Transfusion Reactions

June 2015
Objectives
Be able to recognize the more common
transfusion reactions

Learn about treatment and prevention of

transfusion reactions
Frequency of Transfusion
Reactions
Case 1
Mr Red is a 17 year old male is brought to the ER
after a motor vehicle accident. He is in pain,
tachycardic to 100s, but normotensive.

Given his acute blood loss, transfusion of 2u PRBC

is initiated (after appropriate type and cross-
matching revealing no antibodies, and
compatibility with donor blood).

During transfusion, he develops a fever but

otherwise has no new signs or symptoms.

What is the diagnosis?

Febrile Nonhemolytic
Transfusion Reaction
Fevers are common during transfusion
Pathophysiology: likely involves recipient-derived
leukoreactive antibodies + donor-derived
cytokines
Workup/Treatment: stop the transfusion!
Must r/o acute hemolytic transfusion reaction (AHTR)
Consider non-transfusion causes of fevers
Once AHTR is ruled out, may continue transfusion with
antipyretics

Prevention: antipyretics or leukoreduction of blood

products
Case 1 (continued)
Mr Red does well following discharge. Fifteen years later
(age 32), however, he is unfortunately in a second MVA. He
is brought to the ER, again requiring blood products.

He is type and cross-matched, found to have no

antibodies. He is pre-treated with acetaminophen, and
transfused 2 units PRBC without issue.

The remainder of his hospital course is unremarkable and

the pt is discharged home.

Ten days after the accident he follows up at his PCPs office

with a complaint of fatigue, fevers, and yellowing of his skin.

What is the diagnosis?

Delayed Hemolytic
Transfusion
Reaction
Onset of symptoms: 5-10 days
after RBC transfusion
S/S: hemolytic anemia, jaundice,
fever (can also be asymptomatic)
Life-threatening complications are
rare
Confirmation: repeat type and
screen to detect alloantibody
Treatment: supportive
http://arimmuneresponseassignment.weebly.com/report.html
Acute Hemolytic
Transfusion
Reaction
Abrupt onset of S/S
S/S: intravascular hemolysis,
hypotension, fevers, AKI, pain at
the infusion site, DIC, pink plasma
or urine
Treatment: stop the transfusion!
Send blood back to blood bank to
check for incompatibility, hemolysis
Supportive treatment with IVF,
pressors, diuresis
 Case 1 (continued)
Mr Red is now 78 years old. Since we last
saw him, he has been diagnosed with
diabetes, complicated by ESRD 2/2
diabetic nephropathy for which he is
dialyzed three times per week.

He is admitted for a suspected GI bleed for

which he is transfused 2 units PRBC. An hour
after transfusion, he starts to complain of
shortness of breath and chest tightness. HR
120s, BP 180/90, an S3 gallop is noted, and
new bibasilar crackles are heard on
pulmonary exam. Post-transfusion CXR is
shown (was previously normal).
https://www.med-ed.virginia.edu/courses/
rad/cxr/pathology2chest.html
What is the diagnosis?
Transfusion-Associated
Circulatory Overload
(TACO)
Risk factors deltaco.com
Patients with limited cardiopulmonary reserve (very young and elderly)
High volume transfusion
History of cardiac or renal disease

Onset: within 1-2 hours after transfusion

S/S: shortness of breath, cough, tachycardia, cyanosis, chest

tightness, volume overload (JVD, S3 gallop, peripheral edema)

Tx: supplemental O2, diuretics or other means of removing volume

Prevention: slow administration of blood, pretreatment with

diuretics (or blood administration with dialysis)
Case 2
Mr Reds hospital roommate also
happens to be a 78 year old male
admitted for likely GI bleed. He also
underwent transfusion with 2 units
PRBC 1 hour ago and reports
shortness of breath.
He is febrile to 38.5C, HR 120s, BP
70/40, SpO2 is 85% on RA. New
bibasilar crackles are heard on
pulmonary exam. Post-transfusion
CXR is shown (was normal
previously).
What is the diagnosis? https://www.med-ed.virginia.edu/courses/
rad/cxr/pathology2chest.html
Transfusion-Related Acute
Lung Injury (TRALI)

Onset: during or within 6 hours of

transfusion

S/S: hypoxia, dyspnea, fevers,

hypotension, pulmonary edema

Treatment: stop the transfusion!

Supportive (may need intubation),
O2

Prevention: notify blood bank of

reaction
thelancet.com
TRALI versus TACO

Kim et al. 2015.

Back to Mr Red
Mr Red is now 80 years old and is admitted after
a fall during which he sustained a left hip
fracture. Following surgery, he requires 1 unit
PRBC. He is appropriately type and
crossmatched, pretreated with acetaminophen,
and a slow transfusion is initiated during dialysis.
During the transfusion, he develops diffuse
urticaria but is otherwise stable.

What is the diagnosis?

umm.edu
Allergic Reactions and
Anaphylaxis
Mild allergic reactions (urticaria) are common,
especially in pts who have undergone multiple
transfusions
Prevention: pretreat with anti histamines, or wash
blood products to remove plasma proteins

Severe anaphylaxis is rare

Mechanism: recipient who is IgA deficient and has
anti-IgA antibodies reacts to IgA in donor blood
Prevention: wash all subsequent blood products to
remove plasma proteins
If IgA deficient, then only give blood products
from IgA deficient donors
Summary
It is important to recognize the possible reactions
that can be associated with blood transfusions

If you suspect a reaction, stop the transfusion

and assess the patients vital signs, signs and
symptoms as some reactions may be life-
threatening

Notify the blood bank if serious reactions are

suspected
References
Kim J, Na S. Transfusion-related acute lung injury;
clinical perspectives. Korean J Anesthesiol. 2015
Apr;68(2):101-5.

MKSAP 16

UpToDate