Transfusion Reactions: A clinical audit

S. Prabakar

Consultant, Transfusion Medicine, Kauvery Hospital, Radial Road, Chennai

Abstract

Aim

  • Stabilize blood volume, when essential
  • Improve tissue oxygenation
  • Ensure adequate hemostasis
  • Ensure right blood of right quality to the right patient at the right time

Methods and methodology

  1. Sep 2023 to Feb 2024 – 59 patients were given Avil and Dexamethasone either as premedication or after reaction occurred.
  2. Out of 6000 transfusion 59 transfusions (1%) had reactions (documented).
  3. Under reporting?
  4. Not classifying the type of reaction

Background

The study, transfusion reactions  from blood components, was conducted in this population to validate the rational drug usage and scarce resource associated complications.

Blood components

  1. Packed red blood cells (PRBCs)
  2. Fresh Frozen Plasma (FFP)
  3. Platelet Concentrates (PCs)
  4. Cryoprecipitate (Cryo)

Challenges with Storage of Whole Blood at 40°C

Red cells: O2 carrying capacity decreases within 7-10 days

Platelets: Lose viability within 12 hours

Granulocytes: Disintegrate within 24 hours

FVIII Levels: Decrease to 20-30% within a week

WBCs: Release cytokines, RBC damage

Component preparation

Principle – Differential centrifugation

  • Red cells
  • Plasma – Fresh frozen
  • Platelets
  • Cryoprecipitate

Parameters of Blood Components

S. NoBlood productsUnit volume (ml)Storage temperature Shelf life
1WB (Hct 35–40%)400/5002 – 60C 35 days
2PRBCs (Hct 55–75%)160 – 3502 – 60C 35 days/ 42 days in AS
3PCs (5×1010 or 3×1011)60 – 90/200 – 30020 – 240C 5 days
4FFP160 – 250< – 200COne year
5Cryoprecipitate20 – 40< – 200COne year

Appropriate Transfusion of Red Cells

  1. Symptomatic anemia – oxygen deficit
  2. Co-existing conditions – age, general health, determine hemoglobin trigger.
  3. Not for treatable conditions – Iron/B12/Folate deficiency
  4. Avoid single unit transfusions as far as possible

Appropriate Transfusion of Fresh Frozen Plasma

  1. Replacement of multiple factors: DIC, liver disease, warfarin reversal
  2. Replacement of single factors when appropriate substitute is not available
  3. Dose: 10-15 ml/kg
  4. Not for “maintaining CVP”
  5. Not for protein content

Appropriate Transfusion of Platelet Concentrates

  1. Symptomatic platelet problems
  2. Do not treat the number in isolation –
  • eg Chronic ITP with no bleeds
  1. Prophylactic in specific situations
  • CNS, eye surgery, other major surgeries, acute leukemia, patients on chemoradiotherapy
  1. Dose: 1 RDP/10 Kg or 1 SDP

Appropriate Transfusion of Cryoprecipitate

  1. Deficiency of
  • Factor VIII, Fibrinogen, vWF, F XIII
  • Consumption coagulopathies
  1. Volume is an important consideration
  • WB – FVIII 0.3 u/ml; 120 u/400 ml
  • FFP – FVIII 1 u/ml; 200 u/200 ml
  • Cryo ppt – FVIII 8-10 u/ml; 80 u/10 ml
  1. Dose: 1 bag/10 kg

Bedside Component Administration

  1. Identify the type of component (mentioned in the reaction form)
  2. Positive identification of intended recipient and the blood component
  3. Visual colour change – dark blackish/brown, gaseous distention/frothing, clots.
  4. Check expiry date
  5. Record vital of the patient
  6. Do not add any medication to the bag /administration line.
  7. Leukocyte contamination in blood components ranges from 109 – 105
  8. Blood filters
  • Standard (170-260 µm)
  • Leukoreduction filters

Storage temperatures and maximum bedside storage time allowed

Component typeStorage temperatureAdminister
Whole blood/Packed red cell 2-60C≤30 minutes of issue Within 4 hr
Platelet - Random PC, SDP 22±20C≤30 minutes of issueWithin 4 hr
Plasma, Cryo, CPP≤-200C<30 minutes< 6 hr

During Transfusion

  1. Closely observe, monitor and document patient’s vitals including urine output and colour
  2. Every 5 min for first 15 min
  3. Every 15 min for next ½ hr
  4. Every 30 min for next 1 hr
  5. Every hr till the end of transfusion
  6. 30 min post transfusion.

Issue of blood units

Clinical urgency
ImmediateMinutesWithin an hour
Group O Rh Negative Packed RBCsABO and Rh type Group specific bloodABO and Rh type cross match

Special issues in obstetrics transfusion

  1. Irregular Antibodies
  2. DIC often complicates abruption placentae
  3. Thrombocytopenia, impaired LFT complicates pre-eclampsia/eclampsia

Neonatal transfusion

  1. RBC ABO and Rh typing; no serum grouping
  2. Cross match with maternal serum
  3. WB or PRBCs within 7 days of collection
  4. CMV seronegative, if possible
  5. Blood bags with small satellite bags
Reactiontype Immunologic Nonimmunologic
Acute Transfusion ReactionsHemolytic

Febrile non-hemolytic

Urticaria

Anaphylactic

Trali
Transfusion associated sepsis

Hypotension associated with ace inhibitors

Taco

Non immune hemolysis

Air embolism

Hypocalcemia

Hypothermia
Delayed Transfusion ReactionsAlloimmunization- RBC antigen

Alloimmunization- HLA antigens

Hemolytic

GVHD

Post transfusion purpura

Transfusion related
immuno modulation
Iron overload

Disease transmission

Precautions for Post Transfusion

In case of any untoward reactions;

  1. Stop transfusion immediately
  2. Keep the I/V line patent
  3. Take necessary resuscitative measure
  4. Investigations to be done
  • Complete blood count (CBC)
  • Coagulation screen
  • Renal function test (Urea, creatinine and electrolytes)
  • Liver function tests (bilirubin, ALT and AST)
  • Plasma Hb
  • Urine Hb
  • Blood culture in special blood culture bottles

Blood Bank Requirements

  • Blood bag with BT set
  • Post transfusion samples (EDTA & Plain)
  • Completely filled and signed reaction form

Blood Bank Investigations

  1. Visual check of pre, post and Blood Bag samples
  2. Repeat ABO & Rh (D) grouping
  3. Repeat antibody screen and crossmatch
  4. Direct antiglobulin test

Complications of Massive Transfusion

  1. Citrate toxicity
  2. Hyperkalemia
  3. Hypothermia
  4. Dilutional thrombocytopenia
  5. Coagulapathy

Preventive measures

  1. Do not transfuse if at all possible
  2. Use screened blood
  3. Compatibility testing
  4. Specially processed blood/components
  5. Hemovigilance

Optimizing Clinical Benefit of Transfusion

  1. Start transfusion within 30 minutes of removal from blood bank refrigerator
  2. Check ABO and Rh (D) compatibility in case of PRBC, ABO in case of FFP.
  3. Do not refrigerate in case of Platelets
  4. Complete transfusion within 4 hours
  5. Never add medication

 

Dr Saradha Prabhakar - Transfusion Medicine Specialist in Chennai

Dr. Saradha Prabhakar
Consultant, Transfusion Medicine

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