Blood transfusion reaction

Introduction, definition, classification, immediate, delayed, etiology, pathophysiology, symptoms, management and laboratory diagnosis with interpretations.

1. BLOOD TRANSFUSION REACTIONS By: Nityanand Upadhyay Associate Professor Department of MLT Integral University, Lucknow

2. DEFINITION CAUSES CLASSIFICATION SYMPTOMS MANAGEMENT LABORATORY INVESTIGATION LESSION PLAN

3. “Any unfavorable and harmful transfusion related events occurring in the patient during or after transfusion of blood or components is called transfusion reaction.” => About 10 percent of recipient usually experience Transfusion Reaction. DEFINITION

4. • Misidentification of the patient. • Improper sample identification. • Wrong blood issued. • Administration error. • Technical error. • Storage error. CAUSESOF TRANSFUSION REACTION

5. The transfusion reaction are classified into two group as per the appearance of SIGN and TIME DURATION. A. IMMEDIATE (ACUTE) TRANSFUSION REACTION. 1. IMMUNOLOGICAL A.T.R. 2. NON IMMUNOLOGICAL A.T.R. TYPES/CLASSIFICATION

6. B. DELAYED (CHRONIC) TRANSFUSION RAECTION. 1. IMMUNOLOGICAL C.T.R. 2. NON IMMUNOLOGICAL C.T.R.

7. “ The Acute transfusion may be defined as any undesired reaction appears during or after some times of Blood transfusion.” The Acute transfusion reaction are Two types- 1. Immunological Immediate (Acute )Transfusion Reaction. 2. Non Immunological Immediate ATR. A. IMMEDIATE (ACUTE) TRANSFUSION REACTION.

8. 1. Immunological Immediate (Acute) Transfusion Reaction. “Transfusion reaction due to Involvement of Antigen- Antibody Reaction between Donor and Recipient Blood.” These are- i. Acute (Immediate ) Haemolytic Transfusion Reaction /Intravascular HTR.

9. ii. Non- Haemolytic Fibrile Transfusion Reaction (NHFTR). iii. Allergic Transfusion Reaction. iv. Anaphylatic Transfusion Reaction. v. Non – Cardiogenic Pulmonary Reaction.

10. . In intravascular transfusion reaction the haemolysis of red cells takes place within the circulatory system. i . Acute (Immediate ) Haemolytic Transfusion Reaction /Intravascular HTR .

11. . Haemolysis occur within few min after starting transfusion ( <24 hrs ). . As little as 10-15 ml of ABO incompatible blood infusion can produce symptoms.

12. This type of reaction is mainly due to IgM ab’s (ant-A, & anti-B), mediated by the rapid activation of complement and is usually associated with the transfusion of ABO in compatible blood.

13. • Fever • Chills • Hypotension • Chest and back pain • Nausea • Dyspnea • Vomiting • Haemoglobinuria • Acute renal failure • Pain at transfusion site • Shock & DIC SIGN AND SYMPTOMS

14. Stop transfusion immediately. Intravenous line kept open Administer 0.9% saline to hydrate kidney. Mannitol is the agent used to prevent the renal failure. Hypotension: intravenous fluid and vasoactive drugs .e.g. dopamine MANAGEMENT

15. “ NHFTR is defined as by noting temperature of 1centigrade or more above baseline level during transfusion of blood or its components.” These reactions are the most common and account for over 90 % of TR. These are occur within minutes of starting the transfusion ii. Non- Haemolytic Fibrile Transfusion Reaction (NHFTR).

16. These reactions are due to a reaction between HLA (Human Leukocyte Antigen) class-I antigen on transfused Lymphocytes, Granulocytes or Platelets in Donor blood unit and antibodies in previously alloimmunised Recipients (multi transfused patients) . CAUSES

17. 1. Due to the presence of anti leukocyte antibody and antibodies to platelet in the patients serum. (It may be due to past transfusion or pregnancy.) 2. Ab react with donors(HLA) WBCs PATHOPHYSIOLOGY

18. 3. Ag – Ab complex activate complement system 4. Release of pyrogens from WBCs result in rise of temp.

19. Fever Chills Malaise SIGN AND SYMPTOMS

20. Give leukocyte poor red cells. Patient with history of NHFTR may be premedicated before Transfusion Anti pyretic can be given before starting transfusion, but they must be avoided as much as possible as they mask IHTR. MANAGEMENT

21. A type of immediate hyper sensitivity reaction. Allergic signs and symptoms appear within few minutes of exposure. They may be mild, moderate or life threatening. iii. Allergic Transfusion Reaction

22. Causes: The donors plasma contain allergens which react with reagin present in patients plasma. The donors plasma contains reagin that combines with allergens in the patient plasma. Allergen- Regin Complex Attached The Mast cell Surface Release Histamine

23. Symptoms: Local erythema Urticaria Hives(raised red wheal) Hypotension Loss of consciousness Shock

24. 1. Stop Transfusion. 2. Antihistaminic drugs are given orally or Intramuscularly. Management

25. This reaction is most sever form of allergic transfusion reactions. This is life threatening. These reaction developed quickly- within minutes of starting the transfusion iv. Anaphylactic Transfusion Reaction

26. Causes: In rare patients who are IgA deficient and have developed anti- IgA ab’s .

27. Symptoms: Respiratory tract- cough, bronchospasm , dyspnea . GIT- nausea, vomiting, diarrhoea . Circulatory system- hypotension, syncope. Skin- generalized flushing, Urticaria .

28. 1. Stop Transfusion. 2. Keep the line open with normal saline. 3. Treat Hypotension. 4. Inject epinephrine. 5. Inject antihistaminic 6. Hypoxia- give oxygen by mask Management

29. Also Known as TRANSFUSION RELATED ACUTE LUNGS INJURY(TRALI). They are manifested by apparent pulmonary edema. TRALI is characterized by acute respiratory distress , bilateral pulmonary edema, hypoxemia, fever and hypotension. v. Noncardiogenic Pulmonary Reactions.

30. Causes: 1. Passively transfused leukocyte antibodies in blood or plasma of donor react with the transfusion recipient’s leukocytes. 2. The reaction between leukocyte antigens and antibodies may result in LEUKOAGGLUTINATION with the white cell aggregates becoming trapped in microcirculation of lungs, Causing Pulmonary Edema.

31. Symptoms: Symptoms occurs within 1 to 6 hours of transfusion. Usually symptoms resolve within 24 to 48 hours. Acute onset of respiratory distress Dyspnea Cyanosis Fever Chill

32. 1. Immediate stop blood transfusion. 2. Appropriate respiratory support. 3. Intravenous administration of Steroids. 4. Leukocyte poor component is used. Management

33. 2. Non Immunological Immediate/ATR. “In this types of reaction there is no any involvement of Antigen - Antibody.” Reaction by other factors like, Bacteria. These are- i . Bacterial Contamination. ii. Circulatory Overload iii. Haemolysis due to Physical or Chemical Agents

34. . Bacteria or other microorganisms may enter Blood during phlebotomy and Blood components stored at refrigerated temp. . Blood stored at room temp. has more chances of microbial contamination. “Result of bacterial contamination of blood can be life threatening.” i . Bacterial Contamination.

35. Endotoxins producing gram negative bacteria encountered in blood contamination are- E. Coli Citrobacter freundii Yersinia enterocolitica

36. Symptoms: are as- 1. High grade fever. 2. Shock: is associate with flushing , dryness of skin, Abdominal pain, Cramp, dirrhaea and muscular pain. 3. Haemoglobinuria . 4. Renal failure. 5. DIC.

37. 1. Stop transfusion. 2. Administration of Intravenous antibiotics. 3. Treat Hypotension with fluid. 4. Treat DIC. Management

38. “Due to Hypervolemia by transfusing blood very rapidly” Susceptible patients may be very young, old ones. ii. Circulatory Overload

39. Symptoms: Including . Heart Problem . Chronic Anaemia . Congestive Heart failure . Coughing . Cyanosis . Sever headache . Difficulty in breathing

40. 1. Stop transfusion or continue it very slowly. 2. Intravenous administration of Diuretics. 3. Give Oxygen. 4. If pulmonary edema develops, phlebotomy may be indicated. Management

41. Such as- . Overheating. . Freezing. . Freezing without cryoprotective agents. iii. Haemolysis due to Physical or Chemical Agents

42. . Mechanical stress. . Mixing of hypotonic solution (5% dextrose in saline) or Hypertonic solutions (50% dextrose in water) wiyh RBC may cause hemolysis of RBC.

43. 1. Asymptomatic hemoglobinuria is the common symptoms.(Because transfusion of Hemolytic Blood). 2. DIC may develop. Symptoms

44. Fluid Therapy. Regular monitoring of patient. Management

45. “ The Chronic transfusion may be defined as any undesired reaction appears after Blood transfusion.” The Chronic transfusion reaction are Two types- 1. Immunological Delayed (Chronic ) Transfusion Reaction. 2. Non Immunological Delayed (Chronic)Transfusion Reaction. B. DELAYED (CHRONIC) TRANSFUSION RAECTION.

46. 1. Immunological Delayed (Chronic) Transfusion Reaction. These are- i . Chronic Haemolytic Transfusion Reaction (Delayed/ Extravascular HTR). ii. Trnasfusion Associated Graft Versus Host Disease ( TA-GVHD). iii. Post Transfusion Purpura .

47. 2. Non Immunological (Delayed) Chronic Transfusion Reaction. . Transfusion Induced Haemosiderosis . (Iron Overload)

48. Also known as Extravascular Hemolytic Transfusion Reaction. This reaction appear due to Rh incompatibility . Haemolysis occur after few hours or after about 3-7 days of transfusion. i . Chronic Haemolytic Transfusion Reaction (Delayed/ Extravascular HTR).

49. Causes: 1. Recipient serum amnestic antibody response to alloantigens on donor cells. 2. These ab’s bring about the destruction of red cells by the macrophages in the spleen or liver.

50. IgG of Recipient, coats the RBC,s of Donor and Sensitized them Sensitized RBC,s Interact with Phagocytic Cells Engulf and Destroy RBC,s Pathogenesis

51. IgG antibodies coated red cells interact with receptors of phagocytic cell (macrophage). Phagocytic cell engulfs the antibody coated cell and incorporates it into the intracellular vacuole. Lysis of red cells with in the intra cellular vacuole of phagocytic cell.

52. Symptoms: Fall in Hb Rise in bilirubin and mild jaundice with in 5-7 days of transfusion Fever. Renal failure ( rare )

53. 1. Urine output and renal functions should be followed. 2. If DAT positive identify antibody. Management

54. It results from transfusion of Immunologically components cells ( Cytotoxic CD8 T lymphocytes) in an immunologically incompetent host (who may be incapable of rejecting the CD8 T lymphocytes). ii. Trnasfusion Associated Graft Versus Host Disease ( TA-GVHD).

55. Individual at high risks are: 1.Congenital Immunodeficient . 2. Aquired cell mediated Immunodeficient . 3. Autologous bone marrow transplant Recipient. 4. Fetus receiving intrauterine transfusion. 5. New born infants receiving exchange transfusion. Risks

56. Symptoms: Symptoms of acute TAGVHD is 2 to 30 days after transfusion. And in chronic TAGGVHD it occurs after 100 days. Fever Rash Diarrhea Hepatitis Liver dysfunction Bone marrow suppression Fatal

57. Most communally in women in their Sixty or Seventy years of life. Occur with platelet concentrate transfusion . Due to alloimmunized to platelets antigens through previous transfusion. iii. Post Transfusion Purpura .

58. Symptoms: Symptoms may occurs after 7-14 days from transfusion. 1. Purpura (Due to red discoloration of the skin caused by hemorrhage.) => Hemorrhage resulting from destruction of platelets by antiplatelet antibodies in the recipient.

59. 1. Administration of Corticosteroids. 2. Plasma exchange. 3. Intravenous Immunoglobulin. Management

60. Transfusion Induced Haemosiderosis (Iron Overload). 1. It is deposition of Iron in tissues or organs. 2. It may results from long term administration of blood(RBC,s or Whole) to Recipient. 3. Iron accumulation : affect functions of heart, liver , endocrine system 2 . Non Immunological (Delayed) Chronic Transfusion Reaction.

61. 1. Beta thalassemia major. 2. Congenital Hemolytic anaemia . 3. Aplastic Anaemia . => Hemosiderosis because of blood transfusion may occur after transfusion of as few as 100 units of Blood. Risks

62. Symptoms: 1.Muscle weakness. 2. Fatigue. 3. Weight loss. 4. Mild jaundice . 5. Anaemia .

63. 1. Deferoxamine mesylate is a iron chelating drug. 2. Transfusion should be kept to aminimum . 3. Transfusion of Young Red cells. Management

64. Check all the records to ensure that the correct unit of blood was transfused to the right patient . This includes : a ) Patient’s details b) Blood requisition form c) Compatibility report d) Labels LABORATORY INVESTIGATION IN CASE OF TRANSFUSION RAECTION.

65. Examine the patient pre -transfusion & posttransfusion plasma from EDTA sample for evidence of free Hb or increased bilirubin . Pink or red discolouration in post-transfusion plasma indicates the presence of free Hb due to red cell destruction .

66. Yellow discoluration of the sample drawn 6-8 hr after transfusion indicates increased blirubin . Perform DCT on the pre- and post transfusion sample .

67. A positive DCT test usually indicates the presence of recipient ab’s on the surface of donor red cells, however if all the cells have been already destroyed , the test may be negative. Check urine (post-transfusion) 1st sample. If Dark Yellow Colour :- Extravascular Hemolysis . If Cock or Pink Colour : Intravascular Hemolysis .

68. If nothing abnormal, indicates that no acute hemolytic reaction . If any finding is positive, or clinical finding strongly suggest a hemolytic reaction, the following investigations to be done;- ITERPRETATION OF LABORATORY FINDING

69. 1) Repeat the crossmatch , testing both pre and post transfusion sample of the patient against the sample from the bag by saline/ albumin,coombs techniques. 2 ) Repeat antibody screening and identification of patients pre and post transfusion samples.

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