POLSKI

PRZEGLĄD CHIRURGICZNY 10.1515/pjs-2015-0039

2015, 87, 4, 166–173

Analysis of complications after blood components’

transfusions

Dariusz Timler1, Jadwiga Klepaczka2, Anna Kasielska-Trojan3,

Katarzyna Bogusiak4
Department of Emergency Medicine and Disaster Medicine Medical University in Łódź1
Kierownik: prof. dr hab. T. Gaszyński
Department of Diagnostics, Copernicus Memorial Hospital in Łódź2
Kierownik: mgr. E. Sobolewska
Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University in Łódź3
Kierownik: prof. dr hab. B. Antoszewski
Department of Cranio-Maxillofacial and Oncological Surgery, Medical University in Łódź4
p.o. Kierownika: dr A. Neskoromna-Jędrzejczak

Complications after blood components still constitute an important clinical problem and serve as
limitation of liberal-transfusion strategy.
The aim of the study was to present the 5-year incidence of early blood transfusions complications
and to assess their relation to the type of the transfused blood components.
Material and methods. 58,505 transfusions of blood components performed in the years 2006-2010
were retrospectively analyzed. Data concerning the amount of the transfused blood components and
the numbers of adverse transfusion reactions reported to the Regional Blood Donation and Treatment
Center (RBDTC) was collected.
Results. 95 adverse transfusion reactions were reportedto RBDTC 0.16% of alldonations (95/58 505) – 58
after PRBC transfusions, 28 after platelet concentrate transfusions and 9 after FFP transfusion. Febrile
nonhemolytic and allergic reactions constitute respectively 36.8% and 30.5% of all complications.
Conclusion. Nonhemolyticand allergic reactions are the most common complications of blood compo-
nents transfusion and they are more common after platelet concentrate transfusions in comparison to
PRBC and FFP donations.
Key words: blood components, transfusions, complications

In the last decades new screening proce-
dures and tests were implemented to improve
the safety of blood transfusions. However be-
cause of the most recent risks and threats, a
zero-risk blood supply is still nearly impossible
(1). Transfusion complications can be catego-
rized into infectious and noninfectious: im-
munologic and non-immunologic. The risk of
infections cannot be eliminated completely,
because of window periods during which patho-
gens are not detectable and because of the risk
of new pathogens emerging (2). Currently, infec-
tious agents for which donated blood can be
tested include hepatitis B (HBV) and C (HBC),
HIV-1 and -2, human T-cell lymphotropic virus
(HTLV)-1 and -2, West Nile virus, Treponema
pallidum (syphilis), Trypanosoma cruzi (Chagas
disease), and cytomegalovirus (CMV). Other
infectious threats include Babesia, Plasmodi-
ums (malaria), prions (variant Creutzfeldt-
Jakob disease), hepatitis A virus and human
herpes virus 8. Although various methods of
pathogen inactivation are under investigation
their efficacy and effect on the quality of blood
products need to be determined (3).
Bacterial infections (TTBI) also create an
important issue in blood transfusions.The in-
cidence of TTBI is higher than the incidence
of transfusion transmitted viral infection (4,
5, 6). Many studies showed that the most com-

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 Analysis of complications after blood components’ transfusions
mon bacterial contaminants in case of red
blood cell concentrates (RBCC) are: Yersinia
enterocolitica (51% of all bacterial infections),
Pseudomonas fluorescens (26.5%), Pseudomo-
nas putida (4.1%) and Treponema palidum
(4.1%) (7, 8). Different bacteria are responsible
for platelet concentrates (PC) contamination:
Corynebacterium sp. (36.5%) Staphylococcus
epidermidis (25%), Salmonellscholeraesuis
(13.5%), Serratia marcescens (9.6%), Staphy-
lococcus aureus, Bacillus cereus and Strepto-
coccus viridans group (7).
It was estimated that in the United States
bacterial contamination of transfusion prod-
ucts is the second most common cause of death
from transfusion (mortality rates from 1/20,000
to 1/85,000 donor exposures) (8). However, due
to the recent strategies in blood donation and
newest technologies in pathogens inactivation
the rate of transfusion transmitted bacterial
infection has decreased.
According to some studies, risks of infection
per blood unit range from 1:100,000 to 1:400,000
for HBV, 1:1,600,000 to 1:3,100,000 for HCV,
1:1,400,000 to 1: 4,700,000 for HIV, 1:500,000
to 1: 3,000,000 for HTLV, and 1:4,000,000 for
malaria (9). Bacterial contamination is esti-
mated for approximately 1:60,000 units of
RBCC and is more common in apheresis plate-
lets (1:8000) (10). According to the UK’s Seri-
ous Hazards of Transfusion (SHOT) 2010 re-
port, no confirmed case of transfusion-trans-
mitted infection was detected. However, non-
infectious risks and complications of blood
transfusion have taken the lead (11).
Noninfectious risks of transfusion are far
more common and usually more severe. They
can be grouped under immunologic (hemolytic
and non-hemolytic transfusion reactions, al-
lergic and anaphylactic reactions, multiple
organ failure, immunomodulation, HLA al-
loimmunization, autoimmunization RBC,
transfusion-associated graft versus host
disease,transfusion-associated acute lung in-
jury) and non-immunologic (febrile non-hemo-
lytic transfusion reactions RBC storage
lesions,circulatory overload, iron overload,
metabolic disturbances) complications.
The aim of the study was to presentthe 5-
year incidence of early blood transfusions
complications and to assess their relation to
the type of the transfused blood components in
the Copernicus Memorial Hospital in Łódź.
167
Material and methods
We analyzed 58,505 transfusions of blood
components performer in the years 2006-2010
in the Copernicus Memorial Hospital in Łódź,
which has about 1,000 beds on different wards,
including 9 surgical wards and a Regional
Cancer Centre with a Department of Hematol-
ogy. This retrospective research has IRB ap-
proval No RNN/485/13/KB. Data concerning
the amount of the transfused blood components
and the number of adverse transfusion reac-
tions reported to the Regional Blood Donation
and Treatment Center in Łódź (RBDTC) was
collected. The analysis of transfusion complica-
tions was performed for: surgical wards (to-
gether and separately for the Department of
Surgical Oncology), internal medicine wards
(together and separately for the Department
of Hematology), oncology wards, Intensive
Care Unit and Emergency Department.
A criterion of hemoglobin concentration of
less than 6 g/dL in combination with symptoms
of severe hemorrhagic diathesis was adopted
as the indications for transfusion of packed red
blood cells (PRBC) in patients with chronic
diseases in the study. In the event of a sudden
loss of 1500-2000 mL of blood, a PRBC trans-
fusion was indicated in patients with signs of
cardiac decompensation without prior anemia.
The loss of 40% (> 2000 mL) of circulating blood
volume was treated as an absolute indication
for rapid transfusion of PRBC preparations.
For platelet preparations, the indications for
administration was platelet count of less than
20,000/µL in patients with acute leukemia and
those after transplantation of hematopoietic
stem cells, with concomitant bleeding or below
10,000/µL in stable patients. Transfusion of
fresh frozen plasma (FFP) was performed in
patients with coagulation disorders and those
with symptoms of bleeding disorders. The final
decision on a particular blood component
transfusion was taken on the basis of the pa-
tient’s general state, clinical symptoms and
the patient’s adaptation to the decreased val-
ues of blood counts.
All the transfused PRBC were without buffy
coat and all platelet concentrates were fil-
tered– according to RBDTC issues only buffy-
coat deprived PRBC preparations and platelet
concentrates subjected to previous filtration
are donated. In the Department of Hematol-
ogy, in immunosuppressed and immunocom-
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168 D. Timler et al.
promised recipients, most cell concentrates
were irradiated in order to minimize the risk
of TA-GvHD.
Of the 58,505 transfused blood components,
68.96% (40 348/58 505) were PRBC and 13.22%
(7 734/58 505) were platelet concentrate
preparations. Platelet preparations were ob-
tained with two methods – by apheresis or from
buffy coat with ORBISAK apparatus. The re-
maining 17.82% (10 423/58 505) were plasma
transfusions.
Inthe event of an adverse transfusion reac-
tion, a procedure in accordance with thehospi-
tal standards designed on the basis of the
Minister of Health Regulation was under-
taken – documentation and patient blood
sampleas well as the transfused blood sample
were provided to the Regional Centre. Among
the adverse transfusion reactions, only early
reactions that can be detected during hospi-
talization, were noted.
Statistical Analysis
To seek the relationship between the data,
chi2 test of independence was used. The thresh-
old for statistical significance was the value of
p ≤0.05.
Results
Annually,approximately 9000 units of
PRBC, 2,000 platelet donations and 3,000 FFP
donations were transfused in the hospital. On
average, 20 adverse transfusion reactions were
reported each year. Five-year analysis of data
on early transfusion complications showed that
in the years 2006-2010, 95 adverse transfusion
reactions were reported to RBDTC – 58 after
PRBC transfusions, 28 after platelet concen-
trate transfusions and 9 after FFP transfusion.
In relation to the total number of the trans-
fused blood components, adverse reactions
were reported after 0.16% of all donations
(95/58 505). Most complications occurred after
platelet concentration transfusions and con-
cerned approximately 0.36% of cases. Although
complications after PRBC transfusions oc-
curred only in 0.14% of cases, they constituted
the largest group of reactions reported to RB-
DTC due to the overall number of transfusions
– PRBC were transfused 5 times more often
than platelet concentrates. There was a statis-
tically significant correlation between the fre-
quency of early transfusion complications and
the type of blood component used in the five-
year observation period. Significantly higher
incidence of adverse transfusion reactions was
observed after platelet preparations than for
PRBC (p <0.001) and FFP transfusions (p
<0.001), as shown in tab. 1.
From early adverse transfusion reactions
we observed: febrile non-hemolytic reactions,
allergic reactions, anti-HLA antibodies produc-
tion, symptoms such as pulmonary edema,
shortness of breath, heart failure, transfusion
of AB0-incompatible blood components and in
one patient we observed symptoms, suggesting
bacterial complication. After PRBC transfu-
sions, the most common complications (22
cases) were febrile non-hemolytic reactions.
More rarely the cause of adverse PRBC reaction
were anti-HLA antibodies produced by the pa-
tient (12 cases) and allergic reactions (12 cases).
Platelet concentration transfusions caused al-
lergic reactions more often (12 cases) than the
febrile non-hemolytic reactions (11 cases). Only
in 4 cases the transfusion reaction involved the
production of anti-HLA antibodies in the re-
cipient. Allergic reactions were the most com-
mon cause of reactions after FFP transfusions
and occurred in 5 patients. There was one case
of transfusion of an AB0-incompatible blood
component. FFP group 0 was transfused to a
group B recipient. There were no symptoms
associated with the effect of the transfused
anti-B antibodies to the recipient red blood cells.
Statistical analysis of the incidence of complica-
tions in relation to the type of blood components
showed that platelet concentration transfusions
were associated with a significantly higher risk
of developing a febrile non-hemolytic reaction
and allergic reaction, as compared with PRBC
(p<0.01 and p<0.001) and FFP transfusions
(p<0.001 and p<0.05). Platelet concentration
transfusions significantly more often caused
HLA antibodies production, as compared to
FFP administration (p<0.05) (tab. 2).
Department of Hematology transfused the
largest amounts of blood components. Within
the analyzed 5 years, transfusions on this ward
accounted for approximately 34% (19 900/58
505) of all blood components transfused in the
Copernicus Memorial Hospital. Transfusions
in the Department of Hematology accounted
for almost 30% (11 997/40 348) of PRBC trans-
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 Analysis of complications after blood components’ transfusions 169

fusions, 88.8% (6 869/7 734) of plate-

chi2 significance

chi2 significance chi2 significance chi2 significance

Table 1. Number of transfused blood components and early transfusion complicationsreported to Regional Blood Donation and Treatment Center in the years 2006-2010

let concentrate transfusions and

p<0,001

p<0,001

p<0,001
p>0,05

p>0,05
p>0,05
p>0,05

p<0,05
p<0,05
p>0,05
p>0,05
p>0,05
approximately 9.92% (1 034/10 423)
PC – FFP

PC – FFP
of all FFP transfusion. The number
of adverse reactions in the Depart-
13,228

16,593

11,825
2,602

1,817
0,985
2,230

5,452
5,392
0,710
0,742
ment of Hematology in this period

Comparison of blood components

-
accounted to 54, which constituted
Statistical analysis

approximately 57% (54/95) of all

chi2 significance
p>0,05
p>0,05
p>0,05
p>0,05
p>0,05
p>0,05
confirmed adverse transfusion reac-

p>0,05
p>0,05
p>0,05
p>0,05
p<0,05
p>0,05
PRBC – FFP
PRBC – FFP

tions in the Hospital. Only 11.2% of

platelet concentrations were trans-
fused to recipients outside the He-
1,795
1,694
0,892
0,744
0,055
2,070

3,692
0,823
3,105
1,096
3,874
0,260
matology Department. However, the
Table 2. Analysis of adverse transfusion reactions frequency in relation to blood component

number of adverse reactions after

chi2 significance

transfusion of platelet concentrates

0,23 15,461 p<0,001
p<0,001

17,322 p<0,001

p<0,001
p>0,05

p>0,05
p>0,05

p<0,01

p>0,05
p>0,05
p>0,05
p>0,05
PRBC – PC

PRBC – PC

on wards other than the Department

of Hematology accounted for only
approximately 10% of all complica-
0,21 0,525

0,15 8,478
0,17 0,144
0,09 2,949

5,26 20,463
1,05 7,280

0,940
1,05 0,001

0,190 tions after transfusion of this blood

-

component. Among other wards of

the Copernicus Memorial Hospital,
1,05
%

particularly high numbers of trans-

total

FFP

fusions were carried out in 2 surgical

20
23
19
20
13
95

n
22 23,16 11 11,58 1
12 12,63 12 12,63 5
0
1
1
0
n

departments (Department of Endo-

Number of transfusion complications

Blood components
Note: n – number, PRBC – Packed Red Blood Cells, PC – Platelet Concentrate, FFP – Fresh Frozen Plasma

Note: n – number, PRBC – Packed Red Blood Cells, PC – Platelet Concentrate, FFP – Fresh Frozen Plasma

crine Surgery, Department of Vas-

4,21
2,11
0,05
0,17
0,09
0,06

0
0

cular, General and Oncologic Sur-

%

PC
FFP

gery) and in the Department of In-

n

12 12,63 4
11 11,58 2
0
0

tensive Care Medicine and Anesthe-

n

1
4
2
2
9
-

siology. Total number of transfusions

1,05
%

performed in patients on surgical

PRBC
0,30
0,84
0,39
0,23
0,22
%

wards in the years 2006 – 2010 was

PC

0
1

22 990 (15 293 PRBC units, 2 229

29

platelet concentrates and 5 468 FFP

n
5
9
7
3
4

donations), which represented ap-

0,20
0,18
0,10
0,18
0,08

proximately 40% of all transfusions.

%
PRBC

More than 52% of FFP units trans-

fused in the hospital were adminis-
15
13

15

60
n

tered to recipients from these wards.

Pulmonary edema, shortness of breath, heart failure
Transfusion of AB0-incompatible blood components

Nevertheless, adverse reactions oc-

Adverse transfusion reactions
10304
12417
11933
13908
58505
9943
total

curred in only 20 cases on these

wards, which represented approxi-
Number of donations

mately 21% of all reported adverse

10423
1976
2339
2136
3092
FFP
880

transfusion reactions. In the Depart-

ment of Intensive Care Medicine and
Anty-HLA antibodies production

Anesthesiology there was no adverse

Febrilenon hemolytic reactions
1694
1072
1802
1333
1833
7734
PC

Suspected bacterial infection

reaction observed after FFP dona-

tions (fig. 1).
Statistical analysis disclosed that
PRBC

40348
7369
7256
8276
8464
8983

in departments of Internal Medicine

Allergic reactions

(the Department of Hematology was

included in this group) and in Depart-
ment of Hematology separately,
Year

complications were observed signifi-

Total
2006
2007
2008
2009
2010

cantly more often than in surgical

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170 D. Timler et al.
and oncological departments (p<0.001 and
p<0.05). The frequency of adverse transfusion
reactions in departments of Internal Medicine
and the Department of Hematology was similar
(p>0.05). There was a significantly higher inci-
dence of adverse reactions in patients treated
in the Department of Oncological Surgery than
in other surgical departments altogether
(p<0.05). Complications after PRBC donations
occurred significantly more often in depart-
ments of Internal Medicine (with Department
of Hematology included to this group) and in
the Department of Hematology separately in
comparison to surgical departments (p<0.01
and p<0.01). In all departments, except for the
Department of Intensive Care Medicine and
Anesthesiology, adverse transfusion reactions
after FFP donations were observed with similar
frequency (p<0.05). No statistical difference
was observed among departments in frequency
of complications after platelet concentrate
(p>0.05) (tab. 3).
Discussion
In recent years a great progress was made
in blood components preparation technologies,
however, complications after their transfusion
still constitute an important clinical problem
and serve as limitation of liberal-transfusion
strategy. The data from the UK’s Serious Haz-
ards of Transfusion (SHOT) (2010) showed that
505 serious complications and events resulting
in 4.5 deaths and 35 major morbidities were
reported per 1 million units of blood component
issued (11). The report presents a relatively low
incidence of complications, however the fre-
quency of unfavorable outcomes associated with
allogeneic blood transfusions observed in many
studies examining specific groups of patients is
much higher (12-23). In the analyzed group of
patients the incidence of early adverse transfu-
sion reactions was 0.16%, however it is difficult
to interpret this rate and compare it with the
values presented in the literature as it depends
on the hospital profile, transfusion strategy and
reporting programs. Different programs of
documenting complications result in the fact
that some of them [e.g. transfusion-related
acute lung injury (TRALI)] are vastly under-
diagnosed and under-reported (24, 25). How-
ever as concluded by Shander et al. these sta-
tistics provide an overall picture of the preva-
lence of complications and risks of blood
transfusions and their consequences (26).
It was estimated that a single noninfectious
complication [eg, transfusion-related acute
lung injury (TRALI)] occurs in 1 case per every
5000 units of blood component transfused (25).
Febrile non-hemolytic transfusion reaction is
known to be the most common cause of trans-
fusion-associated fever and occurs in 0.1% to
1% of RBC transfusions (27). The same obser-
vation was made on the basis of our material
analysis, as the most common complications
were febrile non-hemolytic reactions and al-
lergic reactions, which constituted 35.79% and
30.53% of all noted reactions. Moreover, there
was a significantly higher incidence of these
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 Analysis of complications after blood components’ transfusions 171

Table 3. Comparison of adverse transfusion reactions in relation to type of blood component and department
on which the transfusion had place

Statistical analysis
Departments PRBC PC FFP Total
chi2 significance chi2 significance chi2 significance chi2 significance
Internal Medicine vs Surgery 8,582 p<0,01 1,597 p>0,05 2,422 p>0,05 16,615 p<0,001
Internal Medicine vs Oncologic 0,002 p>0,05 0,154 p>0,05 0,327 p>0,05 0,003 p>0,05
Surgery
Internal Medicine vs Emergency 0,219 p>0,05 0,071 p>0,05 0,723 p>0,05 1,140 p>0,05
Department
Internal Medicine vs Oncology 2,999 p>0,05 0,063 p>0,05 0,000 p>0,05 3,953 p<0,05
Internal Medicine vs Intensive Care 0,001 p>0,05 0,990 p>0,05 4,645 p<0,05 2,515 p>0,05
Medicine
Hematology vs Surgery 7,199 p<0,01 1,518 p>0,05 3,807 p>0,05 17,534 p<0,001
Hematology vs Oncologic Surgery 0,001 p>0,05 0,157 p>0,05 0,032 p>0,05 0,031 p>0,05
Hematology vs Emergency 0,193 p>0,05 0,073 p>0,05 1,003 p>0,05 1,258 p>0,05
Department
Hematology vs Oncology 2,656 p>0,05 0,074 p>0,05 0,083 p>0,05 4,409 p<0,05
Hematology vs Intensive Care 0,002 p>0,05 0,944 p>0,05 6,441 p<0,05 2,880 p>0,05
Medicine
Surgery vs Emergency Department 0,168 p>0,05 0,176 p>0,05 0,252 p>0,05 0,003 p>0,05
Surgery vs Oncology 0,027 p>0,05 0,990 p>0,05 0,960 p>0,05 0,269 p>0,05
Surgery vs Intensive Care Medicine 3,502 p>0,05 0,040 p>0,05 1,624 p>0,05 0,751 p>0,05
Oncologic Surgery vs Emergency 0,157 p>0,05 0,000 p>0,05 1,180 p>0,05 0,901 p>0,05
Department
Oncologic Surgery vs Oncology 1,223 p>0,05 0,119 p>0,05 0,166 p>0,05 1,666 p>0,05
Oncologic Surgery vs Intensive Care 0,001 p>0,05 0,408 p>0,05 7,575 p<0,01 1,038 p>0,05
Medicine
Emergency Department vs Oncology 0,094 p>0,05 0,055 p>0,05 0,719 p>0,05 0,059 p>0,05
Emergency Department vs Intensive 0,188 p>0,05 0,190 p>0,05 0,000 p>0,05 0,149 p>0,05
Care Medicine
Oncology vs Intensive Care Medicine 1,831 p>0,05 0,858 p>0,05 4,622 p<0,05 0,081 p>0,05
Internal Medicine without 0,069 p>0,05 0,540 p>0,05 0,706 p>0,05 0,591 p>0,05
Hematology vs Hematology
Surgery without Oncologic Surgery vs 2,676 p>0,05 0,233 p>0,05 6,456 p<0,05 5,806 p<0,05
Oncologic Surgery
Internal Medicine without 7,410 p<0,01 1,601 p>0,05 0,760 p>0,05 7,093 p<0,01
Hematology vs Surgery without
Oncologic Surgery
Note: n – number, PRBC – Packed Red Blood Cells, PC – Platelet Concentrate, FFP – Fresh Frozen Plasma

adverse transfusion reactions after platelet
concentrate transfusions in comparison to
PRBC and FFP donations.
Delayed hemolytic reactions occurrence is
estimated for approximately 1 out of 1000 to
1 out of 9000 RBC units transfused while acute
hemolytic reactions due to AB0-incompatible
blood resulting from transfusion errors is ob-
served in approximately 1:30,000 transfusions.
According to the SHOT 2010 report, 345 criti-
cal transfusion errors occurred per 1 million
units of blood component issued (11). In our
material there was one case of transfusion of
an AB0-incompatible blood component. FFP
group 0 was transfused to a group B recipient.
We did not observed any symptoms associated
with the effect of the transfused anti-B anti-
bodies to the recipient red blood cells. The only
detectable reaction was positive direct anti-
globulin test, persisting for several days after
the transfusion.
Although non-infectious complications of
blood transfusion are considerably more com-
mon and according to the SHOT 2010 report
no transfusion-transmitted infection was de-
tected, such risk needs to be mentioned. The
incidence of bacterial contamination is much
higher in case of platelets donations while

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172 D. Timler et al.
minimal for RBC units (10). Such complica-
tions may result from the fact that the stan-
dard procedure for blood preparation cannot
eliminate the risk completely, because of
pathogens window periods and some new
pathogens emerging. In our analysis, we sus-
pected transfusion-transmitted bacterial infec-
tion in one patient after PRBC donation.
Complications such as: transfusion-associ-
ated acute lung injury (TRALI), post-transfu-
sion purpura, acute hemolytic reactions, ana-
phylactic shock, septic shock did not occur in
our patients. This observation is consistent
with the data presented in the literature as
such complications are rare: 20 per 1 million
units (hemolytic reactions), 5 per million units
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(TRALI) and nearly zero per million units for
the rest (11).
To sum up, it can be seen from the study
that non-hemolytic and allergic reactions are
the most common complications of blood com-
ponents transfusion and they are more com-
mon after platelet concentrate transfusions in
comparison to PRBC and FFP donations. Al-
though strict procedures are applied during
blood donations preparations and transfusions,
errors in transfusion and infection complica-
tions still serve a problem in clinical practice.
We also found that the Department of Hema-
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e-mail: katarzyna.bogusiak@gmail.com
173
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