MedStar Health Institute for Quality and Safety International Training Center for Bloodless Medicine and Surgery MEDSTAR EXPERTS Complications of Blood Transfusions Hiep Trong Dao, MD, Anesthesiology Co-director of MedStar Georgetown University Hospital Program for Bloodless Medicine and Surgery Knowledge and Compassion Focused on You Complications of Blood Transfusions Hyperkalemia Medical evidence has been accumulating over recent Citrate toxicity decades associating blood transfusion with increased Hypothermia risk; but that knowledge has not made a proportionate Clotting abnormalities (afer massive impact on medical training and clinical care. Blood transfusions) transfusion is still viewed by many healthcare providers Late complications: as the only viable, scientifcally sound and responsible Transmission of infection option in many clinical scenarios. Tis strongly held Viral (hepatitis A, B, C, HIV, CMV) conviction on the part of the provider may at times Bacterial (Salmonella) result in an adversarial stance toward the patient who Parasites (malaria, toxoplasma) chooses to decline transfusion, which may in turn bring Graf-vs-host disease stress to the provider and harm to the patient. Iron overload (afer chronic transfusions) Immune sensitization (Rhesus D antigen) It is hoped that a heightened awareness of the risks of blood transfusion along with a better understanding of the body’s tolerance of anemia, will help providers to Acute hemolytic transfusion reactions occur when see that bloodless care is a reasonable, responsible ABO-incompatible blood is transfused, resulting in choice. Such awareness and understanding has proven recipient antibodies attaching to donor RBC antigens to eliminate unnecessary friction in the doctor-patient and forming an antigen-antibody complex. Tis relationship for healthcare providers who treat antigen-antibody complex activates complement, Jehovah’s Witnesses. resulting in intravascular RBC lysis with release of RBC stroma and free Hb. Immune system activation also results in bradykinin release (leading to hypotension) and mast cell activation (causing serotonin and histamine release). Te net result may be shock, renal Early Complications: failure due to Hb precipitation in renal tubules, and Hemolytic reactions (immediate and delayed) DIC. Many signs and symptoms of an acute hemolytic Non-hemolytic febrile reactions transfusion reaction appear immediately and include Allergic reactions to proteins, IgA fever, chest pain, anxiety, back pain, and dyspnea. Transfusion-related acute lung injury Many are masked by general anesthesia, but clues to the Reactions secondary to bacterial contamination diagnosis include fever, hypotension, hemoglobinuria, Circulatory overload unexplained bleeding, or failure of Hct to increase afer Air embolism transfusion. Te incidence of fatal hemolytic Trombophlebitis transfusion reaction in the US is approximately 1 of every 250,000 to Page 1 of 4 MedStar Georgetown University Hospital medstarbloodless.org 1,000,000 units transfused. Most reactions occur with pruritus and erythema is the most common. because of administrative errors, with most due to Allergic transfusion reactions are common, occurring improper identifcation of the blood unit or patient. in 1% to 3% of transfusions. Tey arise from recipient Te importance of adhering to strict policies of antibody response to donor plasma proteins. Urticaria checking blood and matching to the correct patient with pruritus and erythema is the most common in the operating room cannot be overemphasized. manifestation, but rarely bronchospasm or anaphylaxis presents. Many patients also have a fever. Patients with IgA defciency may be at increased risk of allergic transfusion reaction because of the presence of anti-IgA Delayed hemolytic transfusion reactions occur because antibodies that react with transfused IgA. Treatment of incompatibility of minor antigens and are involves stopping the transfusion, excluding a more characterized by extravascular hemolysis. Tey present severe reaction, and administering antihistamines. 2 days to months afer transfusion. Patients complain of no or minimal symptoms but may display signs of anemia and jaundice. Lab studies reveal a positive direct antiglobulin test, hyperbilirubinemia, decreased Transfusion-Related Acute Lung Injury (TRALI) is a haptoglobin levels, and hemosiderin in the urine. condition of severe pulmonary insufciency following blood, FFP, cryoprecipitate, or platelet transfusion. Signs and symptoms include fever, dyspnea, hypoxemia, hypotension, and pulmonary edema Febrile nonhemolytic transfusion reactions are the developing within 4 hours of transfusion. TRALI most common transfusion reactions, occurring in happens when anti-HLA antibodies and anti-leukocyte approximately 1% of RBC transfusions and up to 30% antibodies present in donor plasma cause the recipient of platelet transfusions. Tey occur when anti-leukocyte leukocytes to injure their own tissues. Most cases are antibodies in a recipient react with white blood cells in tracked to female donors who have previously been a transfused blood product. Signs and symptoms pregnant and developed anti-HLA antibodies. include fever, chills, tachycardia, discomfort, nausea, Measures to prevent plasma donation by women who and vomiting. Approach to treatment involves frst have been pregnant may reduce TRALI-related stopping the transfusion and excluding an acute episodes. hemolytic transfusion reaction or bacterial contamination of the donor unit. Acetaminophen and meperidine may diminish fever and rigors. Once the diagnosis of FNHTR has been made, future reactions may be avoided or diminished by administering TACO (transfusion-associated circulatory overload) is leukocyte-reduced blood products, premedicating at- a condition of circulatory congestion secondary to the risk patients with acetaminophen and hydrocortisone fuid volumes administered as transfusions. Te and administering the transfusion slowly. symptoms are similar to congestive heart failure and include dyspnea, pulmonary edema, tachycardia, and increased jugular venous distention. While TRALI also produces pulmonary edema, signs of circulatory Allergic transfusion reactions are common, occurring overload are seen in TACO that helps diferentiate the in 1% to 3% of transfusions. Tey arise from recipient two. TACO ofen afects patients at risk for congestive antibody response to donor plasma proteins. Urticaria heart failure and occurs in less than 1% of transfusions. Page 2 of 4 MedStar Georgetown University Hospital medstarbloodless.org If a patient is at risk for fuid overload, diuretics can be administered with transfusion as a preventative Red blood cells are stored at 4 degrees Celsius. Rapid measure. transfusion at this temperature will quickly lower the recipient’s core temperature and further impair hemostasis. Hypothermia reduces the metabolism of Graf-Versus-Host Disease (GVHD) is a rare and citrate and lactate and increases the likelihood of almost always fatal complication of blood transfusions hypocalcemia, metabolic acidosis and cardiac resulting from an attack of immunocompetent donor arrhythmias. A decrease in core temperature shifs the lymphocytes on the host’s various tissues. Afer the oxyhemoglobin dissociation curve to the lef, reducing majority of transfusions, the donor lymphocytes are tissue oxygen delivery at a time when it should be destroyed by the recipient’s immune system, preventing optimized. Tis reduction in temperature can be GVHD. However, if the host is immunodefcient or if minimized by warming all I.V. fuids and by the use of there is a specifc type of partial HLA matching between forced air convection warming blankets to reduce the donor and recipient, GVHD is more likely to occur. radiant heat loss. It can develop 4 to 30 days afer transfusion, with patients typically presenting with fever and erythematous maculopapular rash that may become Bacterial and viral contamination of blood components generalized. Other symptoms include anorexia, is an infrequent complication of transfusion. However, vomiting, abdominal pain, and cough. Te diagnosis is if it does occur, the potential for fulminant sepsis in a made by a skin biopsy and confrmed by demonstrating recipient is associated with high mortality. It can result circulating lymphocytes that have a diferent HLA from contamination during venipuncture or if a phenotype verifying their origin from the donor. symptomatic donor is bacteremic or viremic at the time GVHD is poorly responsive to available treatments. of donation. Symptoms occur during or shortly afer Terefore, prevention is of utmost importance, which is transfusion of the contaminated unit and include high achieved by irradiating all lymphocyte containing fever, rigors, erythema and cardiovascular collapse. components with gamma radiation, thereby inactivating them. Te incidence of air embolism has now reduced markedly with the use of plastic blood bags. A massive transfusion of RBCs may lead to a dilutional Nevertheless, air can enter a central catheter while coagulopathy, as plasma-reduced RBCs contain neither blood administration sets or blood bags are being coagulation factors nor platelets. Secondly, changed or if blood in an open system is infused under hemorrhage, as a consequence of delayed or inadequate pressure. perfusion, can result in DIC. Tis causes consumption of platelets and coagulation factors and may account for the numerical distortion of clotting studies appearing out of proportion