Transfusion Reactions

1. Transfusion Reactions Education for Individuals Who Transfuse Blood Products

2. Agenda/Topics to Be Covered • Intended Audience • Introduction • Symptoms • Immune Mediated Reactions • Non-Immune Mediated Reactions • Infectious Complications • If a transfusion reaction is suspected…

3. Intended Audience • The intended audience for this module includes all job classes responsible for initiating transfusions and/or monitoring transfusion recipients. • This includes but is not limited to • RN • LPN • Perfusionist • CRNA • Anesthesiologist

4. Introduction • Sometimes there are adverse reactions that occur with the use of a blood component. • Most of these reactions are not common and can usually be easily managed. • Others may be life-threatening, thus is imperative that the patient care staff recognize the problem and act as soon as possible should an adverse reaction occur.

5. Symptoms Indicating a Possible Reaction • Chills • Temperature rise of 2° F or more above pre-transfusion baseline. • Hives/Rash • Hematuria • Dyspnea • Nausea • Pain • Bleeding • Decreased Blood Pressure and/or Shock

6. Immune Mediated Reactions These are caused by a reaction of the patient's immune system against the blood product or a reaction of the immune cells in the blood product against the patient.

7. Immune Mediated Reactions Acute Hemolytic Reaction • The most dramatic reaction is an acute hemolytic reaction. This is due to a mismatch in blood type between the patient and the product the patient receives. This occurs most often with mismatched red blood cells. The signs of this type of reaction are fever and a fast heart rate with chills. Shortness of breath with chest and back pain may develop. The urine may turn red or dark in color. The blood pressure may become unstable and shock may develop. Bleeding may occur. Death may very rarely result (1:633,000 transfused patients). The transfusion is stopped immediately and the reaction is treated intensively to reduce the complications.

8. Immune Mediated Reactions (Cont) Febrile Nonhemolytic Transfusion Reaction • A much less severe and more common reaction is a febrile nonhemolytic transfusion reaction. This type of reaction is often seen as a fever during or shortly after the transfusion. This is often due to antibodies against the white blood cells in the unit of blood. Such reactions are usually not serious. Filtering out a large number of white blood cells from the blood component can usually prevent them. Most products transfused at SJHC are leukocyte reduced.

9. Immune Mediated Reactions (Cont) Febrile Nonhemolytic Transfusion Reaction (Cont) • A febrile nonhemolytic transfusion reaction can also be caused by the white blood cells that make chemicals known as cytokines while the blood product is stored at the blood bank. Reducing the white cells in the blood product when it is prepared can prevent these chemicals from accumulating. Such reactions are therefore now rare. They can be treated easily when they occur.

10. Immune Mediated Reactions (Cont) Allergic Reaction • Signs of an allergic reaction can include hives, wheezing and/or swelling of the body tissues (angioedema). These reactions usually happen when the patient is allergic to some protein in the donor blood. An allergic reaction is very hard to predict. The reaction is treated with antihistamines when it occurs. Occasionally, steroids or epinephrine are needed to treat the reaction.

11. Immune Mediated Reactions (Cont) Anaphylactic Reaction • A more serious form of an allergic reaction is an anaphylactic reaction. This kind of reaction is like what might occur with a bee sting in a person allergic to bees. This type of reaction is life-threatening, and it is promptly treated with antihistamines, steroids and epinephrine.

12. Immune Mediated Reactions (Cont) Transfusion-related Acute Lung Injury (TRALI) • A more serious reaction is transfusion-related acute lung injury (TRALI). It occurs when donor antibodies activate white blood cells and other substances in the patient. This process occurs in the patient's lungs. It causes temporary damage to the blood vessels that allows fluid from the vessels to leak into the lung tissue. This collection of fluid in the lungs makes it hard for the oxygen to pass from the lungs to the blood. This complication is treated promptly with steroids and the patient usually requires ventilator support for two to four days. It usually gets better, but could fail to respond to therapy and could be fatal. In an effort to reduce the incidence of TRALI, most blood centers (including KBC) are no longer making FFP from whole blood donated by female donors.

13. Immune Mediated Reactions (Cont) Graft Versus Host Disease (GVHD) • Patients who have suppressed or poorly functioning immune systems may be at risk of developing graft versus host disease (GVHD). This is an immune reaction of the donor immune cells against the patient, causing skin rash, diarrhea and hepatitis. Such patients at risk for GVHD receive irradiated blood components. The irradiation is a low dose but it changes the immune cells in the blood product so they cannot cause GVHD.

14. Non-Immune Mediated Reactions Circulatory Overload • One non-immune mediated adverse reaction is circulatory overload. If the patient receives more fluid than the body can tolerate, fluid can collect in the lungs, causing shortness of breath and a cough. DIC (disseminated intravascular coagulation) • Patients could receive a red blood cell component with cells that had been somewhat destroyed (hemolyzed) during storage or transfusion. Receiving such a hemolyzed blood product can cause DIC (disseminated intravascular coagulation), which can lead to bleeding problems.

15. Non-Immune Mediated Reactions (Cont) Potassium • During storage of blood, a chemical called potassium builds up in the blood product. Infusion of this extra potassium may be of concern in a child less than 4 months old who receives a large amount of blood. Citrate • Fresh frozen plasma contains large amounts of a chemical called citrate. If a person receives large amounts of citrate from such a transfusion, the blood calcium level can fall, which could cause tingling of the hands and lips.

16. Infectious Complications • The blood product could be contaminated by bacteria, resulting in a potentially serious infection. • Several viruses can be transmitted through transfusion • Cytomegalovirus (CMV) • Hepatitis B and Hepatitis C • HIV • HTLV-I • Parasitic infections from blood products in the United States are very uncommon, but are a much bigger problem in other parts of the world or among US citizens who travel abroad.

17. If A Transfusion Reaction Is Suspected… • Primary steps to take include • Immediately discontinue the transfusion • Notify physician • Notify the blood bank • Complete form MR-57 , Transfusion Reaction Report • Send blood bag and any attached IV solutions to blood bank • Continue to monitor patient vital signs • Treat per MD order • Full instructions may be found in Patient Care Services Protocol PCS-V-26.

18. Please document your completion of this mandatory program by signing the attendance record.