Adverse reaction of blood transfusion

1. Adverse reaction of blood transfusion แบ่งเป็น Acute transfusion reaction : within 24 hrs Delayed transfusion reaction พญ. พิชญานันท์ คู่วัจนกุล กุมารแพทย์ สาขาโลหิตวิทยาและมะเร็ง โรงพยาบาลอุดรธานี

2. Blood component therapy Whole blood Platelet : poor function in 24 hr Coagulation factor Esp. V, VII decrease Reconstituted whole Blood

3. Blood component therapy

4. Blood component therapy Blood component Red blood cell component WBC component Platelet component Coagulation factor

5. Blood from apheresis

6. Red blood cell component • Packed red cell • Leukocyte reduced red blood cell • Leukocyte poor packed red cell • Leukocyte depleted packed red cell • Gamma irradiated blood component • Washed RBC • Deglycerolization RBC

7. Leukocyte depleted packed red cell

8. Red blood cell component • Storage 1-6 C • Volume depend on anticoagulant preservation solution • CDPA-1 [citrate-phosphate-dextrose-adenine] volume 250 ml shelf life35 days • Newer AP solution volume 300ml shelf life 42 days • Dose 10 ml/kg/dose Hb 3 g/dl

9. Acute transfusion reaction • Acute hemolytic reaction: immune, nonimmune • Allergic reaction • Circulatory overload • Transfusion-related acute lung injury • Hypotension reaction to transfusion • Bacterial contamination • Metabolic complication Blood tranfusion therapy A physical handbook AABB

10. Acute transfusion reaction If reaction occurs • Stop transfusion immediately • Verify the correct unit was given correct pt • Maintain IV, adequate urine output • Maintain BP,pulse rate • Maintain adequate ventilation • Notify attending physician and BB Blood tranfusion therapy A physical handbook AABB

11. Acute hemolysis transfusion reaction • Immune or non-immune Immune AHTR : ABO incompatible [common] • 10 ml of incompatible blood • Common : fever with or without rigors • Red or dark urine is first sign of intravascular hemolysis • Mild : Abdominal, chest, flank, back pain • Sever : shock , DIC Technical manual 16th edition

12. Acute hemolysis transfusion reaction Treatment :Cessation of transfusion 1.Mx hypotension : IV, inotropic drug 2.Mx renal blood flow - Hydration, keep urine flow >1ml/kg/hr - Low dose heparin - Furosemide 1-2 mg/kg/dose 3. Treatment DIC : blood component, Heparin is controversy Technical manual 16th edition

13. Acute hemolysis transfusion reaction Non- immune AHTR • Cause : storage temperature, incomplete deglycerolization of frozen red cell, a small bore size of needle[mechanical], inproper use of warmer , microwave, hot water bath, infusion simultaneously with hypotonic solution or drug can cause osmotic hemolysis[alternate IV] • Treatment: same Technical manual 16th edition

14. Acute transfusion reaction If intravascular hemolysis is confirm • Renal status • Initiate diuresis • Analze urine for hemoglobinuria • Monitor coagulation status[PT, PTT, fibrinogen, platelet ] • Monitor sign of hemolysis[LDH, bilirubin, haptoglobin, Hb] • Monitor Hb, Hct • Repeat compatibility testing Blood tranfusion therapy A physical handbook AABB

15. Transfusion-Related sepsis • Fever > 38.5 o C, shaking chills, hypotension during or shortly after transfusion • Key to diagnosis : same organism in pt and remainder component • In severe case develop shock with DIC, renal failure • DDx: mild case: FNHTR • Treatment : supportive care, ATB Technical manual 16th edition

16. Acute transfusion reaction If bacterial contamination is suspected • Obtain blood culture of pt • Return unit or empty bag to BB for c/s, g/s • Maintain circulation and urine output • Initiate broad spectrum ATB • Monitor signs of DIC, renal failure, respiratory failure Blood tranfusion therapy A physical handbook AABB

17. Febrile nonhemolytic transfusion reactions [FNTRs] • BT  1 o C rise associate with transfusion • No other cause is identify • Shaking chill, increase RR, change in BP and anxiety may occur 1-2 hour later • Treatment :Discontinue, antipyretic • Prevention : leukocyte reduced blood component Technical manual 16th edition

18. Allergic reaction • Urticaria to anaphylaxis [most: mild] • Within seconds or minutes of start transfusion • Urticaria : respond quickly to antihistamine • Angioedema • Anaphylaxis : hypotension,shock, loss of concious , 30% : GI, CVS [tacchycardia, arrythmia, sudden cardiac arrest] Technical manual 16th edition

19. Allergic reaction • 1-3 % of transfusion,13-33 % of all reaction • Treatment : Urticaria antihistamineผื่นยุบให้ต่อ Anaphylaxis stop, ประเมิน ABC, epinephrine, antihistamine, steroid, cardiac monitoring Broncospasmbeta II agonist, aminophilline • Prevention : Premedication with antihistamine ในคนที่มีประวัติurticariaบ่อย ๆ หากเคยanaphylaxis ครั้งต่อไปต้องwashed RBC,plt Technical manual 16th edition

20. Transfusion-Related acute lung injury [TRALI] • Fever with chill,dyspnea, cyanosis, hypotension, new onset of bilateral pulmonary edema • Life-threatening or fatal • Within 6 hours of transfusion [most 1-2hr after end of transfusion ] • Can associate with dramatic transient neutropenia or leukopenia Technical manual 16th edition

21. Transfusion-Related acute lung injury [TRALI] • TRALI is a form of acute lung injury [ALI] 1. ALI : Acute hypoxemia [PaO2/FiO2 ≤300, SpO2<90%] 2. No pre-exist ALI before transfusion 3. Onset within 6 hours of transfusion 4. No temporal relationship to an alternative risk factor for ALI Technical manual 16th edition

22. Transfusion-Related acute lung injury [TRALI] • 80% improve within 48-96 hours, 20% do not improve rapidly fatal outcome • 100 % need oxygen support, 72% required mechanical ventilator • DDx: - Anaphylaxis - Transfusion associated circulatory overload [TACO] - Transfusion related sepsis Technical manual 16th edition

23. Transfusion-Related acute lung injury [TRALI] • Treatment : Respiratory and Volume support [oxygen, mechanical ventilator, pressor agent], Diuretic and corticosteriod: not improveclinical outcome • Prevention : Deferring multiparous females from danating plasma rich component Technical manual 16th edition

24. Circulotory overload[TACO] • Pulmonary edema from volume overload • Greater risk : infant • Within several hour of transfusion pt develop Dyspnea + signs of volume overload • DDx :TRALI [both pulmonary edema] • Treatment: stop, sitting, oxygen, reduced the vascular volume, diuretic drug Technical manual 16th edition

25. conclusion From Handbook of transfusion medicine, united kingdom blood service 4th edition

26. Reaction involves mild fever or urticarial rash only

27. Thank you for your attention