Complications Of Blood Transfusion

Even though certain precautions are taken prior to blood transfusion, still blood transfusion reactions are inevitable. These reactions can vary from a mild presentations like fever, chills and pruritus to severe / potentially life threatening complications which we will discuss later.

These adverse reactions are multifactorial. Most feared complication of mismatch transfusion occurs due to clerical errors of health care providers.

Early Complications

  • Acute haemolytic transfusion reaction
  • Non haemolytic febrile reaction
  • Transfusion related allergic reaction
  • Transfusion related lung injury
  • Circulatory overload
  • Complications of massive transfusion
  • Transfusion transmitted infection – Bacterial contamination
  • Air embolism
  • Thrombophlebitis

Late Complications

  • Transfusion transmitted infection
  • Transfusion related graft-vs-host disease
  • Iron overload

Acute Haemolytic Transfusion Reaction

Most common cause of AHTR is ABO incompatibility.
ABO incompatibility means that there is a mismatch between the donor RBC antigens and recipient plasma antibodies resulting in an to a antigen-antibody reaction leading to intravascular haemolysis of transfused blood.  Severity will depend on the degree of incompatibility, amount of blood administered, recipient antibody titre levels, etc.
AHTR is a complement activated reaction mediated by IgM.

Clinical Presentation Of AHTR

Symptoms will start to appear immediately following administration.
Patient will experience symptoms such as….

  • Pain in the head / chest / flank
  • Fever ± chills and / or rigors
  • Anxiety
  • Nausea, vomiting
  • Dyspnoea
  • Hypotension
  • Shock
  • Urticaria
  • Haemoglobinuria
  • DIC

Many preventive measures are being taken to avoid a mismatch blood transfusion such as blood grouping, Rh typing, cross matching and proper documentation.

Treatment Of Mismatch Transfusion

  • Stop the transfusion temporarily
  • Obtain a venous access
  • Recheck patient identification
  • Assess the patient
  • Administer IV Hydrocortisone 200mg stat, IV Chlorpheniramine 10mg stat
  • If anaphylaxis occur – IM Adrenaline
  • Connect to the monitor
  • Inform seniors

Delayed Haemolytic Transfusion Reaction

This is caused by minor blood group incompatibility (Rh, kidd incompatibility)
There are only a trace amount of antibodies present in the recipient at the time of transfusion, but upon exposure an anamnestic response takes place which leading to a production of large amount of antibodies.
DHTR is a IgG mediated reaction where RBC is coated with IgG and become destroyed by the reticuloendothelial system.
Extravascular haemolysis occurs in DHTR.

Symptoms begin to occurs 7 – 21 days after transfusion. DHTR does not have an alarming presentation. Delayed drop of haematocrit level and jaundice are features suggestive of this reaction.

This reaction is difficult to prevent as pre transfusion screening would not be able to detect these antibodies as their titres are very low.

Non Haemolytic Febrile Reaction

The incidence of non haemolytic febrile reaction has declined because of the used of leukodepleted blood.
Results from the reaction between donor leukocyte antigens and recipient plasma antibodies forming a leukocyte antigen antibody complex releasing cytokines (IL-1, IL6, TNF-α).
Unlike haemolytic reactions, there is no attachment of antibodies to RBC antigens, hence Coomb’s test is negative in non haemolytic febrile reaction.

Clinical Presentation Of Non Haemolytic Febrile Reaction

This reaction may occur during transfusion or few hours following the transfusion, but the severity is less severe than that of acute haemolytic transfusion reaction.

  • Fever ± chills and / or rigors
  • Headache
  • Myalgia

Treatment Of Non Haemolytic Febrile Reaction

  • Reduce the rate of transfusion
  • Antipyretics – Paracetamol

Allergic Transfusion Reaction

Allergic transfusion reactions are mild reactions that occurs due to the presence of allergens in donor plasma and less often due to presence of antibodies from an allergic donor.
This is an IgE mediated reaction.
Severe reactions like anaphylaxis can occur in recipients with IgA deficiency.

Clinical Presentation Of Allergic Transfusion Reactions

  • Pruritus
  • Urticaria
  • ± Fever

Management Of Allergic Transfusion Reactions

  • Stop the transfusion
  • Administer antihistamines
  • Continues transfusion if symptoms settles within 30 mins
  • If recur, stop the transfusion

Transfusion Related Lung Injury

Development of ARDS during or within 6 hours of transfusion is called as transfusion related lung injury (TRALI). This is considered as a potentially life threatening condition.
TRALI is believed to occurs in two methods

  • Immune mediated
    • Donor leukocyte antibodies reacts against recipient human leukocyte antigens (HLA) and human neutrophil alloantigens (HNA)
  • Non immune mediated
    • Reactive lipid products are released from the membrane of the donor blood cells and triggers TRALI

Upon activation neutrophils migrate to the lungs and become trapped in the pulmonary vasculature releasing free radicals and enzymes that destroys the pulmonary vascular endothelium leading to exudation, resulting in pulmonary oedema.

Use of leukodepleted blood has reduced the incidence of immune mediated TRALI.

Transfusion Associated Graft-vs-Host Disease

GvHD can occur within 4 to 21 days following a blood transfusion, but it is very rare. The incidence has declines because of the use of leukodepleted blood.
GvHD occurs can occur in immunocompromised patients who receives blood products that contain immunocompetent lymphocytes (T lymphocytes)

Clinical Presentation Of GvHD

  • Fever
  • Maculopapular rash in face, palms and soles
  • Abdominal pain
  • Vomiting
  • Diarrhoea (Watery / Bloody)
  • Lymphadenopathy
  • Pancytopenia (Due to destruction of bone marrow)

GvHD can be prevented by giving irradiated blood which inactivates donor lymphocytes.

Transfusion Related Circulatory Overload

Transfused blood has a high osmotic load and draws fluid into the intravascular space, increasing the volume of the intravascular compartment.
Patient’s with renal and cardiac insufficiency are greatly susceptible to develop transfusion related circulatory overload and should be promptly monitored for the development of heart failure.

Complications Of Massive Transfusion

Massive transfusion is defined as the transfusion of a blood volume greater than or equal to a patient’s blood volume within 24 hours.
When blood is replaced in such massive amount, clotting factors and platelets become diluted causing a coagulopathy. Massive transfusion will also affect serum electrolytes, acid base balance and temperature homeostasis of the patient.

  • Dilutional coagulopathy
    • Treated with transfusion of FFP, platelets and cryoprecipitate
  • Electrolyte imbalance
    • Hypocalcaemia
      • Citric acid is added as the anticoagulant for stored blood
      • Citrate binds with calcium and reduces the ionized calcium level in blood
      • Treated with IV calcium gluconate
    • Hyperkalaemia
      • Occurs when the patient is hypothermic and acidotic
  • Acid base abnormalities
    • Metabolic acidosis is common
    • Improves with fluid resuscitation
  • Hypothermia
    • As RBC is stored at 4 °C, rapid transfusion can cause hypothermia

Transfusion Related Infections

  • Bacterial
    • Not very common
    • Screening is done only for syphilis (Treponema pallidum)
    • Bacterial contaminated bag is dark in colour and may contain gas bubbles
    • RBC can be contaminated by Yersinia Entercolitis Pseudomonas species
    • Platelets can be contaminated by Staphylococcus epidermidisStaphylococcus aureus & bacillus species
  • Viral
    • Screening tests are available
    • Hepatitis B, Hepatitis C, HIV type 1 and 2, HTLV, CMV
  •  Parasitic
    • Screening tests are done against malaria (Plasmodium)
  • Prion
    • Creutzfeldt–Jakob disease (CJD) is a human prion disease that is transmitted through blood
    • No screening tests are available
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