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Transfusion reactions
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Fever with or without chills This is the most frequent transfusion reaction. Cause This reaction is chiefly the result of leukocyte antibodies. Such a reaction is unpleasant but temporary. These antibodies are formed as a result of pregnancy or previous blood transfusions. Fever during or shortly after transfusion can also be caused by haemolysis of erythrocytes by (irregular) antibodies against erythrocytes (see 10.4) or through bacterial contamination of the blood product that can be an immediate cause of sepsis. These reactions can have a serious clinical course and demand direct intervention (11.1.2). It is for this reason that these causes must also be excluded. Fever reactions can also occur with the administration of thrombocytes as a result of antibodies against thrombocytes (HLA or thrombocyte-specific) or cytokines in the product Action
Future policy If the fever reaction occurs repeatedly and investigation of irregular antibodies against erythrocytes and bacterial contamination are negative, it is recommended that premedication be used prior to the transfusion. The administration of selected HLA-compatible thrombocytes is indicated (see also Chapter 4) for patients that had no further increase in the number of thrombocytes after thrombocyte transfusion in the absence of other thrombocyte metabolism-promoting factors. NB: Fever reactions should occur less frequently due to the introduction of leukocyte removal for all cellular blood products. Top Chills with or without slight rise in temperature Cause Chills occurring with the administration of thrombocyte concentrates can be caused by cytokines that are released from leukocytes in the thrombocyte product during storage. As from 1 September 2001, Sanquin has removed the leukocytes from thrombocyte concentrates before storage. See also 10.1. Action Administer antihistamines and/or corticosteroids (dependent upon the local policy), and continue the transfusion under clinical guidance (with slower infusion, if necessary). Future policy If the chills occur repeatedly, and the introduced investigations have disclosed nothing of importance, then consideration may be given to premedication. Fewer reactions have been described with thrombocytes in storage fluids than with thrombocytes in plasma. Allergy: itching, urticaria, glottal oedema, anaphylactic shock Cause These reactions are chiefly the consequence of antibodies in the patient against plasma proteins from the donor, or the presence of atopes in the blood products. Action With itching and/or urticaria: in general, this is no reason for interrupting the transfusion. Antihistamines may be considered. The transfusion rate can be reduced, if necessary. Glottal oedema and/or anaphylactic shock: immediately end the transfusion. Administration of antihistamines, corticosteroids and/or adrenaline, shock control. Examination: the patient’s IgA and anti-IgA. Future policy With anti-IgA: washed erythrocytes; it is preferable that no plasma-containing blood products be administered. In special cases and in consultation with the blood bank, consideration can be given to the calling up of IgA negative donors. Rule out other causes with anaphylactic shock without anti-IgA: test transfusion under intensive supervision. For remaining cases: if the reaction is repeated with washed erythrocytes, consideration can be given to administering antihistamines prior to transfusion. Acute haemolytic transfusion reactions (HTR) Cause These reactions are the result of (irregular) antibodies from the patient directed against donor erythrocytes with the corresponding antigen. The cause is usually a human error in the organisation, such as a switching of cross-match tubes, an incorrect label on the cross-match tube, an incorrect label on the blood bag, and the switching of patients or blood products. With ABO incompatibility, an intravascular haemolysis (which lasts a few hours) can already occur within a few minutes. With irregular antibodies against erythrocytes, the reaction begins only after a few hours and can last for days. Symptoms: warm feeling at the infusion site and in the face, cold chills, agitation, high fever, chest pain, back pain, dyspnea, nausea, tachycardia, hypotension, tendencies towards bleeding as a result of disseminated intravascular coagulation, icterus and reduced kidney function with oliguria/anuria. Action
Future policy (Typed) compatible erythrocytes. A life-long record of information about the presence of antibodies against erythrocytes (attached to the patients’ data) must be kept in the blood transfusion laboratory on a blood groups card (with explanation to the patient) and/or on a Medical Alert Bracelet. Top Delayed HTR This reaction is the consequence of the rapid formation of irregular antibodies against erythrocytes. The antibody production proceeds so rapidly that a reduction of the HB concentration occurs, or the expected Hb increase fails to appear, 2 to 10 days afterwards There may also be the occurrence of icterus, fever and, occasionally, haemoglobinuria. Cause The patient was immunised with a previous pregnancy or transfusion, but these antibodies are not demonstrable at the moment of the compatibility study. The new erythrocyte transfusion acts as a booster injection with secondary immune response and the production of a large titre of antibodies that result in the breakdown of erythrocytes. Action Check the administrative procedure of the most recent transfusion (identification of patient and donor, transfusion history of the patient, T/S report and or matching test, etc.). The patient’s blood is investigated as rapidly as possible after transfusion for antibodies against erythrocytes (direct anti-globulin test, screening against panel test erythrocytes). Other clinical investigation: LDH, bilirubin, haptoglobin, and free haemoglobin in serum and urine. Future policy (Typed) compatible erythrocytes. A life-long record of information about the presence of antibodies against erythrocytes (attached to the patients’ data) must be kept in the blood transfusion laboratory on a blood groups card (with explanation to the patient) and/or on a Medical Alert Bracelet. Blood-transmissible diseases The transfer of viral infections such as HIV and hepatitis currently occurs only rarely. The risk of transmission of the hepatitis B virus in tested blood is estimated at one in 200,000 transfusions, while that of HIV and hepatitis C virus are approximately one in 1 to 2 million transfusions. Bacterial contamination of donor blood can lead in a few cases to the induction of bacteraemia or sepsis. Other blood-transmissible infections such as malaria, toxoplasmosis, babesiosis and Chagas’ disease occur only extremely rarely, or not at all, in the Netherlands. If the recipient of a transfusion/transfusions experiences a blood-transmissible disease, then the Sanquin blood bank (alongside the hospital blood transfusion laboratory) must be notified of this as quickly as possible (including time[s] of transfusions[s] with reports of UIN and product code[s]). Blood products that are from the donor(s) and that are still in storage can be blocked so that transfusions to other patients can still be prevented. Cytomegalovirus (CMV) infection is a persistent infection that occurs in 50-60% of the Dutch population. The virus is latently present in the leukocytes, as a result of which transfer of CMV can occur via leukocyte-containing cellular blood products. CMV-safe blood products are therefore indicated for anti-CMV-negative patients with reduced immunity. CMV-safe cellular blood products include: leukocyte-free blood products or blood products from tested anti-CMV negative donors. As from 1 January 2002, all standard cellular blood products from Sanquin are leukocyte-free. Antenatal CMV infection can lead to serious symptoms of illness, including intra-uterine growth retardation and microcephalia. Intra-uterine transfusions are tested for CMV. Graft Versus Host Disease (GVHD) GVHD can be prevented by radiating cellular blood products upon indication (see 8.3) with at least 25 Gy. See the product description for radiated blood products. Top Post-transfusion purpura (PTP) Post-transfusion purpura (PTP) is a temporary, acute and serious thrombocytopoenia that may arise 5 – 12 days after transfusion, chiefly as the consequence of anti-HPA1a (anti-thrombocytes) antibodies in the recipient. PTP occurs mostly in older, HPA-1a negative women that were earlier immunised by pregnancies or transfusions. PTP also occurs sporadically in men. The tendency towards haemorrhage manifests itself as extensive purpura, but there may also be the occurrence of gastro-intestinal haemorrhages or haemorrhages in the urinary tract. The mechanism of the breakdown of the patient’s own (HPA-1a negative) thrombocytes is not clear. Treatment consists of the prevention of serious haemorrhages. High doses of intravenous immunoglobulin (IVIG) and/or corticosteroids are sometimes effective. Thrombocytes, even HPA typed, frequently have no effect. The administration of plasma must be avoided because this frequently contains dissolvable thrombocyte antigens. Transfusion related lung injury (TRALI) TRALI involves an acutely arising elevated permeability of the pulmonary microcirculation with massive leakage of fluid and protein in the alveolus and the interstitium, mostly within 6 hours after transfusion. The occurrence of TRALI is in many cases associated with anti-granulocyte or anti-HLA antibodies in the donor, and sometimes in the recipient. The precise mechanism is not known. Treatment consists of aggressive respiration therapy. Other transfusion reactions Allo-immunisation: Allo-immunisation against erythrocytes can arise through transfusions and pregnancies. It can cause problems with future erythrocyte transfusions and pregnancies (haemolytic illness of the newborn); see 3.1.4. Allo-immunisation against HLA antigens can arise through transfusions and pregnancies and be the provocation of refractoriness with future thrombocyte transfusions. Allo-immunisation against HPA antigen can arise due to transfusions and pregnancies and can be the provocation of post transfusion purpura with future transfusions and neonatal allo-immune thrombocytopoenia with future pregnancies. Circulatory overfilling leading to pulmonary oedema can occur after transfusion of an excessive volume or an excessive speed of transfusion. This is chiefly a risk for the elderly and patients with serious chronic anaemia for which a low erythrocyte volume is compensated by a high plasma volume. Small concentrations of transfused product can elicit symptoms in patients that are actually already at risk and have a positive fluid balance. Under cooling can be a risk for cardiac arrhythmia or provoke cardiac arrest. Rapid transfusion of a large concentration of blood can cause the body temperature to drop. The risk is particularly large in patients in shock or those who have undergone a surgical procedure under anaesthesia that is already able to influence the temperature regulation. A blood warmer may be considered with rapid transfusions. In order to prevent the occurrence of haemolysis, only blood warmers that were intended for this should be used. Citrate toxicity is caused by a reduction of ionised calcium through the presence of a large concentration of citrate anticoagulants in the circulation. Hypocalcaemia; the stock of calcium in the body is large, citrate is mostly immediately metabolised by the liver, and furthermore, this complication is rare. Patients with serious hepatic disease or with shock resulting in limitation of the hepatic circulation can develop physiologically significant hypocalcaemia after rapid transfusions of large concentrations of blood products (in particular, plasma). It is recommended that there be an assay of ionised calcium and monitoring with an electrocardiogram. Other metabolic changes can arise with rapid transfusion or transfusion of large concentrations (chiefly in patients with already existing circulatory or metabolic problems). This includes, among others, acidosis or alkalosis (caused by the conversion of citrate to citric acid, and the subsequent conversion into pyruvate and bicarbonate) and hyperkalaemia or hypokalaemia. For small children with massive blood loss, people should be prepared for a high to very high potassium in the supernatant if the erythrocytes have been stored longer (5 to 35 days). This potassium can lead to rhythm disorders and cardiac arrest with rapid transfusions of large concentrations. Nonimmunologic haemolysis rarely occurs, but can be provoked by intravenous administration of hypotonic fluids, simultaneous administration of medicines or parenteral feeding, bacterial toxins, physiologic damage of erythrocytes through freezing or heating, metabolic damage with haemoglobinopathy, or enzyme deficiencies. ALWAYS REPORT TRANSFUSION REACTIONS TO THE TRANSFUSION LABORATORY OF YOUR HOSPITAL ALL TRANSFUSION REACTIONS THAT MAY BE RELATED TO THE BLOOD PRODUCT MUST BE REPORTED AS RAPIDLY AS POSSIBLE TO THE SANQUIN BLOOD BLANK. Haemovigilance In 2003 the national Foundation for Transfusion Reactions in Patients (TRIP) will take over the national registration and reporting of complications and undesirable effects of blood transfusions. Top |