Blood Banking
Usually kapag intravascular hemolysis, ang
Transfusion Reactions
ANY unfavorable transfusion-related event occurring
in a patient during or after transfusion of whole
blood, blood components, or human-derived plasma
products.
We can divide it into 2 in general when it comes to
lysis of the RBC: AHTR & DHTR
Acute Hemolytic Transfusion Reaction (AHTR)
Reaction period varies from 1-2 hours
Main cause is INCOMPATILE BLOOD
Pinaka common cause kasi ng AHTR is yung
incompatible ABO type since yung ating body is
meron ng existing naturally occurring antibodies
for the ABO so pag nagbigay ka ng incompatible
blood, automatic, magkakaron ng reaction.
RBCs are destroyed by 2 mechanisms via:
o Intravascular hemolysis
o Extravascular hemolysis
Delayed Hemolytic Transfusion Reaction (DHTR)
Often result of anamnestic response
Usually mas matagal reaction period/time; we
are referring also for the lysis of RBC since we are
talking about delayed hemolytic transfusion
reaction.
Reaction period 3-7 days
Two types of DHTR:
1. Secondary response to RBC
Second exposure sa same antigen. Example:
wala kang Kell antigen then natransfusian ka
ng RBC containing Kell antigen. So what will
happen? Foreign ba para sayo yung Kell
antigen? Yes, so tendency, mag pproduce ka
ng antibody; Secondary response, ito yung
nabigyan ka ulit ng Kell antigen for the 2nd
time and usually kapag secondary response,
mas mabilis yung production ng antibody
and mas matagal din yung shelf-life or
lifespan ng antibody sa circulation.
2. Primary alloimmunization
First exposure to foreign antigens. Meaning,
nabigyan ka ng antigen, which is foreign
sayo, first exposure, so it will lead to primary
alloimmunization.
Acute Transfusion Reactions: IMMUNOLOGIC
i Acute Hemolytic Transfusion Reaction
Associated with Intravascular Hemolysis
involved dito na antibody is the ABO antibodies
and it could lead to severe symptoms. AHTR can
happen after infusion as little as 10cc ABO
incompatible RBCs. Kahit 10cc/mL lang nabigay
sa recipient, it could lead to AHTR.
Etiology: Antibodies that activate complements in
the vasculature: ABO antibodies are predominant/
not the only ones.
May also occur due to ABO incompatible plasma in
platelet products
Can prevent by removing plasma from platelets, or
limiting number of incompatible group O platelets in
a 24-hour period
Yung platelet concentrate natin, it is suspended
in the plasma and sa plasma, andyan yung mga
antibodies so kapag group O yung platelet
concentrate, it means meron yang presence ng
anti-A, anti-B and anti A,B which could attack the
RBCs of those individuals with type A, B and A,B
blood types. So ang ginagawa, tinatanggal yung
plasma since andyan yung offending antibodies
natin. So wala naming problem if parehas group
O yung recipient and donor. Nagkakaron lang
naman ng problem dito kapag group O going to
other ABO types (type A, B, A,B).
° Intravascular Hemolysis
Characteristics Signs may include:
Within Pain along infusion site
minutes Shock
IgM &/or IgG Abnormal bleeding/DIC or
antibody disseminated intravascular
Complement coagulation/
activation Hemoglobinemia/uria
Release of Release of cytokines: fever,
histamine & hypotension
serotonin Renal failure/ Oliguria, may
progress to anuria
Bakit may complement activation? Kasi yung ABO
antibodies natin, they are predominantly IgM
antibodies, and they are best when it comes to
complement activation kasi mas maraming binding
sites, pentameric so kung pentameric yan, each
antibodies contains two binding sites so all in all,
kung lima yan, times 2, that would be 10 binding
sites. Compared to IgG na 2 binding sites kasi
monomeric.
Oliguria: decreased urine output which may progress
to anuria or total cessation of urination, wala
talagang nilalabas na ihi.
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EVANGELISTA, ARA 1
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Febrile non-hemolytic TX Reactions
i.
An INCREASE in temperature of 1 oC during infusion
of blood component
o reaction especially kung determined naman talaga
Non-hemolytic
Possible cause: recipient antibodies to donor WBCs.
Seen in...
o Multiple transfused patients
o Multiple pregnancies
o Previously transplanted individuals
Must rule out the ff if merong Febrile non-hemolytic
tx reactions:
o Hemolytic transfusion reaction
Make sure na it is nonhemolytic para masabi
natin na ito talaga ay febrile non-hemolytic
transfusion reaction.
o Bacterial contamination of unit
Baka kasi kaya nilalagnat si px is
contaminated pala ng bacteria yung blood
and may infection na pala si px.
Prevention: Leukocyte reduction; pagbibigay ng
leuko-reduced RBC
Bakit ba nagkakaroon ng febrile transfusion
reaction? Yung mga packed RBC natin sa storage,
may content yan na WBC and upon storage, itong
mga WBCs natin produces biological response
modifiers or BRMs. Itong mga BRMs na ito can cause
febrile transfusion rxs. So anong gagawin mo?
Maganda is during storage ng packed RBC, tanggalin
na natin yung leukocytes or WBC para wala ng
magpproduce ng BRM which can cause febrile
transfusion reactions. Kaya madalas, yung mga
hospitals ngayon, ang ginagawa nila, yung mga
packed RBC nila is inuundergo na nila ng leukocyte
reduction or tinatanggal na nila yung WBC prior
storage and transfusion.
Allergic (Urticarial-Hives) Transfusion Reactions
Etiology: Form of cutaneous hypersensitivity
triggered by recipient antibodies directed against:
o Donor plasma proteins
o Other allergens (food, medicines) in donor
plasma
Characterized by rash and/or hives and itching.
Pathophysiology: due to activation of mast cells. Si
mast cells kasi are what we called tissue basophils.
So once nagkaroon tayo ng allergic reaction, itong
mga mast cells will release histamine causing these
rash, hives. So anong binibigay kapag may allergic
reaction? Antihistamines to counteract this reaction.
Minsan, kapag meron ng determined na allergy yung
px or recipient natin, bago pa siya mag undergo ng
transfusion, binibigyan na siya ng antihistamine,
hindi na inaantay pa na magkaroon ng allergic
na meron siyang mga allergies.
Prevention: Can pre-treat recipient with
antihistamines before transfusion.
Anaphylaxis
Etiology: Recipient is absolute IgA deficient & has
anti-IgA in PLASMA
Prevention: Wash cellular components or blood
products from IgA deficient
MUST STOP TX IMMEDIATELY
binigyan mo siya ng plasma containing IgA. Very
simple lang naman yan sa blood bank, we should not
give any foreign agent to our recipient kasi the body
will respond to it. Example, si recipient nga is absent
sakanya yung IgA, tapos sa plasma nung donor ay
merong IgA then binigay mo ngayon kay recipient,
foreign ba sakanya yung IgA? Yes, so what will
happen is antibody will be produced causing
reaction/anaphylaxis.
TX Related Acute Lung Injury
Yung mga signs and symptoms natin ng TRALY is
similar to acute respiratory distress syndrome or
ARDS.
Etiology: Acute onset of low oxygen level in the
blood (hypoxemia) and pulmonary edema on CX-RAY
within 6 hrs of TX without evidence of other causes.
Leading cause of transfusion associated fatalities
surpassing yung ABO incompatibility is bacterial
contamination.
:
o Primary Suspect: Donor antibodies to recipient
HLA (human leukocyte antigen; present sa mga
WBC); possible yung donor is merong antibody
against the HLA of the recipient causing TRALY.
o Another cause: Biologically active lipids in the
lungs causing edema
Acute Transfusion Reactions:
NONIMMUNOLOGIC
Circulatory Overload
Etiology: Rapid increases in blood volume to patient.
Signs and Symptoms: Dyspnea, cyanosis (bluish
discoloration of parts of the body), severe
headaches, hypertension, or CHF (congestive heart
failure).
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EVANGELISTA, ARA 2
 Blood Banking
Risk factors: it can compromise yung cardiovascular
function; can cause severe chronic anemia
Pano ba nangyayari yung circulatory overload?
Kapag masyadong mabilis yung transfusion, kapag
yung rate ng transfusion is about 200mL/hr or
higher.
Treatment: Stop infusion and place patient in sitting
position.
Meron tayong indications for circulatory overload:
Example is yung elevated levels of brain natriuretic
peptide (BNP) that can be seen on patients or cases
with circulatory overload.
Physically or Chemically Induced Red Cell
Destruction
Etiology: Destruction of red blood cells in the
collection bag and infusion of free hemoglobin, etc.
Improper temperatures: High or Low
o Malfunctioning blood warmer or water bath
(lumalagpas, dapat regulated yung temp natin
kapag thinathaw natin yung blood kaya lang
nangyayari minsan pag sira yung blood warmer,
masyadong mainit yung ginamit nating blood
warmer, it could destroy/lyse the RBC same with
very low temp, it could also destroy the RBC),
inadvertent freezing of blood.
' Hypocalcemia
Excess citrate: massive transfusion or individuals
with impaired liver function:
o Citrate is broken down by liver.
Ganito yung nangyayari sa hypocalcemia, kapag
nagkaron ng massive transfusion, remember yung
blood bag natin, it contains atleast 63mL of CPDA-1,
so may citrate. Ano ba ginagawa ni citrate? It
chelates, so kapag massive transfusion, kasamang
naittransfuse sa patient yung anticoagulant
preservative which is citrate na present sa blood unit.
Imagine, 1 blood bag contains 63mL of anticoagulant
preservative. The citrate now will chelate calcium
leading to hypocalcemia.
patients who have impaired liver function.
Signs and Symptoms: Facial tingling, nausea,
vomiting.
Prevention: Slowing or discontinuing infusion.
Hypothermia
Etiology: Drop in core body temperature due to rapid
infusion of large volumes of cold blood.
Core temperature that is lower than 350C can be
categorized as hypothermia.
Symptoms: Decreased body temperature and
ventricular arrhythmias.
According to AABB standards, they mandate na
dapat merong mga blood warmers or yung mga
blood warmers na ginagamit should have
temperature monitor and a warning system kasi
kapag malamig yung binigay natin sa px, ano
nangyayari? Syempre bababa rin yung core
temperature niya leading to possible
hypothermia.
Prevention: Reduce rate of infusion or use blood
warmers.
Air Embolism
Etiology: If blood in an open system is infused under
pressure or if air enters the system while container
or blood administration sets are being changed.
The minimum volume of air embolism that is
potentially fatal for an adult is approximately
100mL so yung konting air embolism, konting air
sa ugat na pumasok, hindi naman ganun ka-fatal.
Pero kapag around 100mL pataas na yan,
possible cause ng fatality. Kasi kapag napasukan
ng air yung ugat natin, nagkakaron ng space eh
nagcicirculate yung blood diba so possible na
yung gap sa ugat natin na walang air, possible na
umabot sa diff parts of the body and could case
damage to diff organs.
Treatment: Place patient on left side with head down
to displace air bubble from pulmonic valve.
Delayed (>24 Hours) Transfusion Reaction
It happens pag more than 24 hours na, usually 3-7
days.
1. Immunologic
o Hemolytic; Graft vs. Host Disease;
Posttransfusion Purpura
2. Nonimmunologic
o Iron Overload
Delayed Transfusion Reactions: IMMUNOLOGIC
Delayed Hemolytic Transfusion Reaction
Onset within days (>24 hours)
Associated with Extravascular Hemolysis
Referring to those blood groups outside ABO.
Example: Rh, Kell, duffy. Any blood groups
outside ABO ay may possibility na mag cause ng
extravascular hemolysis.
Etiology: Antibodies that usually do NOT activate
Complements: Rh, Kell, etc.
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EVANGELISTA, ARA 3
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Do not activate complement kasi itong Rh, Kell, inactivates/deactivates T lymphocytes
these are IgG antibodies and monomeric so they preventing GVHD.
are not good in activating complement.
Prevention: Give antigen negative blood. Post-transfusion Purpura
Etiology: Antibodies to platelet antigens HPa1a(Anti-
bibigyan ng RBC containing Kell antigen. Kung PLA1) causes abrupt onset of severe
thrombocytopenia (platelet count <10,000/mm3)
bibigyan ng RBC containing D antigen kasi it can days 7-14 days following transfusion.
cause production of alloantibodies and Signs: Purpura, bleeding, fall in platelet count
eventually, extravascular hemolysis. Usually this affects patients with multiple
pregnancy kasi pag marami na naging anak si px,
Extravascular Hemolysis lima, anim, may chance na nagkaroon siya ng
mga transfusions in some of her pregnancy. So
Characteristics Signs may include:
ngayon, pag nagttransfuse ng blood at including
Reaction within days No release of free
yung platelet for example. Si platelet, meron din
Antibody attaches to Hgb, or enzymes into
yang antigen, yung HPA-1a so pag si pregnant
RBC: RBC destroyed circulation
woman, wala siyang antigen, example yung
in spleen or liver, etc. May be immediate
platelet antigen na HPA-1a tapos naexposed siya
Commonly IgG (hours) or delayed
ron, si pregnant woman will produce an antibody
May or may not (days)
against HPA-1a causing post transfusion
activate complement Bilirubinemia or
purpura.
bilirubinuria
Lagi namang ganun, anything that is foreign to
the recipient, si recipient will produce an
destruction, hemoglobin is composed of heme and antibody against that to fight.
globin. Si heme part will be metabolized producing
Treatment: IVIG, plasmapheresis or corticosteroids;
bilirubin kasama sa mapproduce yung bilirubin platelet transfusions usually NOT recommended
specifically, B1 increasing the concentration of since ang nagiging cause nga rito ng transfusion rxn
bilirubin in the blood. is yung platelet. Ang mangyayari is icoconsume lang
Signs & Symptoms continued... nung antibody yung platelet so it would be useless to
1. Fever or fever & chills transfuse platelets on someone suffering from post-
2. Jaundice (kapag increased B1 or unconjugated transfusion purpura.
bilirubin)
3. Unexpected anemia Delayed Transfusion Reactions:
o Some may present as an ABSENCE of an NONIMMUNOLOGIC
anticipated increase in Hemoglobin and
hematocrit. Iron Overload
Etiology: Excess iron resulting from chronically
Graft vs Host Disease (GVHD) transfused patients such as hemoglobinopathies,
Etiology: Donor CD8+ T-Lymphocytes attack chronic renal failure.
recipient (host) tissues. Nangyayari to for patients na merong long term
Signs: Fever, dermatitis, or erythroderma, hepatitis, complication of RBC transfusion. Also called as
diarrhea, pancytopenia (pan=all, cyto=cell, transfusion hemosiderosis.
penia=decrease; decrease in all cell types), etc. Remember that each unit of RBC contains
Survival period ng patient na nagkaroon ng around 225mg of iron so kapag nagkakaron ng
GVHD is around 21 days long term RBC transfusion, kasama syempre
Signs & symptoms can appear around 3-30 days. dyan yung iron being transfused to the px which
Groups at risk for GVHD: immunocompromised px can cause iron overload.
such as cancer px, fetus, neonatal, those who have Signs: Muscle weakness, fatigue, weight loss, mild
undergone bone marrow transplant jaundice, anemia, etc.
Prevention: Irradiation of blood products. Treatment: Infusion of deferoxamine/
Kasi yung irradiating machine natin, yung desferrioxamine an iron chelating agent that has
radiation, ang target nyan is T lymphocytes. It
F-
EVANGELISTA, ARA 4
 Blood Banking
been useful for treating iron overload for those px
undergoing long term RBC transfusion. TRANSFUSION REACTION FOLLOW-UP
Clinical Information Needed:
Infectious Complications of Blood Transfusion Recipient diagnosis
Yung viral na infection or sabihin nating infection due
Medical history of pregnancy &/or transfusion para
to blood transfusion caused by virus is very seldom
malaman kung may possible bang effect yung
or rare kasi self-limiting ang virus, kapag wala siya sa
previous transfusion niya sa current condition
host, ang tendency, it will disintegrate unlike
Current medications
bacteria, it can proliferate kahit wala sa host.
Signs & symptoms during transfusion reaction
Bacterial Contamination transfused?
Kasi syempre the more blood unit, the more blood
Etiology: At time of collection: either from the donor
volume transfused, mas severe rin yung transfusion
or the venipuncture site.
rxn.
o During component preparation, etc. ( di talaga
na aseptisize yung area bago mag collect ng
blood unit so mag accumulate yung bacteria Were red cells infused under pressure?
tapos ittransfuse natin sa px) What was the size of the needle used? Kasi kapag
Usually involves endotoxins masyado manipis yung needle na ginamit, kasi ang
o Staph, Pseudomonas, Yersinia enterocolitica standard gauge for blood transfusion and donation is
Common isolates found on RBC units is gauge 16. So pag gumamit ka ng mga 21, 23, 25
Yersinia enterocolitica followed by gauge, masyadong maliit/manipis tas nagtrnasfuse
Pseudomonas. ka so possible, ma-lyse yung RBC.
Out of these 3, ang pinaka common Were other solutions given through the IV line at the
isolate is Yersinia enterocolitica followed same time?
by Pseudomonas Were any other drugs given at the time of
Components: Most often from platelet components transfusion? Kasi baka may allergic rxn yung px sa
(room temp). binigay na drugs.
Bakit kaya sa rami ng components (we have What were pre- & post- transfusion vital signs?
leuko-reduced, granulocyte concentrate, packed
RBC), bakit kaya yung platelet concentrate yung 3 steps to be performed when hemolysis is suspected
1. Clerical error (very common)
most common component being contaminated
2. Visual check for hemolysis
by bacteria? It is because platelets are stored at
3. Perform DAT
room temperature for 5 days kaya nga very
limited lang yung storage ng platelet kasi nasa
Post Transfusion Reaction blood samples to be
room temp lang siya unlike other components,
collected from the recipient:
naka-store sa -18, -65, etc so mas prone sa
contamination yung platelet concentrate. Clotted specimen Repeat ABO, Rh, IAT and
Symptoms: Rapid onset Crossmatch. Visual check
o Fever, hypotension, shaking chills, muscle pain for hemolysis and
o Vomiting, abdominal cramps, bloody diarrhea, compare with pre
hemoglobinuria, shock, renal failure, & DIC. transfusion sample.
Transfusion must be stopped immediately Kaya tinatago talaga
o Gram stain & blood cultures should be done on yung sample ng
the unit, patient, and all infusion sets to donor kahit sabihin
determine yung cause ng contamination o kung nating nagstart na
san galing. yung transfusion.
o Broad-spectrum antibiotics should be given Minimum of 7 days
immediately intravenously sa pagstore nung
o Prevention: Maintain standards of donor samples ng donor.
selection, blood collection and proper
maintenance of collected blood components. EDTA specimen DAT (Direct Antiglobulin
Test)
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EVANGELISTA, ARA 5
 Blood Banking
Gusto natin malaman
kung yung RBC ba ni
px is sensitized kasi if
sensitized yan,
automatic, it would
lead to extravascular
hemolysis.
Clotted specimen Collect 5-7 hours post
transfusion to check for
bilirubin
1st voided urine To determine the free
specimen post- hemoglobin
determination kasi in
acute hemolytic
transfusion rxn, free
hemoglobin from
damage cells can cross
the renal glomeruli and
enter the urine pero
yung hematuria and
myoglobinuria, will not
be expected in that case.
Additional: The maximum bilirubin concentration
occurs 3-6 hrs after hemolytic transfusion episode so
dapat, makapag collect ng sample within that period.
TRANSFUSION REACTION WORKUP
CLERICAL CHECKS SPECIMEN CHECKS
1. Correct identification Visual inspection of
of patient, specimen, post-transfusion
and transfused unit. specimen
2. Agreement of Visual inspection of
records and history blood bag and lines
with current results
3. Correct labeling of
transfused unit
Perform Antibody detection
o Recipient Pre- & post-transfusion reaction
specimens will be tested.
o Pre neg and post pos: Identify antibody and
compare results of serum panel with eluate
panel. If previously undetected antibody is
discovered, it should be identified.
1. a sample identification error
2. anamnestic antibody production after a
recent transfusion
3. passive transfer of antibody from a recently
transfused component.
o Repeat crossmatch tests, with prereaction and
postreaction samples to compare.
o A positive crossmatch in a negative antibody
screening test may indicate the presence of an
antibody directed against a low incidence blood
group antigen.
Yung mga dinedetermine natin na
alloantibodies for antibody screening,
limited lang. Hindi lahat ng antibodies are
being detected using the test esp. kapag low
incidence yung blood group antigen kasi ang
tinetest lang sa antibody screening is yung
mga antibodies that will react to high
incidence blood group antigens so kung low
incidence yan, mag nenegative talaga, and
may possibility na mag positive yung
crossmatch, possible yun.

POST TRANSFUSION LAB TESTING

Direct Antiglobulin Test (DAT)
o Recipient post-
o Positive: Perform eluate and identify antibody if
the pre-TX spec negative.
ABO Grouping and Rh Typing
o Recipient pretransfusion and posttransfusion
specimen are collected.
o Donor s bag kasi dito galing yung transfused
blood.

-80dg
EVANGELISTA, ARA 6