Chapter 11: ADVERSE COMPLICATIONS OF TRANSFUSIONS
OVERVIEW of ADVERSE REACTIONS to TRANSFUSION
- Adverse Transfusion Reaction – an undesirable response or effect in a patient temporarily
associated with the administration of blood or blood component
Hemovigilance Model
- Tracks and analyzes adverse transfusion reactions
Recognition of a Transfusion Reaction
- Fever
-
Chills or rigors
-
Hypertension or hypotension
-
Respiratory distress
-
Skin rash, flushing, edema
-
Pain
-
Jaundice
-
Nausea
-
Oliguria
Abnormal bleeding
CATERGORIES of TRANSFUSION REACTIONS
Hemolytic Transfusion Reaction
Chapter 11: ADVERSE COMPLICATIONS OF TRANSFUSIONS
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Acute Hemolytic Transfusion Reaction (AHTRs)
-
Rapid destruction of RBCs within 24 hours of transfusion
-
Signs range in severity from fever to death
-
Usually due to ABO incompatibility
-
As little as 10 mL of incompatible blood can produce symptoms
-
Pathophysiology of AHTRs
-
o
Antibody binds to incompatible RBC antigens
o
Complement is activated (mostly by IgM)  causes intravascular hemolysis
o
Phagocytes are activated and release cytokines
o
Coagulation is activated (e.g. disseminated intravascular coagulation [DIC])
o
Shock and renal failure occur
Clinical consequences of AHTRs
o
Hypotension
o
Irreversible shock
o
Disseminated intravascular
o
Renal failure
coagulation (DIC)
Chapter 11: ADVERSE COMPLICATIONS OF TRANSFUSIONS
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Factors that lead to AHTRs

Delayed Hemolytic Reaction
-
Symptoms usually appear after 24 hours from the time of transfusion
-
Less severe than AHTRs
-
Usually due to IgG antibodies formed from prior exposure to RBCs through previous
transfusion or pregnancy
-
Antibodies may be undetected during pretransfusion testing due to low titers
-
Common antibodies: Rh, Kidd, Duffy, Kell, MNS

Non-Immune-Mediated Mechanisms of Red Cell Destruction
-
RBC destruction when antibodies are not implicated
o
Exposure of RBCs to extreme temperature
o
Improper deglycerolization
o
Mechanical destruction of RBCs
o
Incompatible solutions: use only physiologic saline
o
Bacterially contaminated blood products
o
Intrinsic RBC defects (e.g. sickle cells)
Chapter 11: ADVERSE COMPLICATIONS OF TRANSFUSIONS
Delayed Serologic Transfusion Reactions
Febrile Nonhemolytic Transfusion Reactions
Allergic and Anaphylactic Transfusion Reactions
- Caused by soluble allergens in donor plasma
- Symptoms usually occur within seconds to minutes of being transfused

Urticarial (allergic) Response
-
IgE reacts with plasma proteins

Anaphylactic Response
-
Recipient forms anti-IgA antibodies
Chapter 11: ADVERSE COMPLICATIONS OF TRANSFUSIONS
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Transfusion-Related Acute Lung Injury (TRALI)
Transfusion-Associated Graft-Versus-Host Disease (GVHD)
Chapter 11: ADVERSE COMPLICATIONS OF TRANSFUSIONS
Bacterial Contamination of Blood

Irradiation
-
Eliminates the ability of leukocytes to replicate and mount an immune response

Bacterial Contamination
-
Major sources include
-
-
o
Transient bacteremia in the donor
o
Improper cleansing of the donor’s skin during collection
Some organisms can grow upon storage
o Yersinia enterocolitica (4C)
o
Serratia liquefaciens (4C)
o
Pseudomonas fluorescens (4C)
o
Staphylococcus (platelets, 20C to 24C)
o
Bacillus cereus (platelets, 20C to 24C)
Apheresis platelets and platelet concentrates must be tested for bacteria
Transfusion-Associated Circulatory Overload (TACO)
- Patient’s cardiopulmonary system exceeds its volume capacity
-
Symptoms (signs of congestive heart failure):
o
Dyspnea
o
Severe headache
o
Peripheral edema
-
Treated with oxygen therapy and diuretics
-
Candidates susceptible to circulatory overload should receive RBC units
Transfusion Hemosiderosis
- Accumulation of excess iron in macrophages in tissues
-
Usually occurs in patients undergoing long-term transfusions (e.g. thalassemia)
-
Iron intake exceeds daily iron excretion
-
Prevention involves iron chelation
o
o
Deferiprone
Deferoxamine
Chapter 11: ADVERSE COMPLICATIONS OF TRANSFUSIONS
Citrate Toxicity
- Occurs when large quantities of citrated blood are transfused
-
-
May have adverse effects in:
o
Those receiving large volume of blood
o
Patients with impaired liver function
o
Preterm infants with hepatic or renal insufficiency
Prevention
o
o
Remove plasma that may contain citrate
Inject calcium chloride or calcium gluconate
Posttransfusion Purpura
- Women negative for platelet antigen P1A1 are sensitized through multiple pregnancies
(produce anti-P1A1 antibody)
-
Platelet count decreases 5 to 12 days after transfusion
-
Purpura and bleeding follow
-
Treatment: plasmapheresis, exchange transfusion, and intravenous IgG
EVALUATION and REPORTING a TRANSFUSION REACTION
Initiating a Transfusion Reaction Investigation
 Procedure for Adverse Reactions

Postreaction Workup
Chapter 11: ADVERSE COMPLICATIONS OF TRANSFUSIONS
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Additional Laboratory Testing in a Transfusion Reaction
Records and Reporting of Transfusion Reactions and Fatalities

Hemovigilance Component

Records
-
Records of patients experiencing adverse reactions remain indefinitely in transfusion
services
-
Cases of transfusion-related disease or bacterial contamination are reported to the
donation facility

FDA-Reportable Fatalities
-
Fatalities are reported as soon as possible to the director of the FDA Office of Compliance,
Center for Biologics Evaluation and Research
Chapter 11: ADVERSE COMPLICATIONS OF TRANSFUSIONS
SUMMARY
The major immune-mediated and non-immune-mediated adverse complications of transfusion are
summarized in the following table: