Any adverse reaction that occurs during the administration of blood and blood component must be considered as transfusion reaction unless proved otherwise. Transfusion reactions occur in 7% to 10% of all recipients of blood or blood components, fortunately majority of them are minor reactions. It may be immediate or delayed and may have immune or non-immune mechanism. 10% of these reactions are hemolytic and 90% of these are non-hemolytic.
Incidence of ABO mismatch blood being infused is 1: 30, 000 blood bags. 1 out of 10, ABO mismatch transfusion is fatal and 81% of fatality is due to clerical human errors which can be minimised and prevented by adhering to strict identification procedure. Early recognition and initiation of treatment could further reduce mortality. This is added responsibility of the transfusionist. The initial presenting symptom of a serious hemolytic transfusion reaction is similar to febrile non-hemolytic transfusion reaction.
Any adverse reaction should be treated as potentially life threatening. Transfusion reactions may be divided as follows:
ACUTE ADVERSE REACTIONS (<24 HRS ):
Occur in less than 24 hours of transfusion.
DELAYED ADVERSE REACTION TO TRANSFUSION (> 24 HRS ):
The reaction occurs after 24 hours.
THE ROLE OF TRANSFUSIONIST IN CASE OF AN ACUTE TRANSFUSION REACTION:
He is the first to suspect and first to take action.
THE ROLE OF BLOOD BANK LABORATORY
a) Check for error of identification: Recheck all the steps of transfusion process. IN
CASE OF MISIDENTTFICATION SEARCH FOR OTHER PATIENT AT RISK.
b) Visual check for hemolysis:
Post reaction plasma for hemoglobinemia.
Elevated bilirubin by 5-7 hrs.
Post reaction urine sample for hemoglobinuria
c) Serological check for incompatibility Direct Agglutination
2. FEBRILE NON HEMOLYTIC TRANSFUSION REACTION (FNHTR):
is defined as rise in temperature of 1°C with orwithout rigors.
It occurs early during transfusion or 1-2hoursafter completion.
Incidence: It is common. Incidence is 0. 5 to 1%. Higher incidence is seen with multiple transfusions and in multiparous females.
Aetiology: Antibodies to leucocytes; Cytokine release. Clinical picture: Fever with or without chills, mild rise in temperature; responsive to antipyretic.
Warning sign: Severe rigors, temperature more than 40°C suggest bacterial sepsis. Recurrence: 1 out of 7 with previous Febrile Non Hemolytic Transfusion Reaction.
Management: It is a diagnosis of exclusion. Stop transfusion till hemolytic transfusion reaction ruled out. Blood can be restarted if hemolytic reaction is ruled out. Restart blood transfusion slowly. If hemolytic reaction is ruled out, Chlorpheniramine 50 mg & paracetamol may be administered as a supportive treatment.
Prevention: a) Use Leucodepletion filters if history of more than 2 FNHTR. b) Saline washed RBC. c) Premedication with paracetamol.
3. ALLE RGIC URTICARIAL REACTION:
Incidence: 1 to 3%.
ACUTE IMMUNE HEMOLYTIC TRANSFUSION REACTION (AIHTR):
1) Symptoms: Transfusion recipient complains of chills, flushing, sweating, chest pain, pain at the infusion site, back pain, abdominal discomfort, nausea, vomiting and restlessness.
2) Signs: Fever with rigors, tachycardia, dyspnoea, hypotension, tachypnoea, pallor, yanosis, anuria / oliguria, shock, DIC and hemoglobinuria.
3) In an Unconscious patient: Hypotension, hemoglobin- uria, uncontrolled bleeding (DIC)
“Any febrile reaction — treat as AIHTR unless proved otherwise”
TREATMENT and work up of AIHTR:
STOP THE BLOOD COMPONENT TRANSFUSION
IMMEDIATELY. Maintain IV access with crystalloid.
Maintain blood pressure and pulse (vital parameters).
Maintain adequate ventilation.
Give a diuretic and/or institute fluid diuresis.
Obtain blood and urine samples for transfusion reaction workup.
IF INTRAVASCULAR HEMOLYSIS IS CONFIRMED then
a. Monitor renal status (BUN, Creatinine).
b. Monitor coagulation status (PTA, PTT, fibrinogen, FDP).
c. Monitor for signs of hemolysis (bilirubin, LDH, haptoglobulin).
d. If sepsis is suspected send appropriate blood cultures &start appropriate antibiotics.
All the precaution to be taken to minimize human error.
a. Well drawn protocols are to be followed.
b. The duties of phlebotomist to medical technologist to transfusionist are to be delineated and followed strictly.
c. Education of the transfusionist is a must as he has the last opportunity to prevent misidentification and the first one to identify transfusion reaction.
d. It is desirable to have a well defined transfusion team.
NON IMMUNE HEMOLYSIS - BACTERIAL CONTAMINATION:
TRALI (Transfusion Related Acute Lung Injury):
TRANSFUSION ASSOCIATED GRAFT VERSUS HOST DISEASE - Ta GvHD:
Incidence: Very rare.
CCI = Post transfusion count - Pre Transfusion Count x BSA (M2)* No. of Platelet administered x 1011