OOD PRODUCT TRANSFUSIONS

by Nick Mark MD ONE

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DEFINITIONS: Whole blood version →
TRANSFUSION REACTIONS:
The goal of transfusion is to provide minimum O2 carrying AB+ (stored at 4°C up to 35 days) @nickmmark
Rh positive
REACTION EXPLANATION MANAGEMENT
capacity (RBCs) & sufficient platelets and clotting factors to EXP 2021-01-01 23:30 ~450 ml + 60 ml citrate
permit hemostasis. The goal is not correcting to “normal.”
A9999 20 123456 K
Good at achieving hemostasis

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Most common immune reaction to transfusion. Prevention: APAP + H2 blockers,
Although RBC transfusions increase CaO2 they might not (contains all factors) but limited Febrile Non- Occurs within 4 hours of transfusion due to accumulated consider leukoreduced units
availability (autologous, military) Hemolytic inflammatory cytokines in the banked donor blood. May recur; Treatment: stop infusion, APAP,
normalize DO2 due to less efficient unloading of O2 in Transfusion 25% of patients who had FNHTR once had another reaction meperidine. R/o other causes.
transfused blood (2,3-BPG is degraded in storage). Reaction (FNHTR) subsequently. Notify blood bank.

Type and screen – determines blood type and detects

Occurs during or shortly after transfusion. A true emergency
antibodies in recipient (e.g., indirect Coombs test) AB+
Rh positive
AB+
Rh positive
AB+
Rh positive Occurs due to mismatch of donor antigens (often ABO/Rh) & Prevention: carefully check units
Treatment with anti-CD38 antibodies (daratumumab, EXP 2021-01-01 23:30 EXP 2021-01-01 23:30 EXP 2021-01-01 23:30 Acute Hemolytic recipient antibodies leading to hemolysis & agglutination. Treatment: Stop transfusion,
isatuximab) can cause a false positive on screen for minor A9999 20 123456 K
Transfusion S/sx: Fever, flank pain, dark urine, DIC, hypoTN, renal failure. notify blood bank, test for

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Reaction (AHTR) Hemolysis on labs (↓haptoglobin, ↑LDH, etc) hemolysis & DIC, aggressive IV
antigens for up to six months (notify blood bank). hydration (goal UOP > 100/hr).
Crossmatch – involves testing patient blood and specific
donor units for compatibility. Crossmatch takes ~45 min. RBCs Pooled Platelet FFP Occurs 24 hours to 30 days after transfusion due to mismatch Treatment: Notify blood bank,
(stored at 4°C up (stored at RT up (frozen -25 °C Delayed Hemolytic of minor antigens (often false negative crossmatch). 2nd repeat testing (DAT, type & screen,
In emergencies crossmatch can be skipped. Transfusion
to 42 days) to 5 days) up to 3 yrs) exposure can be faster, more severe. May have drop in Hct, etc)
In extreme emergencies non-type specific blood can be

IMMUNE MEDIATED
Reaction (DHTR) fever, minor hemolysis.
used (e.g., O- RBCs in women, O- or O+ RBCs in men). ~350 ml ~300 ml ~225 ml
↑ Hb ~1 gm/dl* ↑ Plt by ~5-7k* (*in 70 kg pt)
Usually anaphylactoid (not IgE mediated). Prevention: washed (or IgA
v1.0 (2021-07-10) CC BY-SA 3.0

EVIDENCE BASED TRANSFUSION THRESHOLDS: S/sx urticaria, maculopapular rash, pruritis, fv & hypoTN deficient) RBCs.Check for IgA
•Restrictive transfusion strategies (Hb > 7) are comparable/superior to Allergic reaction Occurs minutes to hours after transfusion, due to antibodies deficiency if recurrent anaphylaxis
against proteins on plts, leukocytes, or in plasma, including IgA Tx: epi, H2 blockers, steroids
liberal strategies in most settings including GI bleed, septic shock, (in recipients w/ IgA deficiency)
AB+
Rh positive
0.9% Sodium
cardiac surgery, TBI, and in most ICU patients.
EXP 2021-01-01 23:30
Chloride • Massive transfusion protocols (MTP) (e.g., trauma pts or massive GI Occurs 7-10 days after transfusion, due to anti-platelet Treatment: IVIG, plasmapheresis
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Injection USP
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1000mL
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bleed) target hemodynamic stability not a specific Hb. Among patients Post Transfusion antibodies in donor blood. Causes purpura & severe
thrombocytopenia, may be life-threatening.
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receiving MTP, balanced ratio (e.g., 1 RBC : 1 FFP : 1 Plt unit) is superior
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Purpura (PTP)
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More common in women (85%) & Caucasians.

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• Platelet transfusion thresholds are disease dependent: For most

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diseases 10k is adequate, if bleeding or needing surgery 50k may be

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Leading cause of transfusion related death (15% mortality). Treatment: ventilatory support
required. Limited evidence for higher targets (e.g., 100k for CNS bleed) Transfusion Related TRALI resembles ARDS, onset is 4-6 hours after transfusion. may be required (use LPV), use
SPECIAL BLOOD PRODUCT TYPES: Acute Lung Injury Most common following platelet transfusion from multi- platelets from male donors for
(TRALI) parous female donors (due to anti-HLA or anti-HNA Ab) future transfusions.
•Leukocyte reduced RBC: decreases incidence of febrile rxns &
Each unit prevents allo-immunization. Also makes blood CMV-safe
Y-tubing Occurs 8-10 days post transfusion, donor leukocytes attack Prevention: use irradiated and
contains: •Gamma-irradiated RBC: reduces incidence of GVHD during
combines Transfusion immunosuppressed recipient. leukocyte reduced blood in
·Blood type transfusions; important in very immunosuppressed patients Associated Graft Sx include: fever, cutaneous eruptions, diarrhea, liver immunosuppressed recipients
blood &
·Expiration •Volume Reduced RBC: each unit comes in ~100 ml (instead of ~350 Versus Host Disease abnormalities. May progresses to pancytopenia due to Treatment: no effective treatment
crystalloid (TA-GVHD) marrow aplasia. High mortality.
·Product # ml), can reduce the incidence of febrile rxns because there are fewer
·Barcodes Filter & drip plasma proteins; can also be used in volume overloaded patients
All must be chamber (though giving diuretic is probably better) Transfusion Occurs between 0-6 hrs after transfusion. Volume overload Prevention: minimum # of units,
verified! Associated Cardiac from transfusions, particularly in patients with CHF. Presents volume reduced units, diuresis
removes •Washed RBC: plasma is replaced with crystalloid; this should be done Overload (TACO) as dyspnea potentially progressing to severe hypoxemia. Treatment: diuresis
blood clots only if there was a previous allergic reaction or in IgA deficient patients
NON-IMMUNE

(if no IgA deficient donors)

MEDIATED

Hypocalcemia Citrate in RBCs binds to serum calcium. Blood products contain Treatment: Replete calcium and
Rate of transfusion depends potassium from lysed cells. monitor for hyperkalemia.
•Single donor (apheresis) platelets: a full unit of platelets obtained Hyperkalemia
on severity of illness. In stable
patients, slower infusions (e.g. from a single donor via apheresis (in contrast to pooled platelets
typically combining 5 donors). Single donor limits antigen exposure Due to low temp of transfused products. iatrogenic Prevention/Tx: Use a blood
over 2 hrs) permits earlier Hypothermia hypothermia exacerbates coagulopathy & ↑bleeding warmer for massive transfusions
stopping. In unstable patients
consider using a rapid infuser. STRATEGIES IN PEOPLE WHO DECLINE TRANSFUSION People taking ACEi may develop hypotension due to inability Does not require intervention.
• Discuss specific reasons/concerns, understand what tx is acceptable Hypotension to break down bradykinin in transfused blood Rule out infection/hemolysis
• Correct coagulopathy (consider amicar, TXA, other products)
150 • Stop and minimize blood loss: hormonally suppress menstruation, Infection occurs due to untested organisms (rare), false negatives on testing (very rare), or bacterial contamination.
autotransfuse with cell-saver (OR) or hemothorax/chest tube (ICU) Platelets (stored at RT) are more likely to cause infections with skin flora (GPCs). RBCs (stored at 4C),
Bacterial
IINFECTION

• Minimize iatrogenic blood loss (fewer labs, less frequently, drawn in contamination are more likely to be contaminated with GNRs. Can lead to sepsis.
pediatric tubes); no "routine" labs; every test should be thoughtful
and drawn in pediatric tubes to minimize volume lost Organisms NOT tested include: Malaria, Borrellia (Lyme disease), Trypanosoma (Chagas disease),
Untested organisms Babesiosis, & vCJD (varies by country)
• Optimize hematopoesis (IV iron infusion, folate supplementation,
EPO administration)
False negative Extremely rare: HIV 1 in 2,000,000,000, HBV 1 in 100,000,000, HCV 1 in 2,000,000, HTLV 1 in 650,000
• Consider blood substitute (poly-heme)