REACTIONS TO BLOOD TRANSFUSION

• Human error is responsible for 1 in 3 transfusion related deaths
• Use Positive Patient Identification (PPID) at every step of the transfusion pathway to uphold patient safety
• ask patient to state his/her name and date of birth whilst checking against patient’s wristband
• Encourage patients to report any symptoms experienced during or following a transfusion
• Inform all patients who have received blood components or products that they can no longer be a blood donor

Previous history

• Most common with platelets (particularly apheresis) and plasma
• Increased incidence in patients with a history of hay fever (but not causal)
• Occur early during transfusion
• within 15 min for mild allergic, often within few minutes for severe
• Mild: affecting skin only e.g. rash, itching, hives
• >80% allergic reactions are mild
• Anaphylactic reactions affecting ≥2 organ systems vary in severity from mild to life-threatening
• vast majority the former
• Risk of recurrence is very low
• approximately <1:50 and even in ‘frequent reactors’ <1:20, although reactions may cluster

Management of transfusions in patient with a history of allergic reaction

Previous mild reaction

• No pre-medication
• If reaction re-occurs, administer antihistamine

Moderate previous reaction

• No evidence for routine pre-medication
• if history of chronic recurring reactions, consider pre-medication with non-sedating, long-acting antihistamine
• Monitor patient closely
• Consider slower administration
• Use pooled platelets in Platelet Additive Solution (PAS)
• If reaction re-occurs, administer antihistamine

Severe previous reaction

• Avoid transfusion wherever possible. See Red cell transfusion guideline: Alternatives to transfusion
• Use plasma reduced products
• i.e. pooled platelets in PAS or Solvent-detergent treated Fresh Frozen plasma (SD-FFP)
• Pre-medicate with histamine H₁ (chlorphenamine or non-sedating antihistamine) and H₂ receptor antagonists (cimetidine, ranitidine)
• not hydrocortisone
• Consider washed RBC/platelets (discuss with transfusion consultant/NHSBT), especially if history of life-threatening reaction
• If IgA antibodies, consider components from IgA deficient donors (discuss with transfusion consultant/NHSBT)
• Administer slowly in closely monitored unit

• Acute transfusion reactions (ATRs) occur during or <24 hr following a transfusion
• Transfusion associated circulatory overload (TACO) is the commonest cause of morbidity and mortality relating to transfusion
• For all suspected ATRs
• temporarily stop the transfusion
• confirm product against PPID and ensure component integrity
• perform full set of observations including fluid balance

Symptoms and signs of an ATR

• Fever, chills, rigors, tachycardia, respiratory distress
• Hyper- or hypotension, collapse
• Flushing, urticaria
• Pain (bone, muscle, chest, abdominal)
• Nausea, general malaise
• Rapid onset of loin/abdominal pain, a ‘feeling of impending doom’ and/or warmth along vein may represent an acute haemolytic transfusion reaction e.g. ABO incompatible transfusion
• In an unconscious patient, the first indication of ATR may include tachycardia, hypotension, bleeding

Management of suspected ATR

• Undertake rapid clinical assessment
• Check pateint ID/Blood compatablity label
• Visual assessment of transfusion solution
• Decide on severity of reaction and appropriate action. See advice below

• Delayed haemolytic transfusion reactions (DHTR) occur >24 hr after transfusion in a patient who has been previously allo-immunised to a red cell antigen by blood transfusion or pregnancy

Prevention

• Timings of Group &Save samples should reflect patient’s current immune status
• although allo-antibodies may be undetectable in pre-transfusion screening
• Provide irradiated blood components where necessary to prevent transfusion-associated graft vs host disease (TaGVHD)
• where viable lymphocytes engraft and mount a fatal immune response in susceptible patients
• Patients born after 1/1/1996 should receive non-UK, virally inactivated plasma products
• transmission of variant Creutzfeldt-Jakob disease (vCJD) remains a concern

Symptoms and signs

Delayed haemolytic transfusion reaction (DHTR)

• Occurs <14 days post transfusion
• Jaundice, fever
• Anaemia/poor increment in Hb
• Haemoglobinuria, possibly renal failure

Post-transfusion purpura (PTP)

• Occurs 5–12 days post transfusion
• Bleeding, thrombocytopenia

Post-transfusion viral infection

• Symptoms/signs of infection
• Viral transfusion transmitted infections are now very rare in developed countries
• Confirmation depends on extensive testing

Transfusion associated graft vs host disease (TaGVHD)

• Occurs typically 7–14 days post transfusion
• Fever, rash, diarrhoea, liver dysfunction, cytopaenia
• Fatal

Iron overload

• Occurs over years
• Iron deposition in liver, heart and endocrine organs resulting in organ failure

Allo-antibody formation

• Nil
• but may have implications for future transfusion practice