Introduction #
Safe blood transfusion practice requires observation and monitoring of the patient for adverse reactions and proper management of those reactions should they occur.
It is the responsibility of the registered nurse or physician administering the transfusion to be totally familiar with
- the types of reactions which may occur,
- the causes of those reactions,
- the signs and symptoms of reactions,
- the action required as per patient care guidelines.
Transfusion reactions may appear minutes, hours, days, weeks and even longer after the transfusion has occurred. Immediate reactions obviously require prompt attention.
Allergic Transfusion Reactions #
Allergic Transfusion Reactions are usually due to the presence of some protein in the donor blood that is foreign to the patient and to which the patient is allergic. Minor reactions of this type are fairly common.
Dr. Berry:
Its usually very obviously a very minor transfusion reaction with hives, itching at the site of the transfusion or in that arm or sometimes it becomes a little more diffuse and its again usually easily handled.
Again, the minor Allergic Reaction is characterized by a rash and/or hives, and itching, and is usually not accompanied by fever. Treatment may only involve stopping the transfusion for a short period of time and treating the symptoms.
There are many proteins in blood and blood products. Among them are five classes of immunoglobulins: IgA, IgD, IgE, IgG and IgM. If the patient is IgA-deficient, the allergic reaction to blood products can be much more severe.
Dr. Berry:
These patients with severe IgA deficiency develop anti-IgA antibodies and it’s in the exposure of these blood products that they basically have a classic severe anaphylactic reaction with bronchospasm, shortness of breath, respiratory distress and hypo tension. Similar to a kid with a peanut reaction and that is just like a kid with a peanut reaction – potentially lethal.
An Anaphylactic Transfusion Reaction may begin after transfusion of only a few millilitres, with systemic symptoms that are often mild at first, but can progress from shortness of breath to loss of consciousness and, in rare cases, death. Anaphylactic reactions occur suddenly, and symptoms may involve one or several systems, notably respiratory, gastrointestinal, circulatory, or the skin.
Febrile Non-Hemolytic Transfusion Reactions #
Febrile Transfusion Reactions are primarily caused by the presence of cytokines, leukocytes and/or plasma antibodies in the recipient plasma or in donor blood. In rare instances, a major reaction can occur as a result of bacterial contamination of the blood product.
Dr. Berry:
Febrile transfusion reactions are actually one of the most common transfusion reactions that we see and they can occur in up to 1% of recipients and, although it’s defined as a one degree increase in temperature in the patient. It’s usually associated with, with not only fever, but chills, flushing – it’s uncomfortable for patients. Its rarely is it medically very serious but it is uncomfortable and inconvenient. We feel it’s very important to discontinue those transfused units if they haven’t already been finished and sending them back to the blood bank simply because hemolytic transfusion reactions can be present initially with what appears to be just a febrile transfusion reaction and so its important to them seriously, discontinue them, send them back, and if the patient needs more blood another unit can be prepared for the patient.
Signs and symptoms include pyrexia, muscle cramps, nausea, and headache, flushing of the skin, tachycardia, chills, and rigors. Symptoms begin during or within 4 hours of transfusion, and may persist for 8 hours. In all febrile reactions it is critical that the possibility of bacterial contamination is ruled out.
Dr. Berry:
These are all human blood products and so they are always susceptible to bacterial contamination which can occur at the time of that unit being retrieved from the donor, so skin contamination or in fact bacteria in the donor themselves can flourish or grow in that unit of blood even though it is stored at 4 degrees in a blood bank fridge.
Dr. Growe:
Now platelets are the blood cells that are used for clotting, so they’re not nearly as widely used in transfusion as red cells and plasma, for example. They are mainly used in people that have very low platelet counts and have bleeding tendencies and the majority of these patients are patients with malignant disease, cancer, leukemia and bone marrow transplant and those related conditions. However, they are very susceptible to infection as well because of their underlying condition and their treatment. We do worry about platelets because we know that platelets are being stored at room temperature and if an infection gets into the platelet, that it is very difficult to control.
In cases of Febrile Transfusion Reactions, it is recommended that the blood or blood product be sent to the laboratory for culture. Blood cultures on the patient should be done according to individual hospital policy and/or Physician Orders.
Circulatory or Volume Overload #
Another immediate non-immune reaction is due to rapid administration of large quantities of blood or blood products, resulting in simple volume overload. This is common in elderly patients or infants, and others who may have limited cardiopulmonary reserve, possibly from pre-existing congestive heart failure.
Dr. Berry:
That’s usually manifested by respiratory symptoms, shortness of breath, wheezing, symptoms such as those, may result in signs such as hypertension and in fact hypo tension and other cardiac consequences like angina for instance, because of the patient population in many hospitals, the elderly, patients with cardiac problems, volume overload actually is a relatively common consequence and, although it can be handled with diuresis, or diuretic drugs before, during or after a transfusion it’s important to keep in mind that volume overload can potentially be lethal.
Dr. Growe:
Now the most common cause of shortness of breath with transfusion or after transfusion is that the patient has been given too much fluid overall. Now very often when patients are in emergency or in the operating room or even sometimes on the ward, if they’ve been bleeding or, they may have received a lot of other fluids in order to keep their blood pressure up and it is possible, in that situation, to create an overload of volume, and if people are especially older or have had heart disease of lung disease before it would be very easy to put them into heart failure, if they got too much fluid. So one has to look at the overall fluid infusion to the patient to see if a patient becomes short of breath, whether this is likely, and certainly one of the things that should be done with this as with any other severe reactions is the blood should be stopped while all this investigation is going on.
Immediate Immune Hemolytic Transfusion Reactions #
Dr. Growe:
One of the major problems with transfusion causing adverse reactions is patients getting the wrong blood or blood product. Now if they get the wrong red cell blood group they may very well have what we call a hemolytic transfusion reaction, and in this situation the patient may show initially only a mild reaction such as fever or a bit of restlessness, but as the transfusion continues and it often does not require very much blood, the patient may get short of breath, complain of pain in the chest and the back, and this has to be recognized quickly, because the major, a major problem besides shock in these patients is renal failure, and the results of the hemolysis of the transfusion can effect kidney blood flow and other aspects of kidney function so the kidneys may shut down. So this is a very serious complication, has always been recognized in transfusion circles as the major problem, worry, and this is almost always due to ABO incompatibility and almost always due to the blood product getting to the wrong patient for some reason or other.
Dr. Berry:
Most of the time those are related to clerical errors and those clerical errors can occur anywhere from the time the patient gets a wrist band put on when coming into a hospital, through to a lab technologist taking a pre-transfusion blood sample, through the course of that sample in the blood bank and all the way through to the time the nurse actually administers the blood, there can be mistakes given and the wrong patient can be given the wrong unit of blood, and in the setting of major mis-match, a major ABO mismatch, there is immediate destruction of the transfused red blood cellsImmediate Immune Hemolytic Transfusion Reactions are the most frequent cause of major morbidity and mortality in patients related to red blood cell transfusion.They are most often a result of ABO incompatibility, but on rare occasions Acute Hemolytic Reactions have been due to blood administered to the wrong patient, mislabeling or wrong identification of the blood specimen, the presence of an antibody not detected in testing, or crossmatch error.
Dr. Berry:
It’s critical that the error not occur because once it occurred all the bad side effects can happen thereafter rather quickly. The clinical features that a nurse or a physician should be looking for, really are something as simple as chills and flushing and fever, all the way up through flank pain, nausea, rigors, shortness of breath, wheezing, patients often describe a feeling of impending doom, their blood pressure can become unstable with hypo tension or hypertension, and urinary out put can decrease over time, the bleeding consequences of disseminated intravascular coagulation and renal failure, are ultimately, what can be the demise of the patient, as a result of that kind of reaction.
Non-Immune Hemolytic Transfusion Reactions #
Hemolysis can occur in Non-Immune Transfusion Reactions if there has been physical or chemical damage to the red blood cells.
Dr. Berry:
Damage by overheating, damage by freeze/thawing, damage by hemolysis and hemolizing red blood cells in a bag can occur again as a result of those red cells being overheated – or in fact you can think of it as being cooked. They, they’re destroyed – the contents are spilled. Likewise if those red cells are frozen then in the process of thawing they’re destroyed, the contents are spilled. Another mechanism is diluting those red cells with the inappropriate solution, for instance half normal saline will cause those red cells to swell and be destroyed and spill their contents and the contents that are spilled include the hemoglobin as well other stromal contents of the red cells. And all those combined can initiate disseminated intravascular coagulation with the consequent problems with coagulopathy or bleeding and, as well can result in inner organ damage like renal failure, kidney failure, cardiac arrest and other lethal consequences.
Red blood cells and whole blood must be stored at 1-6 ° Celsius. In some situations blood must be warmed prior to transfusion. Quality control systems must be in place for all blood warmers, as well as fridges, freezers and containers used to store and transport blood and blood products.
Transfusion Related Acute Lung Injury (TRALI) #
Dr. Berry:
Transfusion Acute Lung Injury, also known as TRALI, is an ARDS like reaction, and that occurs in the setting of a donated unit with high titers of anti-neutrophil antibodies. The plasma fraction of the donated unit has a the high titer of anti-neutrophil antibodies and that basically results in white blood cell agglutination and damage to the lungs of the recipient and thus the acute lung injury or ARDS like reaction.
This reaction can occur during or in a few hours following a transfusion. Diagnosis can be difficult as severe symptoms may be indistinguishable from those of other causes. The Blood Transfusion Service should be informed immediately so they can investigate the donor and patient.
Management of Transfusion Reactions #
All reactions should be managed according to established hospital policies and procedures, if any of these symptoms, minor or major occur, first:
- Stop the transfusion immediately, and disconnect the blood set from the IV site.
- Run Normal Saline to keep the vein open.
- Verify patient identification with the blood product and requisition.
- Take vital signs as indicated in hospital policies and procedures.
- Notify the attending Physician and Transfusion Service immediately, and follow instructions.
- Complete the Transfusion Reaction Report Form, identifying all patient and blood product information, symptoms, and transfusion information. It is very important that all relevant information is reported accurately and quickly to your hospital Transfusion Service.
If the reaction consists only of hives and/or itching – that is, a Minor Allergic Reaction:
- No blood or urine specimen is required.
- With appropriate medication and frequent monitoring of vital signs.
- the transfusion may be restarted at a slower rate
- For ALL Other Transfusion Reactions:
Follow hospital procedures or contact the lab for appropriate specimen collection requirements for post transfusion blood and urine samples.
Monitor the patient’s renal function by obtaining the first voided urine.
Be sure to indicate on all specimens, report forms, and requisitions being sent to the laboratory that they are “post-transfusion” specimens.
Return the entire transfusion set-up, including tubing and previously completed blood product containers, to Transfusion Service as soon as possible.
Delayed Hemolytic Transfusion Reactions #
Delayed Transfusion reactions are those occurring more than 24 hours after a transfusion of blood or blood components. Appropriate documentation, storage and retrieval of transfusion information is essential for safe transfusion practice.
Post Transfusion Purpura #
Post Transfusion Purpura is associated with the presence in the patient through pregnancy or previous transfusion, of antibodies directed against human platelet antigens. It is characterized by the development of sudden thrombocytopenia arising 5 – 12 days following transfusion of red cells. The condition is characterized by hemorrages in the skin and mucous membranes that result in the appearance of purplish spots or patches.
Graft-vs-Host Disease #
Graft-vs-Host Disease results when a patient’s immune system is unable to recognize and eliminate HLA-mismatched lymphocytes, causing a characteristic immune response.
As Graft-vs-Host Disease is often fatal, it is essential to recognize in advance patient groups who are at risk. Diagnosis should be supported by skin/bone marrow biopsy appearances and/or the presence of circulating donor lymphocytes. Patients who are susceptible to Graft-vs-Host Disease must only receive Irradiated blood and blood products which are irradiated by a certified agency.
Alloimmunization to Blood Components #
Immune response to foreign antigens on red blood cells or white blood cells and platelets may result in platelet refractoriness, difficulty in finding compatible blood for subsequent transfusion, and could result in hemolytic disease of the newborn.
Infectious Disease #
Significant effort has been focused upon ensuring the safety of the blood supply. However all transfusions of human blood and blood products have an element of risk related to the transmission of disease as well as alloimmunization. Every effort must be made to ensure that patients and/or their guardians are adequately informed regarding the risks of transfusion. They should also have a primary decision making role in determining a course of treatment.
Many people are still quite concerned about the possibility of infections related to transfusion. Now there’s been tremendous strides made in the past 15 years in improving the screening of blood, the screening of blood donors and the treatment of blood products which has markedly diminished the risk that people would face with transfusion. However, blood and blood products are generally biological blood products obtained from human beings so the risks are not zero, and we have to understand that and we also have to be on the alert, which we are, to the possibility of new infections entering the blood system. I think it is important that if people have a concern about infections that they ask either the anesthetist, or the transfusion officer or the pathologist about the current rate risks in Canada regarding blood transfusion for various blood products and have the opportunity to discuss the potential of using some alternatives if they still have a concern about the risks.
Closing and Credits #
While some adverse responses to the transfusion of blood and blood products are unavoidable, the majority of serious reactions are the result of human error.
The skills and knowledge of the hospital staff in administering a transfusion, monitoring the patient, providing appropriate treatment, documenting the transfusion, and reporting adverse reactions are key elements of safe transfusion practice.
Yet the most crucial areas for patient safety involve the correct identification of the patient, the patient specimen, and the blood or blood product. Hospital policies and procedures should be followed carefully at all times, and these policies should be reviewed on an ongoing basis to constantly improve transfusion safety.