Blood transfusion: Non-infective complications

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Blood transfusionNon-infective complications

• Dr Dupe Elebute
• Consultant Haematologist

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Learning objectives

• Complications of blood transfusion
• Haemolytic transfusion reactions
• Febrile non-haemolytic reactions
• Transmitted infections
• Immunological complications
• Transfusion haemosiderosis
• Errors in transfusion (SHOT)

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Indications for red cell transfusions

• To replace blood loss
• Trauma
• Surgery
• Chronic gastrointestinal haemorrhage
• To correct anaemia
• Bone marrow failure aplastic anaemia,
  post-chemotherapy
• Haemoglobinopathies Sickle cell disease,
  Thalassaemia
• Severe haemolysis HDN
• Chronic disorders renal failure, malignancy

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Current mandatory testing

• TPHA (since 1940s)
• HBsAg (1971 - 72)
• anti HIV (October 1985)
• anti HCV (September 1991)
• HCV NAT (April 2001)
• anti HTLV (October 2002)

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Complications of blood transfusion

• EARLY
• Circulatory overload
• Febrile non-haemolytic reactions
• Allergic reactions
• Haemolytic reactions immediate or delayed
• Effects of massive blood transfusion
• Bacterial infections from contamination

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Late Complications of BT

• Transfusion transmitted infections (TTI)
• Viruses
• Hepatitis B, C HIV I II HTLV I II CMV
• Bacteria
• Treponema pallidum (Syphilis) Salmonella
• Parasites
• Malaria Toxoplasma Microfilaria

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Late complications of BT (2)

• Immune sensitisation
• Transfusion associated lung injury (TRALI)
• Post-transfusion purpura (PTP)
• Transfusion associated graft-versus-host disease
  (TA-GvHD)
• Transfusion haemosiderosis (iron overload)

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Early complications of BT..
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Circulatory overload

• Blood transfused too rapidly for compensatory
  fluid redistribution to take place more common
  in elderly and pts with chronic anaemia
• Causes Acute LVF
• Prevention
• Give packed red cells
• Transfuse slowly
• Give diuretic with transfusion e.g. Frusemide
  20mg p.o.
• Management of LVF
• IV Frusemide
• Oxygen (patient propped up in sitting position)
• IV Morphine

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Febrile non-haemolytic transfusion reactions

• Caused by white cells in blood bag reacting
  against anti-leucocyte antibodies in patient
• Affects multi-transfused patients or parous women
• Symptoms Fever, rigors
• Management
• Slow or stop transfusion
• Antipyretic e.g. Paracetamol
• ? incidence following universal leuco-depletion
  of red cells (vCJD initiative)

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Acute transfusion reactions

• Acute haemolytic transfusion reaction due to
• ABO incompatible blood or bacterial contamination
• difficult to differentiate clinically
• causes
• acute intravascular haemolysis
• shock
• acute renal failure
• DIC
• extremely serious, can be fatal

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AHTR 2

• most ABO mismatched transfusions due to human
  error
• if wrong blood to wrong patient,
• 13 chance of ABO incompatibility
• 110 will be fatal!
• may occur after infusion of small volume of blood
• usually occurs soon after start of transfusion

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AHTR Symptoms Signs

• Patient feels unwell and agitated
• Symptoms
• Fever, rigors
• Headache, SOB
• Loin/back pain
• Pain at infusion site
• Signs
• Hypotension
• Reduced urine output ? acute renal failure
• Bleeding from venepuncture sites due to DIC
• Urinalysis haemoglobinuria

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Management of AHTR

• A medical emergency
• Stop transfusion immediately
• Keep line open with N/Saline using new giving set
• Monitor pulse, BP, temp
• Call member of medical staff
• Check identity of patient against blood bag
• Take urgent blood samples
• FBC, cross-match, U Es, clotting screen, blood
  cultures
• Save any urine
• Send blood unit back to the blood bank

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Allergic reactions

• Occurs within minutes of starting transfusion
• More commonly with plasma-containing components
  (platelets, FFP)
• Symptoms urticaria, itching
• Management
• slow/stop transfusion
• Give antihistamine (Piriton, Hydrocortisone)
• Can give pre-med prior to future transfusions
• If still problematic, use saline-washed components

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Allergic reactions 2

• Severe reactions/anaphylaxis are rare but
  potentially life-threatening
• May be due to anti-IgA in patients with severe
  IgA deficiency
• NBS can provide IgA deficient blood components
  for future transfusions

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Delayed haemolytic transfusion reactions

• Due to secondary immune response following
• re-exposure to a red cell antigen
• Patient previously sensitised to a red cell
  antigen by transfusion or pregnancy
• Antibody not detected on routine screening for
  X-match
• Patient given transfusion with blood containing
  same antigen
• Provokes an anamnestic (secondary immune)
  response
• Within days, antibody level rises and transfused
  red cells removed from circulation

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Delayed transfusion reactions (2)

• Occurs ?24hr after transfusion (7-10 days)
• Causes extravascular haemolysis
• Red cells destroyed in liver, spleen occurs
  slowly
• Few clinical signs fever, anaemia, jaundice
• Re-testing of patients serum will now detect
  antibody
• In future, patient must be transfused with
  antigen negative blood

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Massive blood loss

• Medical emergency
• Loss of one blood volume within 24 hour period
• 50 blood volume loss within 3 hours
• Rate of blood loss ? 150ml/min
• Any blood loss gt2L (SGH)
• Usually occurs in AE, operating theatre or
  obstetric department
• High morbidity mortality

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Massive Blood Loss (2)

• Ensure adequate venous access
• Attempt to maintain blood volume with saline,
• plasma expanders
• Flying squad blood (O Rh Neg, CMV neg)
  available if blood required in ?15 minutes

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Massive Blood LossA Vicious Cycle

• Haemorrhage

Dilution of clotting factors and
thrombocytopenia
Massive Blood Transfusion
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Massive Transfusion complications

• Hypothermia ? acidosis
• Hyperkalaemia K leaks out of rbcs during
  storage
• Citrate toxicity red blood cells kept in citrate
  plus additive solution (SAG-M)
• Hypocalcaemia Ca2 ions bound by citrate
• Depletion of platelets and coagulation factors
• Fluid overload ? acute respiratory distress
  syndrome (ARDS)

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Late complications of BT..
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Transfusion infection risks in UK
HIV (1987) 1 1m donations (1993)
lt1 1m (2003) 1 10m HBV (1993) 1
20,000 (2003) 1 1m HCV (1990) 1
1,300 (1993) 1 13,000 (2003) 1 33m
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Immunological complications

• Transfusion related acute lung injury (TRALI)
• Post transfusion purpura (PTP)
• Transfusion associated graft-versus-host disease
  (TA-GvHD)
• Immunomodulation
• Post surgical infection
• Tumour reoccurrence

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TRALI

• Potent white cell antibodies in donors plasma
  which react strongly with the recipients
  granulocytes
• Donors usually multi-parous females
• Causes ARDS-like syndrome
• Fever
• Non-productive cough
• Acute breathlessness
• CXR bilateral infiltrates
• Donors removed from panel

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TRALI 2

• Mainly supportive treatment
• High concentration oxygen
• IV fluids and inotropes
• Mechanical ventilatory support may be required
  urgently
• Improvement within 48 hours with adequate
  respiratory support/ITU management

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Post Transfusion Purpura

• Rare but potentially lethal complication
• Caused by allo-antibodies to human platelet
  antigens
• Most commonly anti-HPA-1a (in HPA-1a-neg
  individual)
• Typically occurs in parous females 7-10 days
  following transfusion
• Presents as severe ?platelets, with haemorrhage
• Treatment
• High dose intravenous immunoglobulins
• Steroids and plasma exchange also effective
• Platelet transfusions ineffective

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TA-GvHD

• Transfused donor lymphocytes that are compatible
  with recipient but recognise recipient as foreign
  engraft and initiate a GvH response
• Syndrome of rash, diarrhoea, deranged liver
  function tests and pancytopenia
• Typically occurs 10-14 days post transfusion
• Bone marrow failure and resistant infections
  result in mortality rates ?90 !

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TA-GvHD 2

• No effective treatment
• Can be prevented by gamma-irradiation of cellular
  blood components to be transfused (inactivates
  donor leucocytes)
• Leucodepletion alone not effective
• Irradiation recommended for
• BMT patients
• Intra-uterine transfusions
• Hodgkins disease and patients with congenital
  cellular immune deficiencies

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Transfusion haemosiderosis

• Each unit of blood contains 200-250mg of iron
• Body excretes approx. 1mg/day
• Frequent transfusions e.g. Thalassaemia major,
  Sickle cell patients can lead to iron overload
• Clinical features caused by iron deposition in
  organs
• Poor growth and sexual development
• Diabetes
• Liver cirrhosis
• Hypoparathyroidism
• Cardiomyopathy ? cardiac failure, arrythmias
  major cause of death!

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Transfusion haemosiderosis 2

• Treatment
• Iron chelation using subcutaneous desferrioxamine
  over 8-12 hours on 5-7 nights/week
• Oral iron chelator, Deferiprone available but
  significant side effects
• Vitamin C enhances iron excretion

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Errors in transfusion

• Wrong blood to wrong patient
• 13 ABO incompatible
• 110 fatal
• Fatal errors in approx 1 600 000 (UK, USA)
• Non-fatal 112000

B blood ?
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Reporting of errors in transfusion

• Immediate internal reporting
• Should be recorded in hospital notes
• Contact hospital transfusion department or blood
  bank
• If confirmed error or near miss, incident form
  filled
• Reported to Hospital Transfusion Committee
• External reporting scheme (SHOT)

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Where do the errors occur?

• incorrect blood sampling
• incorrect/inadequate labelling of request forms
• collecting the wrong blood from the blood bank
  fridge
• errors in the blood bank laboratory
• failure/incorrect checking of blood at the bedside

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Distribution of errors (n552)
from SHOT report 2001-2002
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Further reading

• Essential Haematology
• ABC of Transfusion (BMJ books)
• SGH handbook of blood transfusion policies and
  procedures