Transfusion Reactions in Pediatric Practice

1
Transfusion Reactions in Pediatric Practice

• Case I
• An 8-day old NB, Wt. - 2.8 kgs
• C/o Hyperbilirubinemia - 4 days
• Mothers Bl. Gr. - B neg, Babys Bl Gr. - B
  positive
• O/E Vitals - stable
• Cry/Tone/Activity - WNL
• Icterus (yellowness upto mid-thighs)
• Syst - NAD
• Diagnosis Rh Incompatibility
• Rx given Exchange transfusion

INTP - PPO, PHO, IAP. P8 1/19
2
Transfusion Reactions in Pediatric Practice

• What Precautions necessary?
• In Newborns
• Ideally CMV neg blood products should be used
• to prevent CMV infection
• If possible, irradiated blood products should be
  used
• to prevent GVHD

INTP - PPO, PHO, IAP. P8 2/19
3
Transfusion Reactions in Pediatric Practice

• Case II
• An 8-yr-old m/ch - k/c/o ALL
• Severe Anemia - Hb - 4.0 gms
• Recd. packed red cells x 5 times
• Now one more pack given
• H/o high grade fever with chills, vomiting
  2 hours gt transfusion
• What are the causes? How would one manage this
  complication?

INTP - PPO, PHO, IAP. P8 3/19
4
Transfusion Reactions in Pediatric Practice

• Causes
• Non-hemolytic febrile
  transfusion reactions (NHFTR)
• Malaria
• Bacterial Contamination

INTP - PPO, PHO, IAP. P8 4/19
5
Transfusion Reactions in Pediatric Practice

• Diagnosis
• Confirm NHFTR by R/o hemolysis
• Plasma/Urine - no red discoloration
• Coombs test - neg
• Check Bl. Gr. of donor and recipient
• Malarial parasite on PS - may be positive
• Bacterial contamination - unlikely with closed
  systems in modern blood banks and appropriate
  donor selection

INTP - PPO, PHO, IAP. P8 5/19
6
Transfusion Reactions in Pediatric Practice

• Treatment
• NHFTR symptomatic with antipyretics, tepid
  sponging etc.
• Malaria specific antimalarials
• Bacterial contamination Appropriate
  antibiotics, treatment of shock etc.

INTP - PPO, PHO, IAP. P8 6/19
7
Transfusion Reactions in Pediatric Practice

• Prevention of these complications
• NHFTR
• leukodepletion
• Centrifugation
• Bedside filtration
• Frozen deglycerolized RBCs
• Saline washing
• Bacterial Contamination
• Appropriate Donor selection
• Closed systems

INTP - PPO, PHO, IAP. P8 7/19
8
Transfusion Reactions in Pediatric Practice

• Case III
• A 6 yr old F/Ch.
• k/c/o Thalassemia Major on regular PC Tx
• Hb - suboptimal gt transfusions
• Diagnosis ??
• Hypersplenism
• Alloimmunization
• Inadequate transfusions

INTP - PPO, PHO, IAP. P8 8/19
9
Transfusion Reactions in Pediatric Practice

• How to conclude the diagnosis?
• Hypersplenism
• assess previous years requirement of
  transfusions
• if it exceeds 230 mL/kg/yr - confirmatory of
  hypersplenism
• Alloimmunization
• DCT/ICT ve
• Inadequate transfusions - Mean pre-transfusion Hb
  lt 9 gms

INTP - PPO, PHO, IAP. P8 9/19
10
Transfusion Reactions in Pediatric Practice

• Consequences of allo-immunization
• Inadequate rise in Hb with packed red cells
• Refractoriness to platelet transfusions
• Treatment
• For RBCs - short course steroids
• For platelets - judicious use of platelet
  transfusions

INTP - PPO, PHO, IAP. P8 10/19
11
Transfusion Reactions in Pediatric Practice
(Other common reactions to transfusions)

• Allergic reactions
• Symptoms Urticaria, rash, pruritus etc.
• Cause polymorphic proteins in donor plasma
• Treatment - symptomatic with antihistaminics

INTP - PPO, PHO, IAP. P8 11/19
12
Transfusion Reactions in Pediatric Practice
(Other common reactions to transfusions)

• Anaphylaxis
• Symptoms Dyspnoea, wheezing, anxiety,
  hypotension without fever, bronchospasm
• Cause Recipients with IgA deficiency - due to
  IgA/anti-IgA complexes
• Treatment Adrenaline - SC/IV
• Antihistaminic
• Steroids ???

INTP - PPO, PHO, IAP. P8 12/19
13
Transfusion Reactions in Pediatric Practice
(Other common reactions to transfusions)

• TRALI (Transfusion Related Acute Lung Injury)
• Symptoms Shortness of breath, hypoxemia, rales
  without signs of acute cardiogenic edema
• Cause Antileucocyte antibodies to antigens
  present on recipients leucocytes
• Treatment Supportive with O2 therapy/mechanical
  ventilation

INTP - PPO, PHO, IAP. P8 13/19
14
Transfusion Reactions in Pediatric Practice

• Case IV
• A 10 yr. old boy with H/o acute blood loss
• Started on packed red cells
• Develops loin pains, fever, red colored urine,
  hypotension, flushing gt 50 mL of transfusion
• Diagnosis ? Immune-mediated hemolytic
  transfusion reaction
• Plasma and urine - red colored

INTP - PPO, PHO, IAP. P8 14/19
15
Transfusion Reactions in Pediatric Practice

• Management
• Stop transfusion immediately
• Reduce risk of renal failure
• low dose dopamine - 1 to 5 ug/kg/min
• vigorous hydration with crystalloids
• osmotic diuresis with 20 mannitol
• DIC treat accordingly with FFP/platelets/heparin

INTP - PPO, PHO, IAP. P8 15/19
16
Transfusion Reactions in Pediatric Practice

• Delayed Transfusion Reactions
• Infections
• Hemosiderosis (only if chronic transfusion
  therapy)

INTP - PPO, PHO, IAP. P8 16/19
17
Transfusion Reactions in Pediatric Practice

• Infections
• HIV
• Hepatitis B
• Hepatitis C
• Malaria
• CMV
• Babesiosis

INTP - PPO, PHO, IAP. P8 17/19
18
Transfusion Reactions in Pediatric Practice

• Prevention of infections
• Stringent donor selection
• Donor blood bag screening for HIV, HBsAg, HCV
• HIV - window period
• HBsAg HCV - tests used not very sensitive
• Hepatitis B vaccination prior to transfusion
  therapy
• CMV negative donors
• Population seropositivity - 90 to 95
• Leukodepletion/irradiated blood products

INTP - PPO, PHO, IAP. P8 18/19
19
Transfusion Reactions in Pediatric Practice

• Hemosiderosis
• Chelating agents
• Desferioxamine - SC/IV
• Deferiprone - Oral
• Combination is superior to either drug alone

INTP - PPO, PHO, IAP. P8 19/19