Blood Transfusion Reactions

Definition
• Transfusion Reaction is defined as any unfavorable
event that occurs during or after a transfusion of blood and
its components

Anaphylactic and
Anaphylactoid
reactions

Febrile Nonhemolytic Transfusion Reaction
( FNHTR)
• Frequent kind of reaction, 1:200 cases
Definition
• 1oC temperature rise associated with transfusion, no medical
explanation other than blood transfusion
Cause
• Pt has immunologic sensitization to donor WBC’s, platelets or
plasma proteins
• Common sources: prior transfusions, previous pregnancies,
previous transplants

Signs & Symptoms
• Fever, chills and malaise.
Laboratory Investigation:
• No red/ pink Plasma
• DAT negative
• No increase in bilirubin
• No Hemoglobinuria.

Prevention
• Transfusion of Leucocyte poor red blood cells.
• Antipyretics are used to treat fever or are given as a preventive
measure.

Allergic Reactions
• Due to transfused allergens or soluble substances in donor
plasma.
• The patient will have urticaria (hives) which usually itch.
• Reaction not dangerous, causes discomfort and anxiety to the
patient.
• Commonly caused by transfusion of plasma containing blood
components, e.g.: FFP, Cryoprecipitate, Platelet Concentrates

Treatment
• Interrupt the transfusion temporarily.
• Keep IV line open with Normal saline
• Give antihistamine
• When urticaria disappears resume transfusion.
• Oral/ Parenteral Diphenhydramine 50 mg should be given 1
hour before and at start of transfusion.
• If premedication fails washed red cells should be used.

Anaphylactic Transfusion reaction
• This is a severe, life threatening reaction, which occur in rare
patients who are IgA deficient and have developed anti-IgA
antibodies.
Signs & Symptoms
• Gastro intestinal upset
• Flushing
• Urticaria
• Respiratory distress
• Hypotension & Shock

Management
• Stop transfusion
• Keep IV line open
• Medication :- epinephrine (vasoconstrictor & bronchiole
dilator), corticosteroid
• Washed RBCs and blood components
• Transfuse IgA deficient plasma

Acute Hemolytic Transfusion Reactions
• Most common cause is ABO incompatibility (clerical error)
• Incidence: 1:25,000
• As little as 10-15 mL can trigger a reaction
• Within 24 hours

Causes
• Transfusion of incompatible donor RBC’s into Pt
• Usually an ABO incompatibility, Most commonly Antibodies A,B
or AB
• Also Antibodies to Kell, Jk and Fya
• Red cell destruction due to complement activation by IgM
Antibodies in Pt plasma attach to antigens on donor RBC’s
causing RBC destruction intravascularly.

Signs & symptoms
• Chills , fever
• Facial flushing
• Hypotension
• Renal failure
• DIC
• Shock
• Chest pain
• Dyspnea
• Generalized bleeding
• Hemoglobinemia
• Hemoglobinuria
• Nausea
• Vomitting
• Back pain
• Pain along infusion vein

Immediate Actions to be taken :
1. STOP THE TRANSFUSION
2. Keep IV open with Normal Saline
3. Check all blood component(s) labels, forms, Pt. ID for errors
Usually due to clerical error: wrong Pt.; wrong blood component;
etc.
4. Notify Pt.’s physician as appropriate
5. Notify Blood Bank; submit work-up specimens; submit report
forms

Management
• Treat hypotension, renal failure, DIC, etc.
• Submit blood samples for blood bank/laboratory tests
• Avoid, if possible, further transfusions till work-up complete
and/or Pt recovered from reaction
• To prevent renal failure, fluids (saline) are infused along with
diuretics to increase urine output

Prevention
u preventing or detecting errors in every phase of the transfusion
process :
u sample acquisition
u at all steps in laboratory testing
u at the time of issue
u at the time of transfusion
Good manufacturing Practices with Written Standard
Operating Procedures should be followed
Perform pretransfusion compatibility testing
Ensure that all clinical staff recognize signs and symptoms of
acute reaction

Lab Investigations
• Pre-tranfusion Sample: Reconfirm ABO, Rh and Antibody screen
tests
• Post-tranfusion sample: ABO, Rh, Antibody screen
DCT
Urine-Haemoglobinuria
Serum bilirubin
Blood urea, creatinine
Urine out put
Coagulation screen

Transfusion Related Lung Injury(TRALI)
• 1 in 5,000 transfusions
• Symptoms occur within 2 hours and may end in 2- 4 days if
treated
• Caused by donors leucoagglutinins which react with patient
leucocytes and produce aggregates. They are trapped in
the pulmonary microcirculation, causing endothelial damage
by oxidative or physical.

Signs & Symptoms
• Acute respiratory distress
• Fever
• Chills
• X-ray shows pulmonary edema
• Hypotension

Management & Prevention
• Give steroid (Methyl prednisole 30 mg/kg IV) every 6 hours for
48 hours.
• Give respiratory support (O2)
• Diuretic if volume overload
• Use washed red cells in future transfusion.

Circulatory Overload
• Excessive volume or high speed of transfusion of whole blood
in severely anaemic patient with compromised heart/ lung
functions may precipitate congestive heart failure manifested
by breathlessness, cough and distention of jugular veins.
• Elderly patients, infant and pregnant women are more
prone to induced TACO.

Management
• In severely anaemic patients, it is advisable to give packed red
cell transfusion.
• Rate of transfusion should be slow. (1ml/kg/hr)
• Diuretic should be given before transfusion.
• In severe cases, exchange transfusion should be considered.

Septicaemia
• Results from bacterial contamination of blood products
– Yersinia enterocolitica
– Serratia liquifaciens
• Symptoms appear rapidly:
– include fever, shock, & renal dysfunction, nausea, vomiting
• Stop immediately and treat with antibiotics
– Hypotension can be treated with vasopressors

Management & Prevention
• Give appropriate antibiotic after culture of blood sample.
• Care - Phlebotomy and blood components preparation &
processing , thawing by sterile technique.

Delayed Tranfusion Reactions

Delayed Hemolytic Transfusion Reactions
• DHTRs may not be recognized for weeks or months after
transfusion
• Mediated by IgG antibodies
– Patient previously exposed to RBC antigen and has low antibody titer
until exposed again
– Rh, Kidd, Duffy, and Kell

Graft versus Host Disease
• Caused by donors lymphocytes engrafting in the recipient and
reacting against host antigen.
• Patient at risk are
• Immunocompromised
• Newborn
• Bone marrow transplantation
• Chemotherapy

symptoms
Onset - 3 to 30 days after transfusion
• Fever
• Rash
• Diarrhoea
• Liver dysfunction
• BM suppression

Prevention
• Patients should receive leucocyte free blood or irradiated
blood component.

Post transfusion Purpura
• Pathophysiology
Platelet Ab (anti-PLA1) attach platelet surface destruction by RES
Signs & Symptoms
• Purpura and thrombocytopenia occur
• 1 – 2 weeks after transfusion
• The platelet count drops <10,000/μL
• Therapy and Prevention
• Corticosteroids
• Exchange transfusion
• Plasmapheresis

Iron overload
• 1 unit of PRCs has 250 mg of Iron
• Removed by body - 1 mg / day
• accumulate iron Hemosiderosis
• iron accumulate in tissue Hemochromatosis

• Occurs in individuals who receive multiple transfusions
• Excess iron accumulates in macrophages in various tissues
(liver, heart, endocrine glands)
• It appears as dark brown granules in the cells
• May lead to organ failure
• Therapy Iron – chelating agent
• Prevention transfuse with young RBCs

Transfusion – Transmitted Diseases
• Viral Infections
• Hepatitis Viruses :- HBV, HCV
• Retroviruses :- HIV
• Herpesviruses :- CMV, EBV
• Parvovirus :- Human B19 parvovirus
• Prion :- infectious particle of CJD
• Bacterial Infection
• Gram negative and positive
• Syphilis
• Lyme disease (Borrellosis)
• Parasitic Infections
– Malaria
– Chagas disease
– Toxoplasmosis
– Leishmaniasis

Serological Testing
for Infectious agents
• HIV 1 & 2
• HBsAg
• HCV
• Malaria
• syphilis

Summary & Conclusions
• Transfuse blood only when indicated
• ABO, Rh, Cross match compatible blood given
• Follow SOPs at every step from collection to transfusion
• As far as possible avoid whole blood
• Components encouraged
• Watch for any reactions
• Treat promptly

TAKE CARE OF PATIENTS
WITH
BLOOD TRANSFUSION

References
1. Dr R N Makroo. Compendium of Transfusion medicine.2nd edition,
Kongposh publications pvt ltd, New delhi, 2009.
2. Godkar PB, Godkar DP. Text book of Medical Laboratory Technology.
3rd edn, Bhalani Publishing House, Mumbai, India, 2019.

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