Recognition and management of acute transfusion reactions

Figure 10 - Acute transfusion reactions

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Acute haemolytic reaction

Incompatible transfused red cells react with the patient’s own anti A or anti B antibodies and cause an acute severe clinical reaction (see ABO blood groups). Infusion of ABO-incompatible blood is most commonly due to errors in taking or labelling the sample, collecting the wrong blood from the fridge, or failure to carry out the required checks immediately before transfusion of the pack is started.

If red cells are mistakenly administered to the ‘wrong’ patient, the chance of ABO incompatibility is about one in three. The reaction is usually most severe if group A red cells are infused to a group O patient. Even a few millilitres of ABO incompatible blood may cause symptoms within a few minutes that will be noticed by a conscious patient (see Figure 10). However, if the patient is unconscious or cannot communicate, the first signs of the reaction may be bleeding, tachycardia, hypotension or hypertension. Acute haemolysis may also occur following infusion of plasma-rich components, usually platelets or FFP, containing high-titre anti-red-cell antibodies, usually anti A or B.

Management: Stop the transfusion. Maintain venous access. Resuscitate with crystalloid fluid. Consider inotrope support if hypotension is prolonged. Take blood cultures and samples for culture from component pack. Inform the blood bank. Seek urgent critical care and haematology advice. Admit to ICU if possible.

Infusion of a blood pack contaminated by bacteria

Likely to cause a very severe acute reaction with rapid onset of hyper- or hypotension, rigors and collapse. The signs and symptoms may be similar to acute haemolytic transfusion reactions or severe acute allergic reactions. Bacterial contamination of blood components is rare but is more often reported with platelet concentrates (stored at 22°C) than with red cells (stored at 4−6°C).(PMID16214015)

Examination of the pack (discolouration, smell and gram stain) may rapidly confirm the diagnosis. Organisms associated with contamination include Staphylococcus epidermidis, Staphylococcus aureus, Bacillus cereus, Group B streptococci, E. coli, Pseudomonas species and other gram-negative organisms.

Management: As for acute haemolytic reaction, and administer a combination of antibiotics that will be active against the range of bacteria that may be involved. In the absence of expert microbiology advice it would generally be appropriate to follow the local protocol for antibiotic management of sepsis in neutropenic patients. If this is not available, a combination of the following antibiotics may be considered to provide activity against gram-positive and gram-negative bacteria:

Gram-negative bacteria

Piperacillin/tazobactam (Tazocin) 4.5 g tds iv or

Ceftriaxone 1 g once daily iv (2 g if 'severe' infection) or

Meropenem 1 g tds iv

Gram-positive bacteria including most MRSA

Teicoplanin 400 mg bd iv x 2 doses then once daily (non-nephrotoxic)

Vancomycin − 1 g bd iv then adjusted according to levels − equally effective but potentially adds to any renal impairment

Ceftriaxone/teicoplanin has the advantages of once daily dosing, low renal toxicity

Transfusion-related acute-lung injury (TRALI)

Typically within six hours of a transfusion, the patient develops breathlessness and non-productive cough. The chest X-ray characteristically shows bilateral nodular infiltrates in a batwing pattern, typical of acute respiratory distress syndrome. Loss of circulating volume and hypotension are common. The patient may or may not have fever or chills. Monocytopenia or neutropenia may be seen.(PMID15248168)(PMID15830325)

Differential diagnosis: It may be very difficult to distinguish TRALI from other non-cardiogenic pulmonary oedema or cardiac failure.

Management: Seek urgent critical care and haematology advice. Admit to ICU if possible. Treatment is that of adult respiratory distress syndrome from any cause. Diuretics should be avoided. Steroids are of uncertain benefit.

It is often found that plasma of one of the donors contains antibodies that react strongly with the patient’s leucocytes. The implicated donors are almost always parous women. It is important to report any case of TRALI to the blood service so that an implicated donor can be contacted and, if appropriate, taken off the donor panel.

Fluid overload (transfusion-associated circulatory overload, TACO)

When too much fluid is transfused or the transfusion is too rapid, acute left ventricular failure (LVF) may occur with dyspnoea, tachypnoea, non-productive cough, raised JVP, basal lung crackles, frothy pink sputum, hypertension and tachycardia.

Management: The transfusion should be stopped and standard medical treatment, including diuretic and oxygen, given.

Note: Patients with chronic anaemia are usually normovolaemic or hypervolaemic, and may have signs of cardiac failure before any fluid is infused. If such a patient must be transfused, each unit should be given slowly with diuretic (e.g. frusemide 20−40 mg), and the patient closely observed. Restricting transfusion to one unit of RCC in each 12-hour period should reduce the risk of LVF. Volume overload is a special risk with 20% albumin solutions.

Allergic reactions

Anaphylaxis

A rare but life-threatening complication usually occurring in the early part of a transfusion. Rapid infusion of plasma is one cause. Signs consist of hypotension, bronchospasm, periorbital and laryngeal oedema, vomiting, erythema, urticaria and conjunctivitis. Symptoms include dyspnoea, chest pain, abdominal pain and nausea.

Anaphylaxis occurs when a patient who is pre-sensitised to an allergen producing IgE antibodies is re-exposed to the particular antigen.

IgG antibodies to infused allergens can also cause severe reactions.

A few patients with severe IgA deficiency develop antibodies to IgA and may have severe anaphylaxis if exposed to IgA by transfusion. If the patient who has had a reaction has to have further transfusion, it is essential to seek advice from the blood bank as there is a real risk of a repeat reaction unless blood components are specially selected.(PMID16398725)

Less severe allergic reactions

Urticaria and/or itching within minutes of starting a transfusion are quite common, particularly with components including large volumes of plasma, e.g. platelet concentrates and FFP. Symptoms usually subside if the transfusion is slowed and antihistamine is given (e.g. chlorpheniramine 10 mg, by slow intravenous injection or intramuscular injection in patients who are not thrombocytopenic).

Management: The transfusion may be continued if there is no progression of symptoms after 30 minutes. Chlorpheniramine should be given before transfusion if the patient has previously experienced repeated allergic reactions. If signs and symptoms fail to respond to this, seek advice from haematologist. Saline-washed blood components should be considered.

Febrile non-haemolytic transfusion reactions (FNHTR)

Fever or rigors during red cell or platelet transfusion affect 1−2% of recipients, mainly multi-transfused or previously pregnant patients. These reactions are probably less frequent with leucodepleted components. Features are fever (> 1.5°C above baseline), usually with shivering and general discomfort occurring towards the end of the transfusion or up to two hours after it has been completed.

Management: Most febrile reactions can be managed by slowing or stopping the transfusion and giving an antipyretic, e.g. paracetamol (not aspirin). These reactions are unpleasant but not life-threatening, but it is important to remember that the fever or rigors could be the first warning of a severe acute reaction.