Transfusion Reactions Clinical Presentation

  • Author: S Gerald Sandler, MD, FACP, FCAP; Chief Editor: Emmanuel C Besa, MD   more...
 
Updated: Jan 10, 2012
 

History

  • A history of previous blood transfusions or pregnancy is often present but is not essential for the diagnosis of a febrile nonhemolytic transfusion.
  • Similarly, acute transfusion reactions caused by ABO antibodies, TRALI (donor's antibodies), allergy, IgA/anti-IgA anaphylaxis, or sepsis may occur during the first transfusion or subsequent transfusions.
  • Persons known to have formed red cell alloantibodies as the result of previous transfusions or pregnancy should be informed and provided with a written report listing the antibodies to be presented to the transfusion service if additional transfusions are required at another hospital.
  • Red cell antibodies may decrease in titer, and, although remaining clinically important, they may not be detected by routine compatibility testing before future red cell transfusions. Ask patients scheduled for red cell transfusions about any history of previous transfusions and if they are aware of any complications or blood bank antibody problems. Obtain details of any previous transfusions during the medical history or when obtaining the patient's informed consent for a transfusion.
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Physical

  • Acute hemolytic reactions
    • Early signs may include fever, hypotension, flushing, wheezing, anxiety, and/or red-colored urine.
    • Late signs may include a generalized bleeding tendency (DIC) and/or hypotension.
  • Nonhemolytic febrile reactions
    • Typically, only fever is present.
    • However, some recipients experience severe rigors, shaking, chills, hypotension, and vomiting.
  • Allergic reactions - Maculopapular rash and/or urticaria without fever or hypotension
  • Anaphylactic reactions
    • Dyspnea
    • Wheezing
    • Anxiety
    • Hypotension without fever
    • Bronchospasm in severe cases
  • TRALI: Rapid onset of shortness of breath, hypoxemia, and rales, without signs of acute cardiogenic pulmonary edema and fever
  • Circulatory (volume) overload: Shortness of breath, hypoxemia, and rales, with orthopnea, tachycardia, distended jugular veins, or other evidence of cardiac decompensation
  • Bacterial contamination: High fever, shock, tachycardia, and weak pulse, without a clear focus of infection
  • Examination of the contents of the container of blood being transfused may reveal clots, discoloration, or a difference in color between the contents of the bag (hemolyzed by contaminating bacteria) and the contents of the segmented tubing attached to the bag (not hemolyzed, no bacteria).
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Causes

  • Acute hemolytic reactions (ABO incompatibility): Typically, a recipient with group O blood type is transfused accidentally with group A, group AB, or group B RBCs because of (1) misidentification of either the patient or the blood component when the blood sample was collected for compatibility testing or (2) failure to recognize that 2 patients have the same or similar names but different ABO blood types.
  • Most transfusions of incorrect RBCs to the incorrect patient due to misidentification are clinically benign. More than 60% of random units of RBCs in a blood bank are serologically compatible with random recipients because approximately 40% are type O (ie, universal donor) and 20% are the same blood type as the patient or are otherwise ABO-compatible.
  • Febrile nonhemolytic reactions: Cytokines and other normal constituents of leukocytes, platelets, or plasma accumulate in blood components during storage. When blood components are transfused, some recipients react with varying generalized symptoms, of which fever is the most common symptom.
  • Allergic reactions: The clinical presentation of rash, pruritus, and/or urticaria during a transfusion suggests that the recipient was exposed to a foreign substance in the blood product to which the recipient is sensitized. Usually, a specific allergen is not identified. Studies published in the medical literature suggest that causes of allergic reactions include polymorphic proteins in the donors' plasma, food (eg, nuts, tomatoes), or medications (eg, penicillin) that the donor ingested immediately before collection of the implicated blood product.
  • Anaphylactic reactions: Most cases are reported in recipients with IgA deficiency who developed anti-IgA and whose transfused product contains donor plasma with a normal content of IgA. Not all IgA-deficient persons who have anti-IgA have a history of transfusions or pregnancy. Similar reactions in ahaptoglobinemia have been reported.
  • TRALI: Neutrophils are the effector cells that adhere to the pulmonary endothelium to increase permeability and cause pulmonary edema. Elements leading to activation of the neutrophils include transfused HLA and HNA antibodies and transfused bioactive substances such as lipids or cytokines. Patients with certain clinical conditions, such as infection, inflammation, or surgery, have primed neutrophils that are susceptible to activation by transfused bioactive substances.
  • Because pregnancy is a common cause of alloimmunization to HLAs and HNAs, most cases of TRALI have been traced to plasma-containing blood components collected from female blood donors.[48] When the American Red Cross converted to predominately male-donated plasma, the number of cases of TRALI decreased very significantly from 2006 to 2008.[48]
  • Circulatory (volume) overload: Increased fluid volume in susceptible patients including those with cardiovascular compromise, elderly patients, and small children may result in pulmonary edema. A usual transfusion rate is 2-2.5 mL/kg per hour. In at-risk patients, blood products can be transfused at a slower rate.
  • Bacterial contamination (sepsis): Bacteria may enter the blood product container if it is opened at any time from collection from the donor until transfusion to the recipient. Bacteria on the donor's skin may enter the container if the needle entry site on the donor's skin is sterilized incompletely.
  • Some donors implicated in septic reactions have low concentrations of bacteria (eg, Yersinia enterocolitica) in their blood (eg, bacteremia) that are not associated with a fever or other signs at the time of collection. If such contaminated blood is stored for a few days at room temperature (eg, platelets) or for a few weeks at refrigerated temperature (eg, red cells), bacteria may grow and elaborate endotoxin, which is a major adverse factor in such reactions.[49]
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Contributor Information and Disclosures
Author

S Gerald Sandler, MD, FACP, FCAP  Professor of Medicine and Pathology, Director, Transfusion Medicine, Department of Laboratory Medicine, Georgetown University Hospital

S Gerald Sandler, MD, FACP, FCAP is a member of the following medical societies: American Association of Blood Banks, College of American Pathologists, and International Society of Blood Transfusions

Disclosure: Nothing to disclose.

Coauthor(s)

Viviana V Johnson, MD  Medical Director, Blood Bank, Naval Medical Center, Portsmouth

Viviana V Johnson, MD is a member of the following medical societies: American Association of Blood Banks and College of American Pathologists

Disclosure: Nothing to disclose.

Specialty Editor Board

Pradyumna D Phatak, MBBS, MD  Chair, Division of Hematology and Medical Oncology, Rochester General Hospital; Clinical Professor of Oncology, Roswell Park Cancer Institute

Pradyumna D Phatak, MBBS, MD, is a member of the following medical societies: American Society of Hematology

Disclosure: Novartis Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Ronald A Sacher, MB, BCh, MD, FRCPC  Professor, Internal Medicine and Pathology, Director, Hoxworth Blood Center, University of Cincinnati Academic Health Center

Ronald A Sacher, MB, BCh, MD, FRCPC is a member of the following medical societies: American Association for the Advancement of Science, American Association of Blood Banks, American Clinical and Climatological Association, American Society for Clinical Pathology, American Society of Hematology, College of American Pathologists, International Society of Blood Transfusion, International Society on Thrombosis and Haemostasis, and Royal College of Physicians and Surgeons of Canada

Disclosure: Glaxo Smith Kline Honoraria Speaking and teaching; Talecris Honoraria Board membership

Rajalaxmi McKenna, MD, FACP  Southwest Medical Consultants, SC, Department of Medicine, Good Samaritan Hospital, Advocate Health Systems

Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis

Disclosure: Nothing to disclose.

Chief Editor

Emmanuel C Besa, MD  Professor, Department of Medicine, Division of Hematologic Malignancies, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Clinical Oncology, American Society of Hematology, and New York Academy of Sciences

Disclosure: Nothing to disclose.

Additional Contributors

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.

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Rapid test to distinguish hematuria from hemoglobinuria. The onset of red urine during or shortly after a blood transfusion may represent hemoglobinuria (indicating an acute hemolytic reaction) or hematuria (indicating bleeding in the lower urinary tract). If freshly collected urine from a patient with hematuria is centrifuged, red blood cells settle at the bottom of the tube, leaving a clear yellow urine supernatant. If the red color is due to hemoglobinuria, the urine sample remains clear red after centrifugation.
 
 
 
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