Acute transfusion reaction

Background

• If concern for fluid overload, may need to transfuse as split pRBCs to tranfuse as slow as 1mL/kg/hr
• Sepsis is most commonly due to yersinia, which is able to grow easily in refrigerated blood

Transfusion Risk Ratios

Rate	Complication
1:10	Febrile non-hemolytic transfusion reaction per pool of 5 donor units of platelets (1 pack)
1:100	Minor allergic reactions (urticaria)
1:300	Febrile non-hemolytic transfusion reaction per unit of RBC (1 pack)
1:700	Transfusion-associated circulatory overload per transfusion episode
1:5,000	Transfusion-related acute lung injury (TRALI)
1:7,000	Delayed hemolytic transfusion reaction
1:10,000	Symptomatic bacterial sepsis per pool of 5 donor units of platelets
1:40,000	Death from bacterial sepsis per pool of 5 donor units of platelets
1:40,000	ABO-incompatible transfusion per RBC transfusion episode
1:40,000	Serious allergic reaction per unit of component
1:82,000	Transmission of hepatitis B virus per unit of component
1:100,000	Symptomatic bacterial sepsis per unit of RBC
1:500,000	Death from bacterial sepsis per unit of RBC
1:1,000,000	Transmission of West Nile Virus
1:3,000,000	Transmission of HTLV per unit of component
1:3,100,000	Transmission of hepatitis C virus per unit of component
1:4,700,000	Transmission of HIV per unit of component

Clinical Features

• Etiology specific, see ddx below

Differential Diagnosis

Transfusion Reaction Types

• Acute
  • Intravascular hemolytic tranfusion reaction
  • Febrile nonhemolytic tranfusion reaction
  • Allergic tranfusion reaction
  • Transfusion-associated circulatory overload (TACO)
  • Transfusion-related acute lung injury (TRALI)
  • Transfusion-associated graft-versus-host disease
  • Fluid overload
  • Sepsis
• Delayed
  • Extravascular hemolytic tranfusion reaction
  • Graft-vs-host disease
  • Tranfusion Infections

Acute allergic reaction

• Allergic reaction/urticaria
• Anaphylaxis
• Angioedema
• Asthma exacerbation
• Anxiety attack
• Scombroid
• Cold urticaria
• Contrast induced allergic reaction
• Shock
• Transfusion reaction
• Carcinoid syndrome

Evaluation

• Workup of hemolytic reaction
  • CBC with microscopy differential
  • Formal urinalysis with bilirubin
  • Haptoglobin, LDH, free hemoglobin
  • Serum total and direct bilirubin
  • Coombs test of pre-transfusion and post-transfusion blood

• Consider CXR to help differentiate anaphylaxis, TRALI, TACO

TRALI vs TACO

	TRALI	TACO
Onset	Acute, within 6hrs	Often more gradual
BP	Low	High
Temp	Febrile	Normal
JVD/pedal edema	Unlikely	Likely
CVP/PAWP	Normal	Elevated
BNP	Normal	Elevated
Resp	Dyspneic	Dyspneic
CXR	B/l infiltrates	B/l infiltrates

Management

• For all reactions:
  • Stop the transfusion (at least temporarily)
  • Call the blood bank
  • Draw a new type + screen

See Also

• Transfusions
• Acute transfusion reaction
• Extravascular hemolytic tranfusion reaction
• Graft-vs-host disease

References

Authors

Ross Donaldson, Neil Young