Serious hazards of transfusion
Dr Kenneth S Charles
MB.BS (UWI), FRCP (UK), FRCPath(UK)
Senior Lecturer in Haematology
Introduction
Case study
Definition of adverse effect
Classification
Pathophysiology
Management
Prevention
Red cell concentrate
Cryoprecipitate
Platelet concentrate
Fresh frozen
plasma
When do patients require
transfusion?
Red cells Hb < 7.0 or acute blood loss
- Hb < 9.0 pre-op
Platelets - Active bleeding + platelets < 50
- Prophylactic/ platelets < 10
Fresh frozen plasma prolonged PT and/or
APTT + active
bleeding
or planned procedure
Cryoprecipitate no response to FFP
Case study
26 year old man
Relapsed Hodgkins Lymphoma
Chemotherapy
Sepsis/Disseminated Intravascular
Coagulation
2 U RBC, 6 U platelets, 6 U FFP
6 hours later, dyspnoea, hypoxia
Adverse reaction
Any untoward event occurring within a few
hours, weeks or months of and as a direct
result of administration of a blood
component
Classification
Immediate/Delayed
Infectious/Non-infectious
Immune/Non-immune
Clinical presentation
Adverse reactions classified by
clinical presentation
Febrile
Haemolysis
Acute haemolytic transfusion reaction
Delayed haemolytic transfusion reaction
Sepsis
Bacterial contamination of component
Antileucocyte antibodies
Adverse reactions classified by
clinical presentation
Dyspnoeic
Transfusion related acute lung injury
Congestive cardiac failure
Anaphylaxis caused by IgA deficiency
Adverse reactions classified by
clinical presentation
Urticarial
Allergy to plasma proteins
Adverse reactions classified by
clinical presentation
Other
Iron overload
Transfusion Transmissible infections
HIV
HBV
HCV
Syphilis
HTLV1
Graft versus host disease
Posttransfusion purpura
FEBRILE
Acute Haemolytic Febrile Transfusion
Reaction (AHFTR)
As little as 20 mls incompatible RBCs
1 in 7 000 transfusions
Mortality 10%
Anti-A, anti-B, anti-Kell, anti-Kidd, antiDuffy, anti-Lewis
AHFTR contd
Abs in recipients serum activate
complement to initiate intravascular lysis
Catecholamines and kinins released
DIC in 30-50%
Fever, chills, nausea, pain at IV site,
chest and back pains (intravascular
occlusion by agglutinated red
cells),hypotension, dark urine
Nephrotoxic effects of anti-red cell stroma
AHFTR
Stop transfusion
IV hydration - Normal Saline to systolic BP
> 100 mmHg, UO > 100 ml/hr
Diuresis - +/- IV Frusemide or mannitol
Appropriate samples to blood bench
Conditions mimicking AFHTR
Improperly warmed blood
Blood piggy-backed
(D)Some technical aspects of the
administration of blood and blood
components: blood warming
Rarely indicated
Only with specifically designed blood warmers
with visible thermometer and audible warning
NOT hot water bath, microwave, radiator.
Massive transfusions in adults, exchange
transfusions in neonates, clinically
significant cold agglutinins
BCSH, 1998
Delayed Haemolytic Transfusion
Reaction (DHTR)
Clinically occult
Occur 2-21 days after transfusion
1 in 500 transfusions
Death rare
Anti- Kell, Duffy, Kidd, Rhesus in patients
sensitized by transfusion, pregnancy
Low grade fever, jaundice, no rise in Hb, positive
DCT, spherocytes
Acute Renal Failure rare. Most self-limiting
Direct Coombs Test
Bacterial contamination
Especially platelet concentrate
Sources donor bacteraemia, donor arm,
contamination during processing
Fever, chills, shock, ARF, DIC
G- and G+ bacteria
Mortality 26%
Fate of unused red cells
1
Domestic refrigerator
Returned to Blood
Bench
25
(B) Collection of blood or blood components from
the hospital blood bank or blood transfusion issue
refrigerator and its delivery to the ward or operating
theatre
The transfusion of blood and blood components should
begin as soon as possible after delivery to the ward or
operating theatre. If not possible, return to blood
transfusion refrigerator. If > 30 mins return to hospital
blood bank for disposal (risk of bacterial infection)
If the ward or operating room does not have a
refrigerator that is approved for storing blood, the
blood should not be released from the blood bank
until immediately before transfusion
BCSH, 1999
Wastage: Blood returned from
wards
DYSPNOEIC
Non-haemolytic febrile
transfusion reactions (NHFTR)
Most common type of transfusion reaction
Granulocyte and HLA-specific
antileucocyte Abs develop in recipient by
pregnancy, previous transfusion
Lysis of donor WBCs and release of
cytokines
1 in 200-500 transfusions
Leucocyte antigens
HLA Class I and II
Neutrophil specific antigens NA-1, NA-2,
NB
HLA Antigens
Febrile Non-haemolytic Transfusion
Reaction (FNHTR)
Fever, otherwise well
Stop transfusion
Exclude haemolysis, bacterial
contamination
Acetominophen 650 mg
Resume transfusion
If recurs, leucocyte filter
Non-cardiogenic pulmonary oedema
(TRALI)
1 in 5 000 transfusions
Donor antileucocyte Abs (previous
transfusions, pregnancy) passively
transfused to recipient
Any blood component
Ag/Ab complexes trapped in pulmonary
vasculature
Dyspnoea, hypoxia, chills, fever
TRALI
TRALI
CXR bilateral lower-lobe infiltrates
Donor antileucocyte Abs demonstrated
Rx D/C transfusion, O2, IV methylpred
Most resolve within 12-24 hrs
If not, IPPV until resolved
Donor excluded from future donation
TRALI
Congestive Cardiac Failure
(CCF)
Safe rate for 1U RBCs 2-3 hrs
Anaphylaxis
Hereditary IgA deficiency 1 in 700 in USA
Complement-fixing IgG anti-IgA through
pregnancy or transfusion
Dyspnoea, chest pain, nausea, abdo
cramps, hypotension
IV epinephrine, methylprednisolone
Washed red cells, IgA deficient donors
URTICARIAL
Urticaria
Allergic reaction to plasma proteins
Usually FFP but any component
Skin rash, pruritis
Antihistamine and continue transfusion
OTHER
Infective risks of blood transfusion
Risk factor
Estimated frequency
Hepatitis A
1 in 1 000 000
Hepatitis B
1/30 000-1/250 000
Hepatitis C
1/30 000 1/150 000
HIV
1/200 000 1/2 000 000
HTLV1
1/250 000-1/2000 000
Centralized screening for TTIs
HIV, HBsAg
Syphilis,
HCV
HTLV1, Chagas
NBTS - Day after accident
Risk of HIV seropositivity per 100,000 donors
350
300
250
200
150
100
50
0
Voluntary
WHO,2002
Replacement
Paid
Serological markers NBTS
Year
Sample HIV
(no)
HBsAg
HTLV1
HCV
TP
Chagas
2000
14 882 0.19
0.83
0.94
0.37
0.55
ND
2004
13742
0.58
1.46
0.77
2.16
0.05
0.21
ANNUAL DONATIONS BY TYPE
25000
106
NUMBER
95
165
20000
15000
95
78
66
18055
19589
1551
1322
19209
19867
2707
2908
AUTOLOGOUS
REPLACEMENT
VOLUNTARY
10000
11275
11817
1866
1808
5000
0
2004
2005
2006
2007
YEAR
2008
2009
Seropositivity in blood donors
1.6
1.46
1.4
Percentage
1.2
1
T&T
UK
0.77
0.8
0.58
0.6
0.4
0.21
0.2
0.15
0.1
0.004
0.005
0
HIV
HBsAg
HCV
HTLV1
TTIs 2009
HIV
HBV
HCV
SYPH
HTLV
CHAGAS
ALL
REPLACEMENT
43(0.21)
68(0.33)
41(0.20)
275(1.3)
195(0.97)
11(0.05)
633(3.2)
VOLUNTARY
3(0.14)
1(0.05)
5(0.23)
5(0.23)
14(0.64)
0(0)
28(1.3)
Voluntary donor %
HIV in donors
%
1.2
1
0.8
JAM
0.6
TRT
0.4
CUR
0.2
0
2005
HBsAg in donors %
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
2007
HCV in donors
%
BAR
JAM
TRT
CUR
2005 2006 2007 2008 2009
2006
2008
2009
Window period/days
Virus
ELISA
NAT (PCR)
HCV
88
23
HBV
56
31
HIV
22
12
VIP Blood Screening LATAM meeting, Pleasanton, CA, Oct 2007
Blood donation rate per 10,000 inhabitants and
proportion of units reactive/positive for
infectious markers in 2005
Country
Donation rate
% TTI markers
Jamaica
83.6
5.0
Trinidad and Tobago
104.4
4.69
Curacao
368.6
0.03
From : PAHO, CD 48/11 Annex
A
Wastage: Seropositive units for
discard
Transfusion Associated Graft
Versus Host Disease
Engraftment of donor lymphocytes in the
blood of patients with impaired cellular
immunity
Congenital SCID, organ transplant
recipients, Intrauterine Transfusions,
Hodgkins Disease, purine analogues
7-10 days. Skin, gut, liver, pancytopaenia
90% mortality. No effective Rx
15 Gy irradiation of blood components
Post Transfusion Purpura (PTP)
Middle aged, multiparous
PlA1 negative
Severe thrombocytopenia 7-10 days after
transfusion
AlloAb to PlA1 destroys transfused and
recipient platelets
Rx - IVIg
Iron overload
IU red cells contains 250 mg iron
No iron excretion mechanism
Skin, joints, liver, heart, endocrine glands
Iron chelation intravenous, s/c
- oral
thalassaemia major patients
Case study
26 year old man
Relapsed Hodgkins Lymphoma
Salvage chemotherapy
Sepsis/Disseminated Intravascular
Coagulation
2 U RBC, 6 U platelets, 6 U FFP
6 hours later, dyspnoea, hypoxia
Case study
TRALI
IPPV
Later succumbed to malignancy
Female donor anti NA-1 Abs
WHO integrated strategies to
promote global blood safety
Establishment of nationally co-ordinated
BTSs
Voluntary non-remunerated blood
donors
Testing of all donated blood, screening
for TTIs, blood grouping, compatibility
testing
Reduction in unnecessary transfusions
WHO (2006a) Aide memoire on Blood Safety for National Blood Safety for
National Blood Programmes. Information sheet.
Summary
Case study
Definition of adverse effect
Classification
Pathophysiology
Management
Prevention
When do patients require
transfusion?
Red cells Hb < 7.0 or acute blood loss
- Hb < 9.0 pre-op
Platelets - Active bleeding + platelets < 50
- Prophylactic/ platelets < 10
Fresh frozen plasma prolonged PT and/or
APTT + active
bleeding
or planned procedure
Cryoprecipitate no response to FFP
