Serious hazards of transfusion

Dr Kenneth S Charles
MB.BS (UWI), FRCP (UK), FRCPath(UK)
Senior Lecturer in Haematology
 Introduction
• Case study
• Definition of adverse effect
• Classification
• Pathophysiology
• Management
• Prevention
 Platelet concentrate
Red cell concentrate

Cryoprecipitate Fresh frozen

plasma
Units at 4 degrees C
 Platelet concentrate
• 55 x 109 platelets in 50-70 mls plasma
• Shelf life 5 days
• 22 degrees
• Agitation
• pH > 6.2
• I unit per 10 kg, 10 per unit
• Transfuse ASAP
 Platelet concentrate
• Normal 150-400 x 109/l
• Prophylactic 10, Therapeutic 50 and
bleeding
• Rapid infusion
Fresh frozen plasma
 FFP
• All coagulation factors
• - 30 degrees C soon after collection
• Shelf-life 1 year
• Use within 24 hours of thawing
• Cannot be refrozen
Cryoprecipitate
 Cryoprecipitate
• Separated by controlled thawing of FFP
• VIII, VWF, fibrinogen
• 20 mls per pack
• - 30 degrees C
• Shelf-life 1 year
• Refreeze forbidden
 When do patients require
transfusion?
• Red cells – Hb < 7.0 or acute blood loss
- Hb < 9.0 pre-op
• Platelets - Active bleeding + platelets < 50
- Prophylactic/ platelets < 10
• Fresh frozen plasma – prolonged PT and/or
APTT + active
bleeding
or planned procedure
• Cryoprecipitate – no response to FFP or
fibrinogen < 1 g/l
 Case study
• 26 year old man
• Relapsed Hodgkin’s Lymphoma
• Chemotherapy
• Sepsis
• Prolonged PT/APTT, bleeding
• Replacement therapy
• Respiratory failure
 Adverse reaction
• Any untoward event occurring within a few
hours, weeks or months of and as a direct
result of administration of a blood
component
 Classification
• Immediate/Delayed
• Infectious/Non-infectious
• Immune/Non-immune
• Clinical presentation
 Adverse reactions classified by
clinical presentation
• Febrile
Haemolysis
Acute haemolytic transfusion reaction
Delayed haemolytic transfusion reaction
Sepsis
Bacterial contamination of component
Acute febrile non-haemolytic transfusion
reaction
 Adverse reactions classified by
clinical presentation
Dyspnoeic
Transfusion related acute lung injury
(TRALI)
Congestive cardiac failure
 Adverse reactions classified by
clinical presentation
Urticarial
Allergy to plasma proteins
 Adverse reactions classified by
clinical presentation
• Other
Iron overload
Transfusion Transmissible infections
HIV
HBV
HCV
Syphilis
HTLV1
FEBRILE
Acute Haemolytic Febrile Transfusion
Reaction (AHFTR)
• Mortality 10%
• IgM naturally occurring antibodies activate
complement
• Intravascular haemolysis
• Anti-A, anti-B
 AHFTR cont’d
• Abs in recipient’s serum activate
complement to initiate intravascular lysis
• Catecholamines and kinins released
• DIC in 30-50%
• Fever, chills, nausea, pain at IV site,
chest and back pains (intravascular
occlusion by agglutinated red
cells),hypotension, dark urine
• Nephrotoxic effects of anti-red cell stroma
Conditions mimicking AFHTR
• Improperly ‘warmed’ blood
• Blood ‘piggy-backed’
 Delayed Haemolytic Transfusion
Reaction (DHTR)
• Clinically occult
• Occur 2-21 days after transfusion
• 1 in 500 transfusions
• Death rare
• IgG immune antibodies
• Anti- Kell, Duffy, Kidd, Rhesus in patients
sensitized by transfusion, pregnancy
• Low grade fever, jaundice, no rise in Hb, positive
DCT, spherocytes
• Acute Renal Failure rare. Most self-limiting
Direct Coombs’ Test
 Bacterial contamination
• Especially platelet concentrate
• Sources – donor bacteraemia, donor arm,
contamination during processing
• Fever, chills, shock, ARF, DIC
• G- and G+ bacteria
• Mortality 26%
Fate of unused red cells

Domestic refrigerator

Returned to Blood
Bench

25
 (B) Collection of blood or blood components from
the hospital blood bank or blood transfusion issue
refrigerator and its delivery to the ward or operating
theatre

• The transfusion of blood and blood components should

begin as soon as possible after delivery to the ward or
operating theatre. If not possible, return to blood
transfusion refrigerator. If > 30 mins return to hospital
blood bank for disposal (risk of bacterial infection)
• If the ward or operating room does not have a
refrigerator that is approved for storing blood, the
blood should not be released from the blood bank
until immediately before transfusion

BCSH, 1999
Wastage: Blood returned from
wards
DYSPNOEIC
 Non-haemolytic febrile
transfusion reactions (NHFTR)
• Most common type of transfusion reaction
• Granulocyte and HLA-specific
antileucocyte Abs develop in recipient by
pregnancy, previous transfusion
• Lysis of donor WBCs and release of
cytokines
• 1 in 200-500 transfusions
 Leucocyte antigens

• HLA Class I and II

• Neutrophil specific antigens – NA-1, NA-2,
NB
Febrile Non-haemolytic Transfusion
Reaction (FNHTR)
• Fever, otherwise well
• Stop transfusion
• Exclude haemolysis, bacterial
contamination
• Acetominophen 650 mg
• Resume transfusion
• If recurs, leucocyte filter
 Non-cardiogenic pulmonary oedema
(TRALI)
• 1 in 5 000 transfusions
• Donor antileucocyte Abs (previous
transfusions, pregnancy) passively
transfused to recipient
• Any blood component
• Ag/Ab complexes trapped in pulmonary
vasculature
• Dyspnoea, hypoxia, chills, fever
TRALI
 Congestive Cardiac Failure
(CCF)
• Safe rate for 1U RBCs 2-3 hrs
URTICARIAL
 Urticaria
• Allergic reaction to plasma proteins
• Usually FFP but any component
• Skin rash, pruritis
• Antihistamine and continue transfusion
OTHER
 Risk of HIV seropositivity per 100,000 donors

350

300

250

200

150

100

50

0
Voluntary Replacement Paid

WHO,2002
 Voluntary donor % 1.2 HIV in donors
%
1
0.8
JAM
0.6
TRT
0.4 CUR
0.2
0
2005 2006 2007 2008 2009

HBsAg in donors %
HCV in donors
1
%
0.9
0.8
0.7
BAR
0.6
0.5 JAM
0.4 TRT
0.3 CUR
0.2
0.1
0
2005 2006 2007 2008 2009
 Window period/days
Virus ELISA NAT (PCR)

HCV 88 23

HBV 56 31

HIV 22 12

VIP Blood Screening LATAM meeting, Pleasanton, CA, Oct 2007

Blood donation rate per 10,000 inhabitants and
proportion of units reactive/positive for
infectious markers in 2005

Country Donation rate % TTI markers

Jamaica 83.6 5.0

Trinidad and Tobago 104.4 4.69

Curacao 368.6 0.03

From : PAHO, CD 48/11 Annex

A
Wastage: Seropositive units for
discard
 Iron overload
• IU red cells contains 250 mg iron
• No iron excretion mechanism
• Skin, joints, liver, heart, endocrine glands
• Iron chelation – intravenous, s/c
- oral
• Β thalassaemia major patients
 Case study
• 26 year old man
• Relapsed Hodgkin’s Lymphoma
• Sepsis
• Bleeding from all sites
• Prolonged PT and APTT, reduced
fibrinogen, thrombocytopenia
 Case study
• Disseminated Intravascular Coagulation
• 2 U RBC, 6 U platelets, 6 U FFP
• TRALI
 Processes in DIC

Underlying disorder associated with DIC

Systemic activation of anticoagulation

Widespread fibrin deposition Consumption of platelets and

clotting factors

Microvascular Thrombocytopenia and coagulation

thrombosis deficiency

BLEEDING
ORGAN FAILURE
BJH, 145, 24-33
 Conditions associated with DIC
• Sepsis and severe infection • Vascular abnormalities
• Trauma Large haemangiomata
• Organ destruction e.g Vascular aneurysm
pancreatitis • Toxic and immunological
• Malignancy insults
Solid Tumours • Severe liver failure
Leukaemia Snake bites
• Obstetric Recreational drugs
Amniotic fluid embolism ABO Transfusion
Placental abruption incompatibility
Pre ecclampsia Transplant rejection

BJH, 145, 24-33

 Laboratory abnormalities in DIC
5 reports, 900 patients (Al-Mondhury,1975; Siegal et al, 1978; Mant &
King, 1979; Spero et al, 1980; Wilde et al,1989)

• Thrombocytopenia
• Elevated fibrin degradation products
• Prolonged PT
• Prolonged APTT
• Low fibrinogen
• Microangiopathic haemolytic anaemia

BJH, 145, 24-33

 Summary
• Blood components
• Case presentation
• Acute DIC
• TRALI
Thank you