Transfusion Medicine:

Types, Indications and

Complications

History of Transfusions
Blood transfused in humans since mid-1600s
1828 First successful transfusion
1900 Landsteiner described ABO groups
1916 First use of blood storage
1939 Levine described the Rh factor

Transfusion Overview
Integral part of medical treatment
Most often used in Hematology/Oncology,
but other specialties as well (surgery, ICU,
etc)
Objectives
Blood components
Indications for transfusion
Safe delivery
Complications

Blood Components
Prepared from Whole blood collection or
apheresis
Whole blood is separated by differential
centrifugation
Red Blood Cells (RBCs)
Platelets
Plasma
Cryoprecipitate
Others

Others include Plasma proteinsIVIg,

Coagulation Factors, albumin, Anti-D, Growth
Factors, Colloid volume expanders
Apheresis may also used to collect blood
components

Differential Centrifugation
First Centrifugation

Closed System

Whole Blood
Main Bag

RBCs

Satellite
Bag
1

Satellite Bag
2

First

Platelet-rich
Plasma

Differential Centrifugation
Second Centrifugation

RBCs

Platelet-rich
Plasma

Second

RBCs

Platelet
Concentrate

Plasma

Whole Blood
Storage
4 for up to 35 days

Indications
Massive Blood Loss/Trauma/Exchange
Transfusion

Considerations
Use filter as platelets and coagulation factors
will not be active after 3-5 days
Donor and recipient must be ABO identical

RBC Concentrate
Storage
4 for up to 42 days, can be frozen

Indications
Many indicationsie anemia, hypoxia, etc.

Considerations
Recipient must not have antibodies to donor RBCs
(note: patients can develop antibodies over time)
Usual dose 10 cc/kg (will increase Hgb by 2.5
gm/dl)
Usually transfuse over 2-4 hours (slower for
chronic anemia

Platelets
Storage
Up to 5 days at 20-24

Indications
Thrombocytopenia, Plt <15,000
Bleeding and Plt <50,000
Invasive procedure and Plt <50,000

Considerations
Contain Leukocytes and cytokines
1 unit/10 kg of body weight increases Plt count by
50,000
Donor and Recipient must be ABO identical

Plasma and FFP

ContentsCoagulation Factors (1 unit/ml)
Storage
FFP--12 months at 18 degrees or colder

Indications
Coagulation Factor deficiency, fibrinogen replacement,
DIC, liver disease, exchange transfusion, massive
transfusion

Considerations

Plasma should be recipient RBC ABO compatible

In children, should also be Rh compatible
Account for time to thaw
Usual dose is 20 cc/kg to raise coagulation factors
approx 20%

Cryoprecipitate
Description
Precipitate formed/collected when FFP is thawed at 4

Storage
After collection, refrozen and stored up to 1 year at -18

Indication

Fibrinogen deficiency or dysfibrinogenemia

vonWillebrands Disease
Factor VIII or XIII deficiency
DIC (not used alone)

Considerations
ABO compatible preferred (but not limiting)
Usual dose is 1 unit/5-10 kg of recipient body weight

Granulocyte Transfusions
Prepared at the time for immediate
transfusion (no storage available)
Indications severe neutropenia assoc
with infection that has failed antibiotic
therapy, and recovery of BM is expected
Donor is given G-CSF and steroids or
Hetastarch
Complications
Severe allergic reactions
Can irradiate granulocytes for GVHD
prevention

Leukocyte Reduction Filters

Used for prevention of transfusion
reactions
Filter used with RBCs, Platelets, FFP,
Cryoprecipitate
Other plasma proteins (albumin, colloid
expanders, factors, etc.) do not need
filtersNEVER use filters with stem
cell/bone marrow infusions
May reduce RBCs by 5-10%
Does not prevent Graft Verses Host
Disease (GVHD)

RBC Transfusions
Preparations
Type
Typing of RBCs for ABO and Rh are
determined for both donor and recipient

Screen
Screen RBCs for atypical antibodies
Approx 1-2% of patients have antibodies

Crossmatch
Donor cells and recipient serum are mixed and
evaluated for agglutination

RBC Transfusions
Administration
Dose
Usual dose of 10 cc/kg infused over 2-4 hours
Maximum dose 15-20 cc/kg can be given to
hemodynamically stable patient

Procedure

May need Premedication (Tylenol and/or Benadryl)

Filter useroutinely leukodepleted
MonitoringVS q 15 minutes, clinical status
Do NOT mix with medications

Complications
Rapid infusion may result in Pulmonary edema
Transfusion Reaction

Platelet Transfusions
Preparations

ABO antigens are present on platelets

ABO compatible platelets are ideal
This is not limiting if Platelets indicated and
type specific not available

Rh antigens are not present on platelets

Note: a few RBCs in Platelet unit may
sensitize the Rh- patient

Platelet Transfusions
Administration
Dose
May be given as single units or as apheresis units
Usual dose is approx 4 units/m 2in children using
1-2 apheresis units is ideal
1 apheresis unit contains 6-8 Plt units (packs)
from a single donor

Procedure
Should be administered over 20-40 minutes
Filter use
Premedicate if hx of Transfusion Reaction

ComplicationsTransfusion Reaction

Transfusion Complications

Acute Transfusion Reactions

(ATRs)
Chronic Transfusion Reactions
Transfusion related infections

Acute Transfusion Reactions

Hemolytic Reactions (AHTR)
Febrile Reactions (FNHTR)
Allergic Reactions
TRALI
Coagulopathy with Massive transfusions
Bacteremia

Frequency of Transfusion
Reactions
Adverse Effect

Frequency

Comments

Acute Hemolytic Rxn

1 in 25,000

Red cells only

Anaphylactic hypotensive 1 in 150,000 Including IgA

Febrile Nonhemolytic

1 in 200

Common

Allergic

1 in 1,000

Common

Delayed Hemolytic

1 in 2,500

Red cells only

RBC alloimmunization

1 in 100

Red cells only

WBC/Plt
alloimmunization

1 in 10

WBC and Plt only

Acute Hemolytic Transfusion

Reactions (AHTR)
Occurs when incompatible RBCs are transfused
into a recipient who has pre-formed antibodies
(usually ABO or Rh)
Antibodies activate the complement system,
causing intravascular hemolysis
Symptoms occur within minutes of starting the
transfusion
This hemolytic reaction can occur with as little
as 1-2 cc of RBCs
Labeling error is most common problem
Can be fatal

Symptoms of AHTR
High fever/chills
Hypotension
Back/abdominal pain
Oliguria
Dyspnea
Dark urine
Pallor

What to do?
If an AHTR occurs
STOP TRANSFUSION
ABCs
Maintain IV access and run IVF (NS or LR)
Monitor and maintain BP/pulse
Give diuretic
Obtain blood and urine for transfusion
reaction workup
Send remaining blood back to Blood Bank

Blood Bank Work-up of AHTR

Check paperwork to assure no errors
Check plasma for hemoglobin
DAT
Repeat crossmatch
Repeat Blood group typing
Blood culture

Labs found with AHTR

Hemoglobinemia
Hemoglobinuria
Positive DAT
Hyperbilirubinemia
Abnormal DIC panel

Monitoring in AHTR
Monitor patient clinical status and vital signs
Monitor renal status (BUN, creatinine)
Monitor coagulation status (DIC panel PT/PTT,
fibrinogen, D-dimer/FDP, Plt, Antithrombin-III)
Monitor for signs of hemolysis (LDH, bili, haptoglobin)

Febrile Nonhemolytic
Transfusion Reactions
(FNHTR)

Definition--Rise in patient temperature

>1C (associated with transfusion without
other fever precipitating factors)
Occurs with approx 1% of PRBC
transfusions and approx 20% of Plt
transfusions
FNHTR caused by alloantibodies directed
against HLA antigens
Need to evaluate for AHTR and infection

What to do?
If an FNHTR occurs
STOP TRANSFUSION
Use of Antipyreticsresponds to Tylenol
Use of Corticosteroids for severe
reactions
Use of Narcotics for shaking chills
Future considerations
May prevent reaction with leukocyte filter
Use single donor platelets
Use fresh platelets
Washed RBCs or platelets

Washed Blood Products

PRBCs or platelets washed with saline
Removes all but traces of plasma (>98%)
Indicated to prevent recurrent or severe
reactions
Washed RBCs must be used within 24
hours
RBC dose may be decreased by 10-20%
by washing
Does not prevent GVHD

Allergic Nonhemolytic
Transfusion Reactions
Etiology
May be due to plasma proteins or blood
preservative/anticoagulant
Best characterized with IgA given to an IgA
deficient patients with anti-IgA antibodies

Presents with urticaria and wheezing

Treatment
Mild reactionsCan be continued after Benadryl
Severe reactionsMust STOP transfusion and
may require steroids or epinephrine

PreventionPremedication (Antihistamines)

TRALI

Transfusion Related Acute Lung Injury

Clinical syndrome similar to ARDS
Occurs 1-6 hours after receiving plasma-containing
blood products
Caused by WBC antibodies present in donor blood that
result in pulmonary leukostasis
Treatment is supportive
High mortality

Massive Transfusions
Coagulopathy may occur after transfusion of massive
amounts of blood (trauma/surgery)
Coagulopathy is caused by failure to replace plasma
See electrolyte abnormalities
Due to citrate binding of Calcium
Also due to breakdown of stored RBCs

Bacterial Contamination
More common and more severe with platelet
transfusion (platelets are stored at room temperature)
Organisms
PlateletsGram (+) organisms, ie Staph/Strep
RBCsYersinia, enterobacter

Risk increases as blood products age (use fresh

products for immunocompromised)

Chronic Transfusion Reactions

Alloimmunization
Transfusion Associated Graft Verses Host Disease
(GVHD)
Iron Overload
Transfusion Transmitted Infection

Alloimmunization
Can occur with erythrocytes or platelets
Erythrocytes
Antigen disparity of minor antigens (Kell,
Duffy, Kidd)
Minor antigens D, K, E seen in Sickle patients

Platelets
Usually due to HLA antigens
May reduce alloimmunization by
leukoreduction (since WBCs present the HLA
antigens)

Transfusion Associated GVHD

Mainly seen in infants, BMT patients, SCID
EtiologyResults from engraftment of donor
lymphocytes of an immunocompetent donor into an
immunocompromised host
SymptomsDiarrhea, skin rash, pancytopenia
Usually fatalno treatment
PreventionIrradiation of donor cells

Transfusion Associated Infections

Hepatitis C
Hepatitis B
HIV
CMV
CMV can be diminished by leukoreduction, which is indicated
for immunocompromised patients

Prevention
Leukocyte
Depletion
Filter

Gamma
Irradiation

CMV
Negative

Single Donor
Platelets
(Apheresis)

Febrile Transfusion
Reactions

X1

Alloimmunization

CMV

?2

Transfusion Related
GVHD

X
X

1 In PRBC transfusion
2 Leukocyte Reduction by filtration may be an alternative to CMV-negative blood

Summary
Blood Components
Indications
Considerations

Preparation and Administration of blood products

Acute and chronic transfusion reactions

Transfusion Reaction Summary

AHTR can be fatal
Stop the Transfusion
Monitor for symptoms and complete
evaluation
FNHTR is a diagnosis of exclusion
TRALI (ARDS-like reaction)
Chronic Transfusion reactions
Prevention methods using filters,
irradiation and premedication