ACUTE REACTION OF TRANSFUSION

WIDNYANA
HEMATOLOGY –ONCOLOGY WORKING GROUP
INDONESIA PEDIATRIC SOCIETY
 Curriculum Vitae
Name : dr. A. A N.K P Widnyana Sp.A(K)
Birth : 12 July 1964

Education :
s1 Fk UNUD 1994
Spesialis IKA FK UNUD 2005
Sp2 Fk UI 2016

Training :
Staff IKA Fk UNUD 2007 - Now
Objective

Have the knowledge and ability to

 recognize clinical manifestation of ATR
 identify different types of ATR
 treat and manage different types of ATR
 Blood transfusion
IS THE FIRST AND EARLIEST MODEL OF TRANSPLANTATION,

THEREFORE

HAS THE RISK OF BEING REJECTED WHICH IS USUALLY CALLED

TRANSFUSION REACTION
 Clinical blood transfusion

AIM
Life saving (severe bleeding, acute hemolysis)
Life support (thalassemia, aplastic anemia)
Transfusion reaction

 Not always can be prevented

 Several types of transfusion reaction
 Symptoms not rarely overlapped
Acute Transfusion Reactions (ATRs)
Definition : Acute transfusion reaction can occur at any time up to 24 hours
following a transfusion of blood

1. Febrile non-haemolytic transfusion reactions (FNHTR)

Frequency : 1-3 : 100 (higher in multi transfused recipients
Common
Onset during or within 4 hours following transfusion
 Reaction induced by cytokines
 Other causes may contribute
o Mild : unexplained fever ≥ 38oC and a temperature rise of at
least 1oC but <1.5oC from pre-transfusion baseline, occurring
in the absence of chills, rigors, respiratory distress and
haemodynamic instability

o Moderate : unexplained fever ≥ 38oC and a temperature rise

of at least 1oC but not meeting criteria for either mild or
severe FNHTR
o Severe : unexplained fever>39oC and a temperature rise ≥2oC
from pre-transfusion baseline and chills/rigors

o Secondary symptoms may be present: tachycardia, headache,

nausea, flushing, anxiety, hypertension or occasionally
hypotension

o In severe cases: marked apprehension, loin pain, and/or

angina
Prevention
Check for history of previous transfusion reactions.
Consider pre-transfusion antipyretic paracetamol 10 mg/kg/dose orally
where minor reactions occur and further transfusion are required

Therapy
- Check label and recipient identity
- Slow the transfusion if reaction is mild and MO elects to continue
transfusion
- Antipyretic paracetamol 10 mg/kg/dose orally and monitor closely
- Steroids are not appropriate treatment for minor reactions
2. Allergic Transfusion Reaction
Minor
Incidence: 1 : 100 – 1 : 500
 Most common in patients receiving plasma rich components
such FFP or platelet
 Onset: from commencement to 4 hours after transfusion
 Recipient may have an antibody reacting with antigen in the
transfused product
Sign and Symptom
 Flushed skin; morbilliform rash with itching; urticaria
(hives), angioedema; periorbital itch, erythema and oedema;
conjunctival oedema; minor oedema of lips, tongue and uvula

Prevention
 For recurrent mild reactions prophylaxis with antihistamine
to alleviate symptoms (loratadine or cetirizine orally)
 Routineprophylaxis for all recipients before transfusion is not
indicated
Management
 Slow transfusion
 Check label and recipient identity
 Antihistamine (loratadine or cetirizine) if symptoms are
troublesome
 If symptoms mild and transient, transfusion may resume
 Continuetransfusion at slower rate with increased monitoring
(BP/TPR 15-30min)
 If symptoms increase treat as a moderate or severe reaction
Moderate
 Incidence: 1:500 – 1:5000
 Onset: usually within first 50-100 ml infused and within 4 hours of
transfusion
 Recipient may have an antibody reacting with plasma protein or
leucocyte antigen (HLA or other) in the transfused product
 Sign and Symptom:
 Symptoms as for minor reactions, and cough; hypotension and
tachycardia; dyspnea and oxygen desaturation are common;
chills and rigors; loin pain and angina; severe anxiety
Prevention
 Prophylaxis treatment with an antihistamine or
hydrocortisone will not reliably prevent moderate and
severe allergic reactions but may alleviate symptoms
when present
Management
 Stop transfusion
 Check label and recipient identity
 Replace iv set and give saline to keep vein open and/or maintain BP
 Monitor closely and treat symptomatically as required with iv fluids,
oxygen and antihistamine (Promethazine or loratadine or cetirizine).
Hydrocortisone may be considered
3. Acute Hemolytic Reactions
 Incidence: 1:12,000 - 1:100,000
 Onset within 24 hours, usually immediate
 ABO or other incompatible red cell transfusion reaction caused
by complement-fixing antibodies
 Rarely ABO antibodies in a platelet or plasma component
 Improper handling and storage of blood
Symptoms:
 unexplained fever >1oC; chills, rigors; pain up arm; chest,
abdominal or low back pain; dyspnea; nausea, vomiting;
diarrhea; tachycardia; hypotension, shock;
 pallor, jaundice; bleeding due to DIC
 haemoglobinaemia and haemoglobinuria; oliguria with dark
urine or anuria;
Prevention
 Meticulous checking of
recipient’s ID and labeling of pre-
transfusion blood sample at recipient’s side
 Meticulous
2 person checking of ID of intended recipient of
blood component and component label
 Carefulmonitoring of recipient for first 15 min of each unit
transfused
 Store and handle blood components within specifications
Management
 Stop transfusion
 Check label and recipient identity
 Replace iv set and start normal saline
 Treat shock and maintain blood pressure with iv saline infusion
 Investigate possible DIC and treat if clinically significant bleeding
 Diuretic (furosemide 1-2mg/kg iv and/or mannitol) to help maintain urine flow
 Hydrocortisone

 Samplesto assess renal and liver function, DIC and haemolysis (full blood count,
unconjugated bilirubin, LDH and haptoglobin)
Prevention
 Collect, store and handle blood components within specifications
 Inspect product for any visual abnormality or defect in unit
container before transfusing
 A visibly clumped platelet component
 An unusually dark red cell component
 Punctured or leaking bag
4. Bacterial sepsis
 Blood component contains bacteria that have grown to a high
concentration
 Rare occurrence, more often seen with platelet components (which
are stored at 22-240 C) than with red cells refrigerated at 2-60C and
can rapidly be fatal
 If gram negative bacteria are present, endotoxin levels may be very
high
 Often result in an acute severe reaction soon after the transfusion
is started
 Symptoms and signs : rigors, fever (usually >2oC
above baseline), hypotension, and rapidly developing
shock and impaired consciousness

 Initially this may be indistinguishable from an acute

hemolytic reaction or severe allergic reaction

 Urgent supportive care and high dose intravenous

antibiotic are required
Symptoms and Signs
 Rigor, chills, fever
 Shock, usually within minutes of starting transfusion
 Respiratory distress, wheezing and oxygen desaturation
 Pain up arm
 Chest and back/loin pain
 Nausea, vomiting
 Explosive diarrhea may occur with Yersinia enterocolitica sepsis
 Most common infecting agents: staphylococcal species (platelet components),
gram negative species (red cell components)
Management
 Stop transfusion
 Replace iv set; give saline to maintain BP and/or keep vein open
 Obtain blood cultures from recipient if sepsis suspected
 Give antibiotics (a broad spectrum penicillin or cephalosporin
and gentamicin 5mg/kg)
5. Anaphylactic/Anaphylactoid Allergic Reaction (Severe)
Incidence: 1:20,000 – 1:50,000
 Onset: rapid
 May be due to an antibody in the recipient reacting with a plasma
protein in a blood component (IgA, Haptoglobin, other plasma protein)
Sign and Symptom:
 Symptoms as for moderate reactions, and; severe hypotension, shock
and tachycardia; widespread urticaria with skin flushing and itching;
wheezing, stridor, change in voice; severe anxiety
 Respiratory symptoms may dominate in anaesthetized recipients
Management
 CPAP ventilation, chest X-ray
 ICU liaison
 Collectserum tryptase sample within 1-2 h if anaphylaxis
may be present (returns to normal within 6-8h)
Prevention
 IgA deficient blood/bloodproducts may be appropriate if
recipient is known to have absolute IgA deficiency or to
have anti-IgA
 Washed cellular components may be indicated where the
cause of the reaction is not identified
Management
 Stop transfusion
 Check label and recipient identity
 Follow anaphylaxis guidelines:
 Adrenalin 1:1000 IM and repeat at 5-10min intervals if
required (adult 0.5mg/0.5ml; children 0.01mg/kg IM min dose
0.1ml, max dose 0.5ml)
 Replaceiv set and give rapid iv colloid or saline (adult 2 L,
children 20ml/kg) until SBP>90mmHg, then titrate
 Consider hydrocortisone 4mg/kg (200-400mg IV)
 Consider H1-antihistamine (loratadine or cetirizine 10mg po) for
itch or angioedema
 H2-antihistamine (ranitidine) may be added for severe reactions
 DO NOT give the patient sedating antihistamines (promethazine)
6. Transfusion-Related Acute Lung Injury (TRALI)
 Caused by antibodies in the donor blood reacting with the patients
neutrophil, or HLA antigens causing cell activation that results in
acute severe microvascular lung injury
 Present within 2 hours of transfusion (max 6 hours)
 Symptom: severe dyspnea and cyanosis proceeding to respiratory
failure with bilateral infiltrates on CXR within 6 hours of
transfusion, if during anaesthesia the lungs become very stiff from
rapidly developing pulmonary exudate
 May be difficult to differentiate from acute heart failure due
to circulatory overload and treatment with powerful diuretics
may increase mortality
 Treatment: supportive with high concentration oxygen
therapy and ventilatory support if required
 Majority of patient recover within 1 to 3 days without long
term problems
7. Transfusion Associated Circulatory Overload (TACO)
 Acute or worsen pulmonary oedema within 6 hours of transfusion
 Patients present with acute respiratory distress with cough productive
of frothy pink sputum, tachycardia, raised blood pressure, raised JVP
and CVP, restlessness and anxiety.
 Most reported cases : red cell transfusion but high-volume FFP
transfusion
 Treatment: stopping the transfusion, sit recipient upright with legs
over side of bed, administering oxygen and diuretic therapy with
careful monitoring and critical care support if required
TERIMA KASIH
Thank You