Adverse Effects of Blood Transfusion PDF

Adverse Effects of Blood Transfusion objectives Differentiate the clinical signs & symptoms of acute and delayed transfusion reaction Rapid management of transfusion reaction may save patient’s life specially in acute reaction Understand the procedures to follow in the event of suspect...

Adverse Effects of Blood Transfusion objectives Differentiate the clinical signs & symptoms of acute and delayed transfusion reaction Rapid management of transfusion reaction may save patient’s life specially in acute reaction Understand the procedures to follow in the event of suspected transfusion reaction  However, Blood It always carries potential risks for the recipient, and Transfusion is should be prescribed only for conditions with significant potential for morbidity or mortality, that an Essential cannot be prevented or managed effectively by other means. Part of Modern Health Care WHO – Recommendations, 200 Types of Transfusion Reactions Non immune Immune reactions Immediate reactions During or within Days or weeks few hours of Delayed after the transfusio transfusion  transfusion reaction is defined as any transfusion-related adverse event that occurs during or after the transfusion of whole blood, blood components, or human-derived plasma products. Transfusion reactions are also classified according to the time interval between transfusion and the presentation of adverse effects. A transfusion reaction with signs or symptoms presenting during or within 24 hours of transfusion is defined as an acute transfusion reaction A transfusion reaction with signs or symptoms presenting after 24 hours of transfusion is defined as a delayed transfusion reaction. Transfusion reactions can further be classified as immune versus nonimmune,  Immune hemolysis occurs when previously formed IgM (ABO) or IgG (non-ABO) antibodies in the recipient recognize the corresponding donor RBC antigen and result in complement-mediated intravascular hemolysis. Evidence of immune hemolysis in the pos-treaction sample from the acute transfusion reaction evaluation or test will need to be followed with comparison to the pretransfusion testing results. If necessary, additional testing in duplicate (pre- and post-reaction samples) could include repeat basic immunohematology testing, eluate, and antigen typing to identify the cause of the immune hemolysis. Non-immune hemolysis occurs when the RBC suffers mechanical or chemical damage and is manifested as an asymptomatic hemoglobinuria Immune Transfusion Reactions Patient Abs against donor Ags or vice versa Red cells White cells Platelets Reaction to plasma proteins Acute Transfusion Reactions Acute transfusion reaction is defined as a reaction in which signs and symptoms present within 24 hours of a transfusion. Most of the acute reactions can be grouped according to the common etiology that gives similar presenting signs and symptoms, as illustrated  Increased destruction of donor red cells Acute - Intravascular haemolysis ABO incompatibility – due to activation of Complement cascade Haemolytic Transfusion Delayed Reactions - Extravascular haemolysis Rh / minor group incompatibility - IgG/C3d coated cells removed in RES  Acute hemolytic transfusion reaction (AHTR) consists of acute hemolysis with accompanying presenting symptoms within 24 hours of transfusion. Etiology may be of Acute immune or nonimmune origin. Hemolytic Transfusion In the immune mediated Acute transfusion Reaction reactions include acute hemolytic reactions, transfusion-associated sepsis, febrile nonhemolytic reactions, allergic reactions, TRALI, and TACO.  Red cell incompatibility – ABO incompatibility Accidental heating or freezing of RBC Causes for acute Red cells in contact with water or 5% Dextrose haemolysis Bacterial contamination Administering red cells through small gauge needle  Mainly due to misidentification of the patient : Most occur in emergencies, in ICU, Operation Theaters ABO incompatible In unconscious & anesthetized patients Transfusion Causes – Clerical errors – Reactions commonest cause Misidentification of pt / recipient Wrong samples / blood packs – Technical errors In Grouping of pt. / donor blood In crosmatching  Symptoms Signs Chills Fever Chest / back pain Rigors Clinical Headache Flushing Features Itching Restlessness Palpitation Hypotension Dyspnoea Tachycardia Nausea Urticaria Vomiting Haemoglobinurea  Stop transfusion Provide cardio Maintain an IV line immediately respiratory support Maintain BP, HR and Collect first urine Management of Ensure diuresis sample for airway haemoglobinurea AHTR Check the patient’s Supportive Therapy Treat DIC –Heparin identification and the –O2 , Elevate the foot Treat Renal Failure - blood pack end. Dopamine ,  Report the reaction Record Type of reaction immediately to BTS Length of time Volume, type & unit Send post transfusion sample of blood & remaining blood pack Management of number with filled reaction form to the Blood bank. AHTR… Monitor blood urea & Coagulation screen to creatinine level rule out DIC Transfusion-Associated Sepsis Transfusion-associated sepsis (TAS) is an acute nonimmune transfusion reaction presenting with body temperatures usually 2°C or more above normal and can be accompanied by hypotension. The symptoms usually present shortly after the transfusion begins. TAS occurs when a bacteria-contaminated blood component is transfused. Abruptness of presentation may be similar to AHTR; milder cases may mimic a febrile nonhemolytic transfusion reaction (FNHTR). Transfusion-associated sepsis occurs when bacteria are introduced to the patient via a contaminated blood product, manifested by an increase in body temperature or more than 2°C, rigors, and hypotension. When this condition is suspected, additional testing includes gram staining and cultures of the blood component and the patient. Isolation of the same organism is key for the diagnosis. Transfusion-Associated Sepsis Due to contamination of blood components especially platelets at collection processing Storage in blood bank or ward Bacteremia in donor Endotoxines  HIGH GRADE NAUSEA , VOMITING FEVER Clinical Features ABDOMINAL SHOCK DIC CRAMPS Management Examine blood Stop transfusion Haemolysis, Start intravenous pack for any immediately clots, discoloration line B visible change Blood cultures road-spectrum Dopamine from blood pack, antibiotics tubing, recipient Prevention Aseptic collection, processing Proper storage and transportation Start transfusion within half an hour after receiving. Complete Red cell transfusion within 4 hrs Avoid unnecessary blood warming Change transfusion set every 24 hrs  Febrile Nonhemolytic Transfusion Reaction Febrile nonhemolytic transfusion reaction (FNHTR) is an acute complication of transfusion presenting with at least a 1°C increase in body temperature that can be accompanied by chills, nausea or vomiting, tachycardia, increase in blood pressure, and Occasionally, shaking chills is the only initial presenting symptom followed by an increase in body temperature up to 30 minutes after discontinuing the transfusion. Febrile nonhemolytic reactions occur when the recipient is exposed to the donor cytokines present in the WBC or plasma and is manifested by an increase in body temperature of more than 1°C with or without chills. Workup must exclude hemolytic (transfusion reaction workup testing) and septic reactions (symptoms and patient evaluation). Febrile Nonhemolytic Transfusion Reaction Abs in recipient against Ags of o Granulocyte Due to o HLA Antigens donor platelets or specific Antigens WBC Presence of More common in o Platelet specific cytokines in blood multi-transfused Antigens components patients Clinical Features of FNHTR FEVER CHILLS RIGORS NAUSEA VOMITING HYPOTENSIO N SHOCK  – Slow down the If mild : Use Antipyretics infusion If severe : – Stop transfusion Antipyretics and Management of symptomatic treatment FNHTR Can be prevented by Usually reactions are self Leucoreduced / Antipyretic cover /warm limiting leucodepleted blood pt/ slow transfusion components Allergic transfusion reactions (ALTR) are acute, immune complications of transfusion presenting with a variety of symptoms that can vary according to the reaction’s degreeof severity. ALTR occurs as a response of recipient antibodies to an allergen present in the blood component. ALTR can range from minor urticarial effects to fulminant anaphylactic shock and death. milder reactions consist of weals, hives, erythema, or pruritus. Allergic Severe reactions(anaphylactoid or anaphylactic) are rare and can present with bronchoconstriction (wheezes), angioedema(periorbital edema, tongue swelling), (diarrhea), and cardiovascular instability Transfusion mainly caused by the release of histamine from the interaction between the allergen present in the donor plasma and recipient Reactions Performed IgE antibodies. A classic example of a severe allergic reaction is the one seen due to the presence of anti-IgA antibodies in a patient with absolute IgA deficiency Allergic / Anaphylactic Reactions Mainly due to plasma Severity is variable Mild – urticaria Severe – anaphylactoid proteins Occurs within minutes Common in patients with o Due to IgA deficiency of commencing repeated plasma transfusion component therapy Mild – urticaria Severe / Anaphylactoid Cough Clinical Respiratory distress Features Bronchospasm Nausea, vomiting, diarrhea Circulatory collapse Hypotension & shock Management – slow down rate & administer - Stop the Mild Severe of transfusion antihistamine transfusion Treat hypotension Prevention Adrenaline – 0.5ml Use Washed Antihistamine Steroids – Transfuse at slow IM (1 : 1000) blood Hydrocortisone rate Blood from IgA Autologous blood deficient donor transfusion (1in 600) Transfusion-Related Acute Lung Injury Transfusion-related acute lung injury (TRALI) consists of an acute transfusion reaction presenting with respiratory distress and severe hypoxemia during or within 6 hours of transfusion in the absence of other causes of acute lung injury (e.g., aspiration, pneumonia, toxic inhalation, lung contusion, near drowning, severe sepsis, shock, multiple trauma, burn injury, acute pancreatitis, cardiopulmonary bypass, drug overdose). It can be accompanied by fever or hypotension. This syndrome is now considered the leading cause of transfusion-associated fatalities, surpassing ABO incompatibility and bacterial contamination. Patients with specific clinical diagnoses (i.e., infection, surgery, trauma) have an increased risk of developing TRALI with a significant impact on morbidity and outcome TRALI occurs most frequently when donor leukocyte antibodies react with the WBCs in the recipient’s lung vasculature,.  Not rare but under diagnosed Transfusion Presents as pulmonary oedema Within 1-4 hrs of Related Acute starting transfusion Due to reaction between donor leucoagglutinin with recipient leukocytes Lung Injury - Aggregates of recipient leukocytes trapped in pulmonary circulation Vascular damage & change in TRALI vascular permeability causes oedema  Acute respiratory distress Fever with chills Non productive cough Clinical Chest pain Features Bilateral pulmonary oedema Chest X-ray – bilateral pulmonary infiltrates in hilar region Cyanosis Hypotension Management - TRALI No specific treatment Largely supportive Respiratory support with O2 Most cases require mechanical ventilation Steroids Clinical staff who administer transfusions must be aware to diagnose & manage promptly transfusion-Associated Circulatory Overload Transfusion-associated circulatory overload (TACO) is an acute, nonimmune complication of transfusion presenting with respiratory distress and hypoxemia TACO occurs when the patient’s cardiovascular that can be accompanied by cough, headache, chest system’s ability to handle additional workload is tightness, hypertension, jugular vein distention, exceeded, elevated central venous pressure, and elevated pulmonary wedge pressure during or after transfusion. manifesting as congestive heart failure. The chest TACO occurs when the patient’s cardiovascular radiography is characterized by the presence of system is unable to handle the transfused volume, pulmonary edema, cardiomegaly, and distended resulting in congestive heart failure pulmonary artery  Delayed transfusion reactions are defined as reactions in which signs and symptoms present after 24 hours of a transfusion and represent a Delayed diverse etiology Transfusion Reactions Delayed transfusion reactions include delayed serologic/hemolytic reactions, transfusion-associated graft-versus-host disease, post-transfusion purpura, and iron overload. Delayed Serologic/Hemolytic Transfusion Reaction The DSHTR may be discovered when a It usually occurs secondarily to an amnestic new sample is tested during a request for a Delayed serologic/hemolytic transfusion response but can also occur during a type and crossmatch and the hemoglobin reaction (DSHTR) is defined as the primary immune response and may levels are lower than expected for the detection of “new” red cell antibodies after (delayed hemolytic) or may not (delayed transfusion interval, or when a patient 24 hours of transfusion. serologic) be associated with shortened returns to see the physician and complains survival of the transfused cells. of flulike symptoms, with or without jaundice. be associated with clinical evidence of shortened red cell survival of the transfused Most often the only presenting sign is an additional testing will include DAT and, RBCs. Besides standard basic unexplained or unexpected drop in when indicated, an eluate and antigen immunohematology testing (ABO/Rh, hemoglobin or hematocrit. typing of the units recently transfused antibody screen and when indicated antibody identification) Delayed HTR Days or weeks after the blood transfusion Due to secondary immune response Rh or minor blood group antibodies Extra- vascular hemolysis  Gradual red cell destruction Occurs 5-10 days after transfusion Clinical Features of Jaundice appears 5-7 days after transfusion DHTR Fall in Hemoglobin level Prevention –screening for alloantibodies & selection of appropriate red cells.  Transfusion-associated graft-versus-host disease (TA-GVHD) is defined as a delayed immune transfusion reaction due to an immunologic attack by viable donor lymphocytes contained in the transfused blood component against the transfusion recipient. Transfusion-Ass The presenting reaction with a maculopapular rash, fever, watery diarrhea (accompanied by bloody stools and abdominal pain), ociated elevated liver function tests, and pancytopenia occurs between 3 and 30 days Graft-Versus-H Transfusion-associated graft-versus-host disease occurs when the transfusion-derived donor lymphocytes attack and destroy the recipient immune system, causing pancytopenia and death. ost Disease It is prevented by the gamma irradiation of blood components for transfusion to patient populations at risk  Rare & potentially fatal complication Transfusion -Mortality rate - > 90% Associtate In severely immunocompromised pts Pts with immature -Graft vs. immunological system (premature infants) Host Disease (TA-GVHD) Impaired immunological system (thymic alymphoplasia) In immunocompetent patients, when donor is homozygous for one of the patients’ HLA haplotypes ( certain communities/ blood relative (TA-GVHD) Due to successful engraftment of Donor lymphocytes Engrafted lymphocytes allogeneic T engrafted in recipient & react with host tissues lymphocytes & their multiply precursors Transfusion Associated Occurs 4-30 days after GVHD, has not been transfusion observed in patients with AIDS. Clinical feature Diffuse Maculopapular Fever skin rash erythematous eruption Formation of Watery / bloody Nausea Vomiting bullae diarrhoea Hepatitis Pancytopenia  Diagnosis detection of donor DNA by PCR (TA-GVHD) How to prevent ? Use irradiated blood/blood components ( leucodepletion does not prevent TA-GVHD) Post-Transfusion Purpura Post-transfusion purpura (PTP) is a delayed immune complication of transfusion that presents with profound thrombocytopenia, frequently accompanied by bleeding, 1 to 24 days after a blood transfusion. PTP occurs when a patient who is previously sensitized to human platelet antigens by pregnancy or transfusion is reexposed via a transfusion. This is characteristically a red blood cell or whole blood transfusion, expressing that human platelet antigen specificity and causing an anamnestic immune response, destroying not only transfused but also the autologous platelets PTP More common in multiparous Antibodies destroy transfused women Due to platelet Marked thrombocytopenia 5-10 days after transfusion. platelets as well as patient’s specific alloantibodies-HPA own platelets 1a,1b, 3a and 5b herapeutic Plasma Exchange Thrombocytopenia : severe Platelet transfusion : not or Intravenous but self-limiting effective T Immunoglobulins are helpful Iron Overload 1 2 3 4 5 Iron overload is a Each unit of red blood Chronic red cell Therefore, preventing the Iron overload occurs due delayed, nonimmune cells contains transfusion recipients accumulation of iron to long-term complication of approximately 250 mg of have the greatest risk for stores by chelation is accumulation of iron in transfusion, presenting iron. After 10 to 15 red developing iron overload, extremely important for the body tissues from with multiorgan (i.e., cell transfusions, excess with a cumulative 50 to this patient population multiple RBC liver, heart, endocrine iron is present in the liver, 100 red blood cell unit transfusions.This causes organs) damage heart, and endocrine transfusions causing organ damage. secondary to excessive organs. greater morbidity than the iron accumulation. underlying anemia. Precautions to Avoid Transfusion Reactions Avoidance of Proper identification Correctly labeled clerical errors of patient. samples Careful & close Proper identification observation of the Avoid unnecessary of the recipient and patient while blood transfusion the blood pack transfusion Discussion -WORKSHEE –CASE T STUDY