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BLOOD TRANSFUSION

INDICATION
1. Blood loss greater than 20% of blood volume when more than 100 mL
2. Hemoglobin level less than 8 g/dL
3. Hemoglobin level less than 10 g/dL with major disease (e.g., emphysema,
ischemic heart disease)
4. Hemoglobin level of less than 10 g/dL with autologous blood
5. Hemoglobin level less than 12 g/dL and ventilator dependent
COMPLICATION
FEBRILE
1.
2.
3.
4.
5.
6.
7.
8.
9.

most common mild reaction, 0.5%-4% of transfusions


due to alloantibodies to WBC, platelet, or other donorplasma antigens
fever likely caused by pyrogens liberated from lysed cells
more common if previous transfusion
mild fever < 38 with or without rigors, fever may be > 38with restlessness
and shivering
nausea, facial flushing, headache, myalgias; hypotension,chest and back pain
(less common)
near completion of transfusion or within 2 hours
up to 40% with mild reactions will not experience anotherreaction with future
transfusions
with severe/recurrent reactions, future transfusions maycause leukocyte
depletion

Management

rule out fever due to hemolytic reaction or bacterial contamination.


mild < 38 - decrease infusion rate and antipyretics
severe - stop transfusion, antipyretics, antihistamines,symptomatic treatment

ALLERGIC
1. mild allergic reaction occurs in about 3% of transfusionsdue to IgE
alloantibodies vs. substances in donor plasma
2. mast cells activated with histamine release
3. usually occurs in pre-exposed e.g. multiple transfusions,multiparous
4. often have history of similar reactions
5. abrupt onset pruritic erythema / urticaria on arms andtrunk, occasionally with
fever
6. less common - involvement of face, larynx, and bronchioles
Management

mild - slow transfusion rate, IV antihistamines


moderate to severe - stop transfusion, IVantihistamines, subcutaneous
epinephrine,hydrocortisone, IV fluids, bronchodilators

prophylactic - antihistamines 15-60 minutes priorto transfusion, washed or


deglycerolized frozen RBC

ANAPHYLACTIC
1. rare, potentially lethal
2. in IgA deficient patients with anti-IgA antibodies
3. immune complexes activate mast cells, basophils,eosinophils, and
complement system= severe symptoms after transfusion of RBC,
plasma,platelets, or other components with IgA
4. apprehension, urticarial eruptions, dyspnea,hypotension, laryngeal and
airway edema,wheezing, chest pain, shock, sudden death
management

circulatory support with fluids,catecholamines, bronchodilators,


respiratoryassistance as indicated
evaluate for IgA deficiency and anti-IgAantibodies
future transfusions must be free of IgA:washed/deglycerolized RBCs free of
IgA,blood from IgA deficient donor

TRANSFUSION - RELATED ACUTE LUNG INJURY(TRALI)


1. form of non-cardiogenic pulmonary edema
2. occurs 2-4 hours post transfusion
3. immunologic cause; not due to fluid overload or cardiacfailure - is a reaction
to transfusion
4. respiratory distress - mild dyspnoea to severe hypoxia
5. chest x-ray - consistent with acute pulmonary edema, but pulmonary artery
and wedge pressures are not elevated
management

usually resolves within 48 hours with O2, mechanicalventilation, supportive


treatment

IMMUNOSUPPRESSION
some studies show associations between perioperative transfusion and post
operative infection , earlier cancer recurrence, and pooreroutcome
Immune Hemolytic
1. most serious and life threatening transfusion reaction
2. caused by donor incompatibility with recipients blood
3. Can be caused by as low as 10 ml of blood
ACUTEIntravascular hemolysis

most severe

often due to clerical error


antibody coated RBC is destroyed by activation of complement system
I.
ABO incompatibility common cause, other RBC Ag- Ab systems can be
involved
II.
fever, chills, chest or back pain, hypotension, tachycardia, nausea,
flushing, dyspnoea , haemoglobinuria , diffuse bleeding due to
disseminated intravascular coagulation (DIC), acute renal failure (ARF)
III.
in anesthetized patients, signs include hypotension, tachycardia,
wheezing, hypoxemia and hemoglobinuria

Management

stop transfusion
notify blood bank, confirm or rule out diagnosis-clerical check, direct Coombs
test, repeat grouping, Rg screen and crossmatch , serum haptoglobin
manage hypotension with fluids, inotropes, other blood product
maintain urine output with crystalloids,furosemide, dopamine, alkalinize urine
component treatment if DIC

DELAYED
I.
II.
III.
IV.

Extravascular hemolysis
anemia, mild jaundice, fever 1-21 days posttransfusion
incompatibility of antigen and antibody that do notbind complement
Ab coated RBC destroyed by macrophagicphagocytosis by in
reticuloendothelial system (RES)
failure to recognize these antibodies at crossmatchoften involved
low titre antibodies may be undetectable, butamnestic response in recipient
= buildup ofantibodiesto incompatible RBC several days post transfusion
predisposing factors to hemolytic transfusionreactions
a. F to M = 3:1
b. increasing age
c. blood products administered on emergent basis

V.
VI.
VII.

Nonimmune

infectious risks
o HIV, hepatitis, Epstein-Barr virus(EBV), cytomegalovirus (CMV),
brucellosis, malaria,salmonellosis, measles, syphilis
hypervolemia
electrolyte changes
o increased K+ in stored blood
coagulopathy
hypothermia
citrate toxicity
hypocalcemia

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