Transfusion Reactions

by Elizabeth Haxton MD (’24)

Transfusion reactions range from common and easily treated to rare and life threatening. It is important for pediatric residents to be able to identify transfusion reactions and differentiate between the different types. Below is a brief summary of each type of acute transfusion reaction.

 

Transfusion Associated Lung Injury (TRALI)

Pathophysiology:

       Anti-HLA or anti-neutrophil antibodies in transfused product activate host neutrophils in the lungs leading to endothelial injury in pulmonary vasculature and subsequent pulmonary edema

Presentation:

       Fever, chills, and respiratory distress

Diagnosis:

       Clinical: hypoxia, pulmonary infiltrates, no evidence of circulatory overload

Management:

       Stop transfusion

       Supportive care, up to 80% require mechanical ventilation

       If TRALI is confirmed, no more blood products from the donor should be transfused to any recipients

 

Transfusion Associated Circulatory Overload (TACO)

Pathophysiology:

       Volume overload often in the setting of large volume transfusion in patients who already have a positive fluid balance or have underlying cardiovascular/renal disease

Presentation:

       Respiratory distress, evidence of pulmonary edema, increased CVP, elevated BNP, elevated BP

Diagnosis:

       Clinical presentation

       Chest x-ray, BNP

       Evidence of fluid overload (elevated JVP, BP, BNP)

       It can initially be difficult to distinguish from TRALI until response to diuretics is assessed

Management:

       Stop transfusion

       Supplemental oxygen and diuretics

       Future transfusions are safe if the patient is not in a fluid overloaded state

       Can be prevented by limiting volume and rate of transfusions

 

Acute Hemolytic Transfusion Reaction

Pathophysiology:

       ABO incompatibility (due to clerical error): preformed recipient antibodies against donor RBC antigens leading to intravascular hemolysis

       Usually occurs with pRBCs but can rarely occur with platelets, FFP, or even IVIG if product contains antibodies against recipient RBC antigens

Presentation:

       Fever, chills, flank pain, hematuria, DIC, kidney failure, shock

Diagnosis:

       Lab evidence of hemolysis: elevated LDH, bilirubin, decreased haptoglobin, hemoglobinuria, DAT

Management:

       Stop transfusion

       Close electrolyte (particularly K) monitoring and cardiac monitoring

       Hemodynamic support

       Monitoring of hemoglobin with additional transfusion if necessary (pre-transfusion testing to avoid implicated antigen).

 

Transfusion Associated Sepsis

Pathophysiology:

       Infusion of blood product containing bacteria

Presentation:

       High fever, chills, hypotension

Diagnosis:

       Blood cultures and cultures of transfused blood product

Management:

       Stop transfusion

       Broad spectrum antibiotics (e.g. ceftriaxone)

       Fluids/vasopressors if needed to support BP

 

Anaphylactic Transfusion Reaction

 Pathophysiology:

       Allergic reaction to a component of the blood product

       IgA deficient patients can form anti-IgA antibodies leading to anaphylaxis

       Patients with congenital deficiency of haptoglobin can react to haptoglobin in transfused blood products

       Patients can react to substances used to inactivate pathogens or sterilize supplies

Presentation:

       Angioedema, wheezing, urticaria, hypotension

Diagnosis:

       Initial diagnosis is clinical

       Later workup can be done for IgA deficiency

Management:

       Stop transfusion and give IM epi, BP support

       If IgA deficiency is confirmed, future transfusions should be from IgA deficient donors when possible

       Prevention with antihistamine +/- corticosteroids is controversial

       If history of multiple reactions, can prevent by transfusing washed blood products

 

Other Allergic Transfusion Reactions

 Pathophysiology:

       Common and occur more frequently with platelet or plasma transfusions

       Usually caused by reaction to donor serum proteins

Presentation:

       Most commonly with hives and itching

Diagnosis:

       Clinical, ensure no evidence of anaphylaxis

Management:

       Stop transfusion

       Treat with antihistamines

       Can resume transfusion as long as there is no concern for anaphylaxis

 

Febrile Non Hemolytic Transfusion Reaction (FNHTR)

Pathophysiology:

       Caused by release of cytokines in stored blood product

       Can happen with transfusion of pRBCs or platelets, less likely with plasma

Presentation:

       Fever and chills during transfusion or within 4 hours after transfusion ends

Diagnosis:

       Clinical, ensure no evidence of hemolysis or sepsis

Management:

       Stop transfusion

       Treat with tylenol

       No evidence of benefit to pre-medicating to prevent FNHTR

 

 

 

 

 

Sources:

Tobian, A. Approach to the patient with a suspected acute transfusion reaction. In: UpToDate, Post TW (Ed), Wolters Kluwer. https://www.uptodate.com (Accessed on September 16, 2023.)

 

Hastings, Caroline A., Joseph Torkildson, Anurag Agrawal. Handbook of Pediatric Hematology and Oncology,  3rd Edition. Wiley Professional, Reference & Trade, 20210208.