TRANSFUSION

REACTIONS
Revison 2016
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 BLOCK 2 REVISION COURSE
MEDICAL STUDENTS

24 November, 2016.

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 Dr. T. S. Akingbola
FWACP (Lab. Med.)
Senior Lecturer.
Haematology Department,
University College of Medicine,
University College Hospital,
Ibadan.

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 OUTLINE OF PRESENTATION
• Introduction
• Definitions: i) Blood Safety
• Definition ii) Anaemia
• Indications for Blood transfusion
• The Who, When, What, How of blood transfusion
• General guidelines to donation: : age, weight, volume
• Contraindications to donation: Conditions that may disqualify a donor
• Complications of Blood transfusion
• Immediate, Delayed , Febrile transfusion reaction
• Haemostasis
• Disseminated Intravascular Coagulopathy
• Management

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 Blood Safety
• All individuals have access to blood & blood
products that are as safe as possible, available at
reasonable cost, adequate to meet the needs of all
patients, transfused only when necessary and
provide as part of a sustainable blood programme
within the existing health care system.
(WHO Dept. of Blood Safety and Clinical
Technology)

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 Anaemia
Definition:
The level of circulating Hb or Red cell is lower
than that in healthy subjects of the same sex and
age group and in the same environment

BLOOD IS LIFE & LIFE SAVING PARTICULARLY IN THE

DEVELOPING COUNTRIES

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 There are greater than 300 Antigens in man recognized with
specific antisera.

The 16 most important blood groups are listed below:

System Important Antigens Chromosome Association with HDN

ABO A1, A2, B, H 9 Yes

MNSs M, N, S, s, U 4 Yes
Rhesus D, C, E, c, e, G 1 Yes
Lutheran Lua, Lub, - -
Kell K, k, Kpa, Kpb, Jsa - -
Lewis Lea, Leb 19 -
Duffy Fya, Fyb, 1 -
Kidd Jka, Jkb 2 -
Diego Dia, Dib - -
Cartwright Yta, Ytb - -
Auberger Aua, Aub - -
Dombrock Doa, Dob - -
Colton Coa, Cob - -
Sid Sda - -
Scianna Sc1, Sc2 1 -
Xg Xga X -
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 TRANSFUSION REACTIONS

Frequency of transfusion reaction varies

inversely with the care exercised in the
preparation for and especially in the
supervision of the transfusion

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 Majority of the Side Effects are mild

Overall incidence of complication is estimated

at 2-5% (1 in 100,000 patients)

50% caused by ABO incompatibilities,

mainly due to failure to identify correctly the

donor or the recipient.

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 Ultimate aim of Blood transfusion –

Prescribed where there are definite clinical

indications & there are no alternatives.

Complications of blood transfusion Immunology

Non-immunology

Immunological Complications

(a) Sensitization to red cell antigens

Routinely only the ABO & Rh D antigens are routinely

matched.

There is always a possibility of sensitization to other

red cell antigens, more likely in multiply transfused
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patients 11
 Consequences of (a) – May be negligible

HDN
Difficult with compatibility testing
Haemolytic Transfusion Reaction

Haemolytic transfusion Reactions (Immediate

& Delayed)
These are the results of premature destruction
of red cells, almost always due to donor red
cells being destroyed by reaction with immune
antibodies in the recipient.
May occur immediately after the transfusion;
01/29/24 or may be delayed for up to2-3weeks. 12
 Immediate haemolytic transfusion reaction

(a) Destruction of recipients cells should be avoided

Only likely instances in practice, where group O Donor with high

titre anti A or anti B is transfused to a recipient – Group A, B or
AB.

Group O – should not routinely be used for non-O recipients; O

blood screened to the presence of high titre haemolysins. Also screen
blood products especially in children.

Secondly leads to shortages of O blood.

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 (b) Destruction of donor red cells;
•Brought about by antibodies in the recipient.

•The most dangerous type of transfusion reaction.

• It may be fatal, but should be avoidable. Causes:

1.Clinical/ administrative error

 Failure to confirm the identity of the patient

when taking samples.

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  Mislabeling of the sample of blood
 Failure to perform proper checks before
transfusing the blood.

2. Very rarely there is lab every error where

antibodies in the recipient’s plasma not
detected (or there’s insufficient time to
complete an antibody screening or
compatibility test)

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 Set procedures for checking should always be
followed to avert the serious consequences of
such failures.

Very rarely, weak rbc alloantibodies

undetectable routinely pretransfusion may
destroy donor Red cells carrying
corresponding antigens.

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 Haemolytic antibodies are generally IgM or,
rarely IgG complement binding

Binding of such antibodies to Ag on rbc

activates full complement cascade

Lysis of red cells in the circulation

(intravascular lysis)

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 Features of immediate haemolytic transfusion
proportionately vary according to a number of
factors
 Red cells destroyed within the circulation/RES
 Strength of class of antibody
 Nature of Ag
 Number of incompatible red cells transfused
 Clinical state of the patient

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 Intravascular red cell destruction is the most
dangerous type of haemolytic transfusion
reaction; it is associated with activation of the
full compliment cascade and is practically
always due to ABO incompatible blood
transfusion.

Mortality up to 10%

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 Symptoms – in the recipient are dramatic &
severe (most are due to anaphylatoxins C3a
and C5a liberated during compliment
activation although IL-1 & IL-8 and TNF also
seem to play a role.

These molecules (C3a, C5a, +IL-1, IL-8) may

cause smooth muscle contraction, platelet
aggregation and increase capillary permeability
and release vasoactive amines and hydrolases
from most cells and granulocytes respectively.

01/29/24 Typically within <1hr from start of transfusion 20

 Patient complains of heat in the vein
 Throbbing in the head,
 Flushing of the face,
 Chest tightness,
 Nausea and
 Lumbar pain.

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  Usually accompanied by tachycardia and
hypotension. In severe cases there is
hypotension and collapse. Rigors and
pyrexia usually follow

 Initial symptoms may be modified in

anaesthetized patients

 Intravascular destruction of rbcs: –

liberation of thromboplastins-like
substances causing DIC.

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  Intravascular destruction of red cells –
haemoglobins, once haptoglobins are
saturated, haemoglobin will appear in urine.
 Renal complications – acute RF with oliguria
and anuria possibly the result of activated
complement.

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 Differentials of above symptoms

 Transfusion of lysed red cells (over heated)

 Blood subjected to extreme cold
 Injection of 5% Dextrose with transfused
red cells.
 May follow transfusion in patients with
severe AIHA

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 Immediate extravascular destruction of red cells
may be accompanied by
 Hyperbilirubinaemia,

 Occasional mild haemoglobinaemia (in severe

ceases),
 Fever and

 Failure to achieve expected rise in Hb level.

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 Signs/Symptoms

 Less dramatic than in the intravascular haemolysis

 Appears > 1hour after the start of transfusion

 There may be no Signs/Symptoms

 RF is very rare;

 Mortality is extremely low.

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 Diagnosis and management
 Terminate transfusion immediately
 Circulating blood volume should be restored
 B.P and Urinary flow maintained.

Check identity of the patient and the units

transfused against the appropriate
documentation

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 Investigations
 Blood samples – haemoglobinaemia,
bilirubinaemia, FBC, Platelet, Haptoglobins,
coagulation
 Serological tests
(DAT, repeat antibody screening and
compatibility testing.)

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 Pretransfusion samples in parallel

If no identification mistake within 24hrs

 Sample for bacteriological test

 Urine within 24hrs check haemoglobin

But if patient develops only increased

temperature without other symptoms red cell
incompatibility is unlikely

Treatment: Transfusion should be slowed down.

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 Immediate haemolytic Transfusion Reaction –
WARNING !!!!
Often the result of administrative /clerical error.
If an identification mistake has been made, check
as a matter of urgency that the units intended for
a patient under study have not been misdirected
to another recipient.

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 Delayed haemolytic transfusion Reaction
(DHTR)
 Neither predictable nor preventable
 Majority of cases/ individuals have been
previously sensitized to one or more Ag (by
transfusion or pregnancy e g Abortion)
 Antibody is not detectable in routine
pretransfusion testing but the transfusion of
blood containing the Ags to which the
recipient has been previously sensitized
provokes a brisk amnaestic response
characteristic of the secondary immune
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  Within Days the antibody level rises and the
transfused cells are removed from the
circulation.
 Results of incompatibility – usually seen with
seven (7) days of transfusion (fever, Jaundice
and anaemia)

Note: To prevent DHTR; always take fresh serum

samples for antibody screening and compatibility
if previous transfusion > 48hours.

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 (a.) Febrile transfusion Reactions (FRT)

Most frequently due to sensitization to white cell

Ag and more rarely to Platelet antigens.

 Most common type of immunological reaction

to blood transfusion.

 Characteristically delayed until 30-90 mins

after start of transfusion. A rise in temp may
be the sole symptom. + Chills, headache,
rigors, Hypotension, lumbar pain chest
discomfort.

 Reactions troublesome rather than dangerous.

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  + Chills, headache, rigors, Hypotension,
lumbar pain chest discomfort.

 Reactions more usually troublesome rather

than dangerous

Treatment

 Slow transfusion
 Aspirin
 Antihistamines not beneficial

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 Deplete WBC content – cheapest method –
centrifugation with removal of buffy coat.
Other – filtration (specific leucocytes filter)
(b) Post-transfusion purpura
 Rare
 Sudden onset after 7-10 days of blood
transfusion of severe thrombocytopenia
 Positive History of previous transfusion or
pregnancies
 Most frequent cause is the presence in the
recipient of an antibody (anti-HPA-Ia) against
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platelet specific antigen HPA –Ia (PIAI) 35
  Self limiting
 In severe cases if bleeding occurs

(c) Reactions due to plasma protein

antibodies causing Urticarial and anaphylactic
reaction.
Urticarial reactions ----
 Usually due to sensitizing antibodies in the
recipient interacting with an exogenous
antigen in the donor plasma.
 Most common in the plasma of patients
suffering from atopy, diseases (asthma, hay
fever)
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 Allergic Reactions continued
Management of Urticarial Reaction
• Slow down transfusion
• Give antihistamine – Chlorpheniramine 10mg slow i.v. or
deep i. m. (non thrombocytopenic pts)
• Continue transfusion if no progression after 30 minutes
• If no response saline-washed blood components are
specially selected

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 Anaphylaxis
• Rare but could be life threatening
• In the early part of transfusion
Causes:
Rapid infusion of plasma

Signs : Hypotension, bronchospasm, periorbital or laryngeal oedema,

vomiting, erythema, urticarial and conjunctivitis

Symptoms: dyspnoea, chest pain, abdominal pain and nausea

Anaphylaxis occurs

1 when a patient pre-sensitised to IgE antibodies is re-exposed to the

particular antigen

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 Transfusion-related acute-lung
injury (TRALI)
• Typically within 6 hours of a transfusion
• Pt develops breathlessness & non
productive cough
• CXRay: bilateral infiltrates in a bat wing
pattern (typical of ARD)
• HYPOTENSION
• Monocytopenia or neutropenia

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 TRALI
• Often found that the plasma of an implicated donor
(usually a multip) contains antibodies that reacts strongly
with the patient’s leucocytes
• Differentials
Cardiac failure
Non-cardiogenic pulmonary oedema
Rx : as in ARD, conservative, give Oxygen
Avoid DIURETICS
Steroids – uncertain benefit

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 Non-immunological complications

TRANSFUSION TRANSMISCIBLE INFECTIONS

Hepatitis A- rarely transmitted by transfusion

B- Frequently sequel to blood tx.

ELISA will detect 0.5IU of HbSAg/ml of serum

C- Now recognized as the cause of

majority of non A and non B

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 Syphilis: - T. Pallidum does not survive well at
4oC and red cells are likely to be non infectious
>4 days of refrigeration.

Malaria: - Parasites are viable in blood stream at

4oC and easily transmitted by blood transfusion.

Cytomegalovirus

(CMV): Post transfusion CMV is not common.

Most cases are sub clinical but the syndrome of

post transfusion infectious mononucleosis like
illness is well recognized especially after
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transfusion of large volumes of blood. 42
 Groups at risk
 Premature babies weighing <1500g.
 Women;
Therefore provide anti CMV free blood or
leucodepletion.

Non-immunological complications
Bacteria in transfused blood: Causing Febrile
Reactions due to pyrogens or
Manifestations of septic /endotoxic shock.
Infection of stored blood – extremely rare.
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 Skin contaminants
(Predominantly staph) do not survive storage
4oC and 22oC.

Other sources – Apparently healthy donors

who are bacteraemic at the time of donation

Circulatory overload
All patients (except those bleeding++)
experience an increase in blood volume in
venous pressure.
Young people with normal CVS – usually No
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embarrassment. 44
 In contrast- pregnant women with severe
anaemia, elderly with compromised CVS will
not tolerate the increase in plasma volume and
acute pulmonary oedema

Therefore, transfuse packed cells over 4hours

Patients with severe chronic Anaemia: –
•Partial exchange or use diuretics.
•Avoid overnight transfusion.
•Emergency venesection for fluid overload if

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all precautions fails. 45
 Thrombophlebites
Air embolism – Practically unknown as blood
and its components are administered in
plastic bags

Transfusion haemosiderosis
Complications of massive transfusion
Massive Blood Transfusion:
Defined as the replacement of total blood
volume of a recipient within 24hours.

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 Dilution of platelets
Dilution of coagulation factors
Low 2, 3 DPG (from stored blood particularly
after 21days of storage.)
Hyperkaelaemia

Treatment: Replace blood loss quickly and

adequate prevention as below

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 Alternatives to Transfusion

1. Minimize blood loss - controlled

hypotension

2. Tolerate a lower HCT

3. Transfuse Autologous Blood

4. CELL SALVAGE
Alternatives to Transfusion

3. Transfuse Autologous Blood

a. Preoperative donation and storage - 72
hours to normalize plasma proteins.
b. Acute preoperative phlebotomy and
hemodilution - inexpensive compared to
preop donation. Progressively decreases
the Hct of units saved.
c. Perioperative blood salvage from the
surgical site
CONCLUSION
• Effective clinical transfusion requires
that whole blood is separated into its
various components so that the right
components is available for the right
patient
• The appropriate use of blood and blood
products is also dependent on
consistent and adequate blood
donation,infrastructure
 THANK YOU FOR
LISTENING

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