs: crackles bilaterally.
Chest X-ray: bilateral infiltrates
Heis placed on 100% non-rebreather and
O2 saturation improves to only 85%.
 Case # 1
CriticalCare is consulted. He is intubated
and transferred to the ICU
Over the next several days, he improves
and is extubated.
 Transfusion-Related Acute Lung Injury

New acute lung injury that develops with a

clear temporal relations to transfusions
Leading cause of transfusion-related death
reported to FDA (30% of transfusion-related
fatalities)
Antineutrophil antigen antibodies or anti-HLA
antibodies are primarily responsible
Most commonly, donors are multiparous
females
Happens more often with FFP and Platelets
Risk of fatality from TRALI
 TRALI
Patients p/w Chest Imaging shows
Dyspnea bilateral fluffy infiltrates
Hypoxia No evidence of volume
Hypotension overload
Fever Leaky capillary
Tachycardia
endothelium results in
Cyanosis
fluid in the lung
Pulmonary Edema
 TRALI
Before Transfusion After Transfusion
TRALI Criteria
 Management of TRALI
Doesnot improve with diuretics
Supportive Care
May need Ventilatory support
Alertthe Blood Bank FDA reportable
Usually recover quickly
Steroids has not been shown to help
Incidence has decreased with the use of
only male donor plasma
 Case # 2
78yro male h/o of COPD and BPH presents
with suprapubic pain
Workup showed metastatic prostate cancer
He was found to be anemic and hemoglobin
started to trend down.
Once his hemoglobin reached 6.6, he was
transfused 2units of PRBC
 Case # 2
Approx 500cc into the blood transfusion,
patient became short of breath and
dyspnec
VS: T 100.4F, BP 106/57, RR 25/min, HR
110, 85% on RA 94% on 2L NC
On physical exam, crackles were noted
bilaterally, along with 7cm JVD.
He was given IV Lasix and symptoms
improved
 Transfusion-Associated Circulatory
Overload (TACO)
Occur up to 1% of all transfusions
Due to circulatory overload
Symptoms: Dyspnea, cough, tachycardia,
hypertension.
Those patients @ highest risk:
Cardiopulmonary compromise
Renal failure
Infants
Treatment: Diuretics and slow down rate
 Case # 3
51yro male h/o of CVA, alcohol abuse,
ESLD, HTN presents from Nursing Home
for evaluation after an unwitnessed fall
CT head: Subarachnoid hemorrhage in the
parietal and occipital regions
Next day, goes into respiratory distress and
intubated for pneumonia
Patient develops VDRF and is transferred to
ICU service 3 weeks later.
 Case #3
He stays in ICU for weeks. His hemoglobin
slowly trends down to 6.4
Decision is made to perform tracheostomy
and insert a peg tube.
Pt is transfused 2 units of PRBC prior to the
procedure.
He goes into respiratory distress on the
vent. He desaturates to 84% with 70%
FiO2
 Case #3
VS: Temp 102.9, BP 70/50, HR 140
Physical Exam
Gen: In respiratory distress
CV: Tachycardic
Resp: wheezing bilaterally diffusely
Transfusion stopped. Pt given Benadryl and
Solumedrol and Pepcid.
He is fluid resuscitated.
Notified by RN: Pt got A+ blood. His blood
type is O+
 Case #3
Blood work during the following days
showed severe hemolysis
Hemoglobin drops to 3.9
He goes into anuric renal failure and is
started on CVVHD
Eventually becomes hemodialysis
dependent
 Hemolytic Transfusion Reaction
Risk: 1:2,500 1:11,000 units transfused
Mortality: 1 in 1.8 million units transfused
Symptoms: Fever, chills, rigors,
chest/back/abdominal pain, N/V, dyspnea,
hypotension, hemoglobinuria, renal failure
Most frequently, due to naturally occurring IgM
antibodies (anti-A, anti-B)
Can happen with PRBC, FFP or platelets
Can be due to either ABO or non-ABO antibodies
 Hemolytic Transfusion Reaction
Delayed hemolytic transfusion reactions
Much more common, but less severe
Incidence is 1 in 6,000 units transfused
Much higher risk in Sickle Cell patients.
Patient sensitized by pregnancy or transfusions
Due to alloimmunization to minor RBC antigens
Alloantibodies present in such low levels that
they are undetectable in antibody screen
 Hemolytic Transfusion Reaction
Delayed Hemolytic Transfusion Reactions
Occur 3-10 days after transfusion
Signs and Symptoms:
Low grade fever
Fatigue
Mild jaundice
Decline in hemoglobin concentrations
 Case # 4
18yro female with no medical history
admitted to Trauma service after a MVA
Patient had multiple fractures, requiring
several orthopedic operations
She was transfused 2 units of PRBC
During transfusion, her temperature went
from 98.7 to 101.2 post-transfusion
She had no other symptoms
 Case # 4
Workup on patients side, including cultures
were negative
However, cultures of the PRBC unit grew
Group G Streptococcus and Staph aureus
 Bacterial Contamination
Approximately 57% of all transfusion
transmitted infections
11% of transfusion-related deaths
Risk:
PRBC: 1 in 38,500 units
Random Donor Platelets: 1 in 3,300 units
Aphaeresis platelets: 1 in 2,000 units
All platelets: risk of bacterial sepsis is 1 in
50,200
 Bacterial Transmission
PRBC: typically Gram-negative bacilli
Yersinia
enterocolitica
Pseudomonas fluorescens

Risk increases with PRBC stored > 21 days

Platelets mostly Gram-positive bacteria
Staphylococcus and Streptococcus
At higher risk since they are stored at close to
room temp (20o-24oC)
Risk increases with platelets stored > 3 days
 Risk of Viral Transmission
Hepatitis B: 1 in 350,000 transfusions
Hepatitis C: 1 in 1.8 million transfusions
HIV: 1 in 2.3 million transfusions
HTLV: 1 in 2 million transfusions
Cytomegalovirus
Epstein-Barr Virus
West Nile Virus
 Other Infectious Transmissions?
Treponema pallidum Erhlichiosis
Risk: 6 in 1 million Babesiosis
Plasmodium spp. Leishmaniasis
Trypanosoma Bartonella spp.
Toxoplasmosis Borrelia spp.
Rickettsia rickettsii Brucella spp

Creutzfeldt-Jakob Disease
We had to clone our interns to meet
the latest work hour rules."
Indications for Red Blood Cell Transfusions
Acute blood loss (Trauma, Surgery): at volumes of >40% loss
replacement in a manner reflective of whole blood infusions (5 units
RBC: 5 units FFP: 1 unit platelets)
Acute Anemia:
patient should be normovolemic and symptomatic and non-bleeding.
Crystalloid infusion should be used to correct hypovolemia.
A CBC should be checked after each unit.
Hemoglobin <6: transfuse 1-2 units, reevaluate
Hemoglobin 6-7 g/dL: transfuse 1 unit, reevaluate
Hemoglobin 7-8 g/dL + indications of organ ischemia (e.g., acute
STEMI, unstable angina) transfuse 1-2 units and reevaluate.
Hemoglobin >9 g/dL: transfusion rarely indicated
Chronic Anemia: Patient should be symptomatic and have
failed alternative therapy (vitamin B12, iron)
 Indications for Platelet Transfusions
Prophylaxis: non-bleeding patients
<5-10 and stable: transfuse 1 dose
<20 and unstable (sepsis, coagulopathy, necrotic tumors, etc):
transfuse 1 dose
<50 + invasive surgery: transfuse 1-2 dose(s) depending on the type of
procedure
Most procedures can safely be performed in patients with platelet
counts 40-50. There is precedent for higher levels in patients
undergoing neurosurgery.
The following procedures have documented limited safety at lower
levels and may warrant consideration in refractory cases:
Lumbar puncture safe at counts >20 and >25 in children
Gastrointestinal Biopsies safe at 20-40
bone marrow biopsies safe at counts <20
 Indications for Platelet Transfusions
Refractory:call the blood bank for guidance
Active Bleeding: maintain >50.
For large volume loss, use 1 unit of platelet for every 5
units of RBCs and 5 units of FFP administered.

Contraindications:
Platelet>100 with no dysfunction
Dysfunction extrinsic to the platelet (uremia, certain
types of von willebrand disease, hyperglobulinemia)
HIT, TTP, or ITP, except in a life-threatening hemorrhage
Indications for Fresh Frozen Plasma
Active bleeding due to deficiency of multiple
coagulation factors
High Risk (PT >18, PTT> 60, clinical judgment) of
bleeding during an invasive procedure
Urgent reversal of warfarin
Massive transfusion
TTP
Rare coagulation factor and plasma protein
deficiencies
 References
1. Hendrickson JE & Hillyer CD. Noninfectious serious hazards of
transfusion. Anesth Analg 2009; 108:759-769.
2. Alter HJ & Klein HG. The hazards of blood transfusion inhistorical
perspective. Blood 2008; 112:2617-2623.
3. Triulzi D. Transfusion-Related Acute Lung Injury: Current Concepts
for the Clinician. Anesth Analg 2009; 108:770-776
4. Bux J. Transfusion-related acute lung injury (TRALI): a serious
adverse event of blood transfusion. Vox Sanguinis 2005; 89:110