para>Reaction is greater, and the outlook poorer in the very young.
Geriatric Considerations
Higher risk of complications among the elderly
EPIDEMIOLOGY
- Frequency of immunologic reaction per unit of blood
- Allergic: 1:100
- Febrile: 1:100
- Delayed hemolytic: 1:1,600
- Acute hemolytic: 1:50,000
- Fatal hemolytic reaction: 1:500,000
- Infectious complications per unit of blood
- Hepatitis B virus: 1:81,000
- Human T-lymphotropic virus, type 1: 1:642,000
- Hepatitis C virus: 1:1,600,000
- HIV, type 1: 1:2 million
Incidence
In 1 series of 265 documented emergency transfusions without cross-matching, only 1 hemolytic reaction was reported (0.4%).
ETIOLOGY AND PATHOPHYSIOLOGY
- Acute hemolytic transfusion reactions (AHTR)
- When ABO-incompatible blood is transfused, donor erythrocytes are destroyed by the recipient 's preformed antibodies, causing intravascular hemolysis.
- Most commonly occurs when group O recipients receive non " group O blood; IgM antibodies to group A and B antigens fix complement and cause rapid hemolysis.
- Misidentification of blood product or patient, often because of clerical error
- AHTRs
- Patient has preformed IgM antibodies reactive to protein on surfaces of RBCs.
- IgM fixes complement to surfaces of RBCs.
- Complement cascade leads to rapid intravascular destruction of transfused cells.
- Delayed hemolytic transfusion reactions (DHTRs) can occur in patients sensitized to an antigen by prior transfusions or pregnancy. It may be difficult to detect because antibody titer falls after initial sensitization and reaction occurs 2 to 10 days after transfusion.
- DHTRs
- Pathophysiology of DHTRs is the subject of intense study.
- Recent research implicates a similar pathway to IgG-mediated anaphylactic reaction.
- Fc ³Rs on the patient 's macrophages react with IgG-coated transfused RBCs.
- Resulting cascade of proinflammatory cytokines and platelet-activating factor
Genetics
No known genetic pattern
RISK FACTORS
- Patients with chronic requirements for blood transfusions:
- Sickle cell anemia
- ²-Thalassemia major
- Patients requiring massive transfusion:
- Trauma
- Organ transplantation
GENERAL PREVENTION
- Reduce risks of clerical and administrative error (1)[B]:
- At a minimum, two practitioners should verify blood product and patient identity match.
- Obtain detailed history of patient 's responses to previous blood product transfusion.
- Use matched blood whenever possible.
- If matched blood is not available, thoroughly check universal blood for agglutination titer.
- Blood bank should screen consistently for bacteria and viruses.
- Reduce number of allogenic transfusions:
- Carefully consider the risk-to-benefit analysis of every transfusion.
- Treatment with recombinant human erythropoietin may reduce transfusion requirement for patients with chronic kidney disease.
- Peritransfusion clinical practice
- Observe patient closely during transfusion with serial vital signs.
- Avoid prophylactic antipyretics.
- Use genotype-specific RBCs in sickle cell anemia.
- Consider leukocyte-depleted blood in people with history of recurrent febrile reactions.
- Case reports have indicated that prophylactic treatment with rituximab may prevent delayed hemolytic transfusion reactions; however, higher level evidence is lacking.
COMMONLY ASSOCIATED CONDITIONS
- Disseminated intravascular coagulation (DIC)
- Shock
- Acute renal failure
DIAGNOSIS
ALERT
Symptoms are masked in the anesthetized patient; among this population, the first sign of hemolytic reaction may be red-tinged urine in the catheter.
Shortness of breath, high fever, loss of consciousness, and hematuria are all signs of a more serious reaction.
If the patient is short of breath after transfusion, there is a low threshold for obtaining at least a portable chest x-ray because transfusion-related acute lung injury is an important consideration, especially in the critically ill patient.
DHTR is an extravascular process; symptoms include the following:
HISTORY
- Anxiety
- Pruritus
- Fever/chills
PHYSICAL EXAM
- Flushing
- Tachycardia
- Hypotension
- Chest, back, or flank pain
- Wine-colored urine indicating hemoglobinuria
- Urticaria
- Tachypnea
- Dyspnea
DIFFERENTIAL DIAGNOSIS
Other causes of acute hemolysis:
- Autoimmune diseases
- Hemoglobinopathies
- RBC enzyme defects
- Bacterial contamination of stored blood
DIAGNOSTIC TESTS & INTERPRETATION
- If you suspect that the patient may have a hemolytic transfusion reaction, the following workup is indicated:
- Direct antiglobulin (Coombs) test
- LFTs, total and direct bilirubin
- Lactate dehydrogenase (LDH)
- Serum haptoglobin
- CBC
- Chem-7
- Coagulation (PT/PTT/international normalized ratio)
- A hemolytic reaction is evidenced by the following:
- Positive direct antiglobulin test (Coombs) in the case of autoimmune etiology
- Plasma obtained 2 to 4 hours after lysis is red or pink, indicating free hemoglobin.
- Elevated serum bilirubin (may be mild)
- Elevated LDH
- Reduced serum haptoglobin
- Tissue factor released from lysed RBCs can initiate DIC; platelet count and coagulation studies should be monitored.
- Monitor BUN and creatinine, given risk of renal failure.
TREATMENT
GENERAL MEASURES
- Follow hospital protocol for evaluation of transfusion reactions.
- Stop transfusion immediately if hemolytic transfusion reaction is suspected.
- IV normal saline to support BP and adequate urine output, especially in DIC
- Avoid lactated Ringer solution.
- Repeat thorough evaluation of transfusion paperwork to rule out any clerical error (a common cause of an ABO-incompatible transfusion).
- Monitor vital signs.
- Recognize and treat DIC if it occurs.
- Supportive therapy: Maintain BP using vasopressors in indicated airways.
MEDICATION
- Oxygen and ventilation support, as needed
- Epinephrine for anaphylaxis
- Corticosteroids may be helpful to reduce inflammation.
- Normal saline and/or vasopressors to maintain systolic BP
- Treat DIC if present, including supportive therapy and possibly heparin.
- Diphenhydramine for urticarial reaction
ADDITIONAL THERAPIES
IV immunoglobulin/steroids have been successful in resolving hemolysis without transfusion.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Until hemolytic signs are gone
DIET
As tolerated
PATIENT EDUCATION
Before starting a transfusion, give the patient instructions to report any unusual symptoms (e.g., rash, itching, or fever) to the nursing staff immediately.
PROGNOSIS
- Usual course: acute
- Usually no harm if transfusion is stopped at onset of manifestations.
- Most fatalities associated with ABO RBC transfusions of >200 mL; mortality approaches 44% for transfusions >1,000 mL.
COMPLICATIONS
- Uremia, oliguria, anuria
- Right-sided heart failure
- Respiratory failure
- Multiorgan dysfunction syndrome
REFERENCES
11 Bryan S. Hemolytic transfusion reaction: safeguards for practice. J Perianesth Nurs. 2002;17(6):399 " 403.
ADDITIONAL READING
- Davenport RD. Pathophysiology of hemolytic transfusion reactions. Semin Hematol. 2005;42(3):165 " 168.
- Gaines AR, Lee-Stroka H, Byrne K, et al. Investigation of whether the acute hemolysis associated with Rh(o)(D) immune globulin intravenous (human) administration for treatment of immune thrombocytopenic purpura is consistent with the acute hemolytic transfusion reaction model. Transfusion. 2009;49(6):1050 " 1058.
- Gilstad CW. Anaphylactic transfusion reactions. Curr Opin Hematol. 2003;10(6):419 " 423.
- Goodell PP, Uhl L, Mohammed M, et al. Risk of hemolytic transfusion reactions following emergency-release RBC transfusion. Am J Clin Pathol. 2010;134(2):202 " 206.
- Hod EA, Sokol SA, Zimring JC, et al. Hypothesis: hemolytic transfusion reactions represent an alternative type of anaphylaxis. Int J Clin Exp Pathol. 2009;2(1):71 " 82.
- Lacroix J, Hebert PC, Hutchison JS, et al. Transfusion strategies for patients in pediatric intensive care units. N Engl J Med. 2007;356(16):1609 " 1619.
- Noizat-Pirenne F, Bachir D, Chadebech P, et al. Rituximab for prevention of delayed hemolytic transfusion reaction in sickle cell disease. Haematologica. 2007;92(12):e132 " e135.
- Sazama K, DeChristopher PJ, Dodd R, et al. Practice parameter for the recognition, management, and prevention of adverse consequences of blood transfusion. College of American Pathologists. Arch Pathol Lab Med. 2000;124(1):61 " 70.
- Silver M, Corwin MJ, Bazan A, et al. Efficacy of recombinant human erythropoietin in critically ill patients admitted to a long-term acute care facility: a randomized, double-blind, placebo-controlled trial. Crit Care Med. 2006;34(9):2310 " 2316.
- Vamvakas EC, Blajchman MA. Transfusion-related mortality: the ongoing risks of allogeneic blood transfusion and the available strategies for their prevention. Blood. 2009;113(15):3406 " 3417.
- Win N, Sinha S, Lee E, et al. Treatment with intravenous immunoglobulin and steroids may correct severe anemia in hyperhemolytic transfusion reactions: case report and literature review. Transfus Med Rev. 2010;24(1):64 " 67.
CODES
ICD10
- T80.919A Hemolytic transfusion reaction, unspecified incompatibility, unspecified as acute or delayed, initial encounter
- T80.910A Acute hemolytic transfusion reaction, unspecified incompatibility, initial encounter
- T80.911A Delayed hemolytic transfusion reaction, unspecified incompatibility, initial encounter
ICD9
- 999.83 Hemolytic transfusion reaction, incompatibility unspecified
- 999.84 Acute hemolytic transfusion reaction, incompatibility unspecified
- 999.85 Delayed hemolytic transfusion reaction, incompatibility unspecified
SNOMED
- Hemolytic transfusion reaction (disorder)
- Immediate hemolytic transfusion reaction (disorder)
- Delayed hemolytic transfusion reaction (disorder)
CLINICAL PEARLS
- Transfusion of packed RBCs depresses the immune response in patients undergoing renal transplantation.
- In an anesthetized patient, increased bleeding, oozing from catheter sites, and red-tinged urine are signs that indicate transfusion reaction.
- To reduce transfusion requirements in the critically ill ICU patient, institute restrictive transfusion policies, such as accepting hemoglobin values of 7 to 9 rather than >10, which will decrease transfusion rates by up to 50% (erythropoietin can maintain hemoglobin level by stimulating RBC production) and decrease the use of blood samples for nonessential tests.
- Posttransfusion purpura: Delayed thrombocytopenia (7 to 10 days after platelet transfusion) caused by production of antibodies to donor or recipient platelets is more common in women. Treat with IV immunoglobulin or plasmapheresis. Avoid additional platelet transfusions, which may worsen thrombocytopenia.