BLOOD TRANSFUSION

REACTIONS

P SUNIL KUMAR
Department of Haematology
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St.John's Medical College1
 DEFINITION
• Any unfavorable and harmful transfusion
related events occurring in the patient during
or after transfusion of blood or components is
called transfusion reaction.”

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 COMMON CAUSES OF TR
• Misidentification of the patient.
• Improper sample identification.
• Wrong blood issued.
• Administration error.
• Technical error.
• Storage error.

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TYPES OF TRANSFUSION REACTIONS

Immune mediated
HEMOLYTIC TR Non immune
• Immediate
mediated
• Delayed 1.Immediate
• NON-HEMOLYTIC TR
• Immediate 2.Delayed
• Delayed

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 CLASSIFICATION
IMMEDIATE

HAEMOLYTIC
DELAYED
IMMUNE
MEDIATED
IMMEDIATE
NON
TR HAEMOLYTIC
DELAYED

IMMEDIATE
NON-IMMUNE
MEDIATED
DELAYED
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 Haemolytic TR ( HTR)
• Haemolytic TR are most severe type of
transfusion reactions and can be categorized
into two types.
• A. Immediate HTR / Intravascular HTR
• B.Delayed HTR / Extra vascular HTR

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 IHTR or Intravascular HTR
• In intravascular transfusion reaction the
haemolysis of red cells takes place within the
circulatory system.
• Haemolysis occur within few min after starting
transfusion ( <24 hrs ).

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• This type of reaction is mainly due to IgM ab’s
(ant-A, & anti-B), mediated by the rapid
activation of complement and is usually
associated with the transfusion of ABO in
compatible blood

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 SIGNS AND SYMPTOMS
• Fever
• Chills
• Hypotension
• Chest and back pain
• Nausea
• Dyspnea
• Vomiting
• Haemoglobinuria
• Acute renal failure
• Pain at transfusion site
• Shock & DIC
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 MANAGEMENT AND THERAPY

• Stop transfusion immediately.

• Mannitol is the agent used to prevent the
renal failure.
• Hypotension: intravenous fluid and vasoactive
drugs .e.g. dopamine

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Delayed HTR / Extra vascular HTR
• Extravascular TR are rarely severe and mainly
due to IgG antibodies, e.g. Rh, kell or Duffy
system.
• These ab’s bring about the destruction of red
cells by the macrophages in the spleen or liver.
• Haemolysis occur after few hours or after
about 3-7 days of transfusion.

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 IgG Ab coats the RBC and sensitize them

Sensitized cell interact with the phagocytic cells

They engulf the sensitized RBC and destroy them

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Conti..

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• IgG antibodies coated red cells interact with
receptors of phagocytic cell (macrophage).
• Phagocytic cell engulfs the antibody coated
cell and incorporates it into the intracellular
vacuole.
• Lysis of red cells with in the intra cellular
vacuole of phagocytic cell.

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 Extra vascular HTR cont..
• Delayed HTR which could be due to..
• Primary allo-immunization
• Anamnestic or secondary response

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 ANAMNESTIC RESPONSE TO
TRANSFUSED RBC
• Occurs in patients who has previously been
sensitized by transfusion or pregnancy.
• The level of incomplete Ab is very low.
• Cannot be detected by standard
pretransfusion procedure.
• There will be increased Ab production
resulting in red cell destruction.

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 SIGNS & SYMPTOMS

• Fall in Hb
• Rise in bilirubin and mild jaundice with in 5-7
days of transfusion.
• Renal failure ( rare )

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 NON HAEMOLYTIC TRANSFUSION
REACTIONS
• Non haemolytic TR can be classified as
I. Febrile non haemolytic TR (FNHTR)
II. Urticarial (allergic) transfusion reaction
III. Anaphylactic transfusion reaction
IV. Non cardiogenic pulmonary edema(TRALI)
V. Circulatory overload
VI. Graft versus host disease (GVHD)

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 FNHTR
• These reactions are the most common and
account for over 90 % of TR.
• These are benign, self limiting reaction due to
the presence of ab’s to WBC or PLT antigens
and are usually seen in multi transfused
patients.
• These are occur within minutes of starting the
transfusion

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• PATHOPHYSIOLOGY
Due to the presence of anti leukocyte antibody and
antibodies to platelet in the patients serum. It may be
due to past transfusion or pregnancy.

Ab react with donors WBCs

Ag – Ab complex activate complement system

Release of pyrogens from WBCs result in rise of temp.

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 SIGNS AND SYMPTIMS

 Fever
 Chills
 Malaise

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 THERAPY AND PREVENTION

 Give leukocyte poor red cells.

 Anti pyretic can be given before starting
transfusion, but they must be avoided as
much as possible as they mask IHTR.

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 Laboratory investigations
• No evidence of haemolysis in post transfusion
sample i.e.
• No red/pink plasma
• DCT negative
• No increase in bilirubin
• No haemoglobinuria

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 URTICARIAL(ALLERGIC) TR
 A type of immediate hyper sensitivity
reaction.
 Allergic signs and symptoms appear within
few minutes of exposure.

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 Causes of urticarial TR
The donors plasma contain allergens which
react with reagin present in patients plasma.
The donors plasma contains reagin that
combines with allergens in the patient plasma.

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 Allergen-Reagin complex

Attaches the mast cell surface

Release histamine

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 SIGNS AND SYMPTOMS

 Local erythema
 Pruritis
 Hives(raised red wheal)
 Hypotension
 Loss of consciousness
 Shock

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 THERAPY AND PREVENTION

• Anti histamine

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 Anaphylactic TR
• This is a severe, life threatening reaction,
which occur in rare patients who are IgA
deficient and have developed anti-IgA ab’s.
• These reaction developed quickly- within
minutes of starting the transfusion

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 SIGNS & SYMPTOMS

• Respiratory tract- cough, bronchospasm,

dyspnea
• GIT- nausea, vomiting, diarrhoea
• Circulatory system- hypotension, syncope
• Skin- generalized flushing, Urticaria

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 THERAPY & MANAGEMENT
• Keep IV line open with normal saline.
• Inject epinephrine
• Inject antihistaminic
• Hypoxia- give oxygen by mask

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 TRANSFUSION RELATED ACUTE
LUNG INJURY(TRALI)
• Also known as non cardiac pulmonary edema
• Altered permeability of the pulmonary
capillary bed by activation of complement ,
histamine mediated events, or prostaglandins
which leads to fluid accumulation, inadequate
oxygenation, and reduced cardiac return.

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 SIGNS & SYMPTOMS

• Acute onset of respiratory distress

• Dyspnea
• Cyanosis
• Fever
• Chill

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 THERAPY & MANAGEMENT

• Oxygen therapy
• Intubation
• Intravenous steroids
• Leukocyte poor component is used

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 POST TRANSFUSION PURPURA
• Occur with platelet concentrate transfusion.
• Rapid onset of thrombocytopenia due to
production of platelet allo antibodies.
• Usually in multiparous female.
• Duration: 7-14 days from transfusion.
• Therapy: corticosteroids

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 GRAFT VERSUS HOST DISEASE
• Complication of blood component therapy or
bone marrow transplantation.
Patients at risk:
• Lymphopenic patients
• Bone marrow suppressed cases
• Fetus receiving intrauterine transfusion
• New born infants receiving exchange transfusion
• Congenital immunodeficiency syndrome

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 SIGNS & SYMPTOMS

• Fever
• Rash
• Diarrhea
• Hepatitis
• Liver dysfunction
• Bone marrow suppression
• Fatal
THERAPY: corticosteroids , prevention.

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 NON IMMUNE NON HEMOLYTIC
TRANSFUSION REACTION
• IMMEDIATE: bacterial overload
circulatory overload

• DELAYED : iron overload

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 BACTERIAL OVERLOAD
• Bacterial contamination
• Due to toxins
• Antibiotics can be used for therapy.

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 CIRCULATORY OVERLOAD

• More volume of blood transfused

• Cause : fast rate
• Leads to congenital heart failure , pulmonary
edema
• Signs: chest pain, cough, hypertension

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 IRON OVERLOAD

• Long term complication of RBC transfusion

• Also known as transfusion haemosiderosis.
• Iron accumulation : affect functions of heart,
liver, endocrine system
• Signs: muscle weakness, fatigue, weight loss,
mild jaundice, anaemia.
• Therapy: iron chelating agent.

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 LABORATORY INVESTIGATIONS
 Check all the records to ensure that the
correct unit of blood was transfused to the
right patient.
This includes :
a) Patient’s details
b) Blood requisition form
c) Compatibility report
d) Labels
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 LABORATORY INVESTIGATIONS
• Examine the patient pre-transfusion & post-
transfusion plasma from EDTA sample for
evidence of free Hb or increased bilirubin.
• Pink or red discolouration in post-transfusion
plasma indicates the presence of free Hb due
to red cell destruction.
• Yellow discoluration of the sample drawn 6-8
hr after transfusion indicates increased
blirubin.

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• Perform DCT on the pre- and post transfusion
sample.
• A positive DCT test usually indicates the
presence of recipient ab’s on the surface of
donor red cells, however if all the cells have
been already destroyed , the test may be
negative.
• check urine (post-transfusion) 1st sample

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 Interpretation of laboratory findings
• If nothing abnormal, indicates that no acute
hemolytic reaction.
• If any finding is positive, or clinical finding
strongly suggest a hemolytic reaction, the
following investigations to be done;
• 1) Repeat the crossmatch, testing both pre and
post transfusion sample of the patient against the
sample from the bag by saline/albumin,coombs
techniques.
• 2) Repeat antibody screening and identification of
patients pre and post transfusion samples.
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 REFERENCES
• Text book of practical Transfusion medicine
R.N.Makroo.
• Text book of transfusion Technical manual
WHO

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THANK YOU
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