POTD: Complications of Blood Transfusion

>> Hemolytic:

  • Acute Intravascular Hemolytic Reaction

    • Overview:

      • Occurs when recipient's antibodies recognize and induce hemolysis of donor's RBCs

        • Most of the transfused cells are destroyed, which may result in activation of the coagulation system, DIC, and release of anaphylatoxins and other vasoactive amines

      • Caused by ABO incompatibility; usually the result of technical errors

      • Risk is 1 to 4 per million units transfused

      • Serum haptoglobin will be decreased, serum lactate dehydrogenase will be elevated, and direct antigen (Coombs) test usually will be positive

    • Signs/Symptoms: Fever, chills, low back pain, flushing, dyspnea, tachycardia, shock, hemoglobinuria

    • Management:

      • Immediately stop transfusion

      • IV hydration to maintain diuresis; diuretics may be necessary

      • Cardiorespiratory support as indicated

    • Evaluation:

      • Retype and repeat cross-match

      • Direct and indirect Coombs test

      • CBC, creatinine, prothrombin time, activated partial thromboplastin time

      • Haptoglobin, indirect bilirubin, lactate dehydrogenase, plasma free hemoglobin

      • Urine for hemoglobin

  • Delayed Extravascular Hemolytic Reaction

    • Often have low-grade fever but may be entirely asymptomatic

    • Usually presents days to weeks after transfusion

    • More common than intravascular hemolytic reaction; rarely causes clinical instability

    • Hemolysis most commonly occurs in the spleen and occasionally in liver and bone marrow

    • Requires hemolytic workup as above to investigate the possibility of intravascular hemolysis

      • May be identified by a positive Coombs test, elevated unconjugated (indirect) bilirubin level, and less than expected increase in hemoglobin from the transfusion

>> Febrile:

  • Overview:

    • Characterized by fever during or within a few hours of a blood transfusion

    • Quite common => occurs in approximately 1 per 300 units of PRBCs infused 

    • Most common in multiparous women or multiply transfused patients (pts who have been exposed to foreign blood antigens)

    • For patients with recurrent febrile reactions, use of leukocyte-reduced blood products may be helpful

  • Signs/Symptoms: Fever, chills

  • Management:

    • Stop transfusion

    • Initially manage as intravascular hemolytic reaction because one cannot reliably distinguish between the two

    • Can treat fever and chills with Acetaminophen

    • Consider infectious workup

  • Evaluation:

    • Hemolytic workup as above

>> Allergic:

  • Overview:

    • Caused by an immune response to transfused plasma proteins

    • Pts with immunoglobulin A deficiency may experience severe anaphylactic reactions due to presence of immunoglobulin A in donor products

      • Washing the plasma from the RBCs minimizes this type of reaction

  • Signs/Symptoms: 

    • Mild: urticaria, pruritus

    • Severe: anaphylaxis => dyspnea, bronchospasm, hypotension, tachycardia, shock

  • Management:

    • Stop transfusion

    • If mild, reaction can be treated with Diphenhydramine; if symptoms resolve, can resume transfusion

    • If severe, may require cardiopulmonary support; do not restart transfusion

  • Evaluation:

    • For mild symptoms that resolve with Diphenhydramine, no further workup is necessary

    • For severe reaction, do hemolytic workup because initially may be indistinguishable from a hemolytic reaction

>> Infectious:

  • HIV-1: 1 per 6 million units transfused

  • HIV-2: Unknown, but extremely low

  • Human T-cell Lymphotropic Virus Types 1 and 2: 1 per 640,000 units transfused

  • Hepatitis B: 1 per 1 million units transfused

  • Hepatitis C: 1 per 100 million units transfused

  • Parvovirus B19: 1 per 10,000 units transfused

  • Note: Blood is not tested routinely for CMV unless recipient is seronegative AND either pregnant, a potential or present transplant candidate, immunocompromised, or a premature infant

    • Leukocyte-reduced blood components further decrease the risk of CMV transmission to susceptible populations because most of the virus resides in leukocytes

>> Transfusion Related Acute Lung Injury:

  • Thought to be due to granulocyte recruitment and degranulation within the lung

  • Usually a complication of fresh frozen plasma or platelet transfusion; rare after PRBC transfusion alone

  • Presents with respiratory distress and bilateral pulmonary infiltrates due to noncardiogenic pulmonary edema, during or within 6 hours of transfusion

  • Often self-limiting and resolves spontaneously with supportive care

>> Other:

  • Hypervolemia

    • Rapid volume expansion may occur leading to transfusion-associated cardiovascular overload

    • Pts with limited cardiovascular reserve (infants, severe chronic anemia, elderly) => highest risk

  • Electrolyte Imbalance

    • Hypocalcemia, hypokalemia or hyperkalemia rarely occur

    • The anticoagulant citrate is a component of many blood preservatives and chelates calcium

      • Pts with normal hepatic function metabolize the citrate to bicarbonate

    • Rarely, hepatic metabolism is overwhelmed; hypocalcemia can develop and/or the excess bicarbonate generated causes alkalemia, driving potassium into cells and causing hypokalemia

    • Potassium content in stored blood products increases during storage; uncommonly, pts with renal insufficiency or neonates can develop hyperkalemia


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