Transfusion Reactions
June 2015
Objectives
 Be able to recognize the more common
transfusion reactions
 Learn about treatment and prevention of
transfusion reactions
Frequency of Transfusion
Reactions
Case 1
 Mr Red is a 17 year old male is brought to the ER
after a motor vehicle accident. He is in pain,
tachycardic to 100s, but normotensive.
 Given his acute blood loss, transfusion of 2u PRBC
is initiated (after appropriate type and crossmatching revealing no antibodies, and
compatibility with donor blood).
 During transfusion, he develops a fever but
otherwise has no new signs or symptoms.
 What is the diagnosis?
Febrile Nonhemolytic
Transfusion Reaction
 Fevers are common during transfusion
 Pathophysiology: likely involves recipient-derived
leukoreactive antibodies + donor-derived
cytokines
 Workup/Treatment: stop the transfusion!
 Must r/o acute hemolytic transfusion reaction (AHTR)
 Consider non-transfusion causes of fevers
 Once AHTR is ruled out, may continue transfusion with
antipyretics
 Prevention: antipyretics or leukoreduction of blood
products
Case 1 (continued)
 Mr Red does well following discharge. Fifteen years later
(age 32), however, he is unfortunately in a second MVA. He
is brought to the ER, again requiring blood products.
 He is type and cross-matched, found to have no
antibodies. He is pre-treated with acetaminophen, and
transfused 2 units PRBC without issue.
 The remainder of his hospital course is unremarkable and
the pt is discharged home.
 Ten days after the accident he follows up at his PCP’s office
with a complaint of fatigue, fevers, and yellowing of his skin.
 What is the diagnosis?
Delayed Hemolytic
Transfusion
Reaction
 Onset of symptoms: 5-10 days
after RBC transfusion
Acute Hemolytic
Transfusion
Reaction
 Abrupt onset of S/S
 S/S: hemolytic anemia, jaundice,
fever (can also be asymptomatic)
 S/S: intravascular hemolysis,
hypotension, fevers, AKI, pain at
the infusion site, DIC, pink plasma
or urine
 Life-threatening complications are
rare
 Treatment: stop the transfusion!
 Confirmation: repeat type and
screen to detect alloantibody
 Send blood back to blood bank to
check for incompatibility, hemolysis
 Supportive treatment with IVF,
pressors, diuresis
 Treatment: supportive
http://arimmuneresponseassignment.weebly.com/report.html
Case 1 (continued)
 Mr Red is now 78 years old. Since we last
saw him, he has been diagnosed with
diabetes, complicated by ESRD 2/2
diabetic nephropathy for which he is
dialyzed three times per week.
 He is admitted for a suspected GI bleed for
which he is transfused 2 units PRBC. An hour
after transfusion, he starts to complain of
shortness of breath and chest tightness. HR
120s, BP 180/90, an S3 gallop is noted, and
new bibasilar crackles are heard on
pulmonary exam. Post-transfusion CXR is
shown (was previously normal).
 What is the diagnosis?
https://www.med-ed.virginia.edu/courses/
rad/cxr/pathology2chest.html
Transfusion-Associated
Circulatory Overload
(TACO)
 Risk factors
 Patients with limited cardiopulmonary reserve (very young and elderly)
 High volume transfusion
 History of cardiac or renal disease
 Onset: within 1-2 hours after transfusion
 S/S: shortness of breath, cough, tachycardia, cyanosis, chest
tightness, volume overload (JVD, S3 gallop, peripheral edema)
 Tx: supplemental O2, diuretics or other means of removing volume
 Prevention: slow administration of blood, pretreatment with
diuretics (or blood administration with dialysis)
deltaco.com
Case 2
 Mr Red’s hospital roommate also
happens to be a 78 year old male
admitted for likely GI bleed. He also
underwent transfusion with 2 units
PRBC 1 hour ago and reports
shortness of breath.
 He is febrile to 38.5C, HR 120s, BP
70/40, SpO2 is 85% on RA. New
bibasilar crackles are heard on
pulmonary exam. Post-transfusion
CXR is shown (was normal
previously).
 What is the diagnosis?
https://www.med-ed.virginia.edu/courses/
rad/cxr/pathology2chest.html
Transfusion-Related Acute
Lung Injury (TRALI)
 Onset: during or within 6 hours of
transfusion
 S/S: hypoxia, dyspnea, fevers,
hypotension, pulmonary edema
 Treatment: stop the transfusion!
 Supportive (may need intubation),
O2
 Prevention: notify blood bank of
reaction
thelancet.com
TRALI versus TACO
Kim et al. 2015.
Back to Mr Red…
 Mr Red is now 80 years old and is admitted after
a fall during which he sustained a left hip
fracture. Following surgery, he requires 1 unit
PRBC. He is appropriately type and
crossmatched, pretreated with acetaminophen,
and a slow transfusion is initiated during dialysis.
During the transfusion, he develops diffuse
urticaria but is otherwise stable.
 What is the diagnosis?
umm.edu
Allergic Reactions and
Anaphylaxis
 Mild allergic reactions (urticaria) are common,
especially in pts who have undergone multiple
transfusions
 Prevention: pretreat with anti histamines, or wash
blood products to remove plasma proteins
 Severe anaphylaxis is rare
 Mechanism: recipient who is IgA deficient and has
anti-IgA antibodies reacts to IgA in donor blood
 Prevention: wash all subsequent blood products to
remove plasma proteins
 If IgA deficient, then only give blood products
from IgA deficient donors
Summary
 It is important to recognize the possible reactions
that can be associated with blood transfusions
 If you suspect a reaction, stop the transfusion
and assess the patient’s vital signs, signs and
symptoms as some reactions may be lifethreatening
 Notify the blood bank if serious reactions are
suspected
References
 Kim J, Na S. Transfusion-related acute lung injury;
clinical perspectives. Korean J Anesthesiol. 2015
Apr;68(2):101-5.
 MKSAP 16
 UpToDate