Hemolytic transfusion reactions

Hemolytic transfusion reactions (HTR)

v  Accelerated clearance or lysis of red cells in the transfusion recipient. Usually  d/t immunological incompatibility b/w blood donor and the recipient

A. C LASSIFICATION WITH RESPECT TO TIME OF OCCURRENCE

v  Acute  (AHTRs )
                During or within 24 hours of transfusion

v  Delayed ( DHTRs )
                After 24 hours of transfusion.( 5-7 days )

Signs and Symptoms of Acute HTR

Conscious patient

Abrupt onset                     Nausea, Vomiting                          

Anxiety                                                Shock   

Facial flushing                   Oliguria                               

Fever, chills                       Hemoglobinuria

Pain in back or flanks     Bleeding

                                                Dyspnoea

Under GA

•          Hypotension

•          Hemoglobinuria (This may be masked in patients

  undergoing GU surgeries due to hematuria)

•          Undue bleeding from surgical site

•          Complications of AHTRS

Renal failure  :- 36 %

Thrombus formation  in renal arterioles

DIC :- 10 %

Immediate Mx of suspected AHTRs

A. Action for nursing staff

In presence of fever > 38 ⁰ C and / or any S/s

•       Stop the transfusion

•       Check the pt identity and unit transfused

•       Save any urine the pt passes

•       Monitor pulse, BP and temp at 15 min interval

B. Action for medical staff

1. Isolated fever / fever & shivering, stable observations, correct unit given :- FNHTR  = Paracetemol 1 g orally , observe  P, BP and T every 15 min for 1 hr, then hourly. If no  improvement call hematology medical staff

2. Fever with pruritis, urticaria :- Allergic transfusion reaction = Chlorpheniramine 10 mg iv

3. Any other s/s, hypotension, incorrect unit :- AHTR = discontinue transfusion, N saline to maintain urine output   1ml /kg / h. full and continuous monitoring

Mx of AHTRs

v  Take immediate note and inform blood bank

v  Seek help immediately from skilled anaesthetist or emergency team

v  Complete the transfusion reaction form and appropriately record the following

•          Type of transfusion reaction

•          Time after the start of transfusion to the occurrence of reaction

•          Unit No. of component transfused

•          Volume of the component transfused

Investigation of suspected AHTRs

Send the following lab investigations:

                Immediate post transfusion blood samples (clotted and  EDTA) for:

Ø  Repeat ABO & Rh (D) grouping

Ø  Repeat antibody screen and crossmatch

Ø  Direct antiglobulin test

Ø  Complete blood count (CBC)

Ø  Plasma hemoglobin

Ø  Coagulation screen

Ø  Renal function test (urea, creatinine and electrolytes)

Ø  Liver function tests (bilirubin, ALT and AST)

                Blood culture in special blood culture bottles

                Blood unit alongwith BT set

                Specimen of patient’s first urine following reaction

Mx of confirmed AHTRs

Maintain adequate renal perfusion by

-          Fluid challenges

-          Frusemide infusion

-          If hypovolumic – dopamine infusion

Transfer  to high dependency area

 Repeat coagulation and biochemistry screens ever 2- 4 hrly

If urinary output not maintained seek expert renal advice

Hemofiltration or dialysis m/b required for acute tubular necrosis

DIC development – component therapy may be required

l  DELAYED HEMOLYTIC TRANSFUSION REACTIONS

Due to secondary  immune  responses following re-exposure  to a given red cell antigen

-          Ab most commonly involved – Rh , Kidd, Duffy  and  Kell

-          No clinical signs of red cell destruction but positive DAT

-          Rarely fatal

Sign and symptoms

 - fever

-  fall in Hb concentration

-          Jaundice and hemoglobinuria

Mx

-          Requires no Tt.

-          Hypotension  & renal failure – may require expert  medical advice

l  Diagnosis & Management

l  Routine examination

l  Stop Tx immediately

l  Monitor vital signs, urine out put

l  Verify identification of the patient

l   IV line kept open with NS

l  Evaluate for evidence of HTR, septic shock, anaphylaxis

                TRALI other D/D fever

l  Report and send transfusion set to B/B

l  Treatment

l  Antipyretics

                                acetaminophen ;   325-650mg orally  

                    (adult)  10-15mg/kg (children)

l  Meperiedine

                                severe chills  - 25-50mg IV

                                contraindication: renal failure

                                                                      Pts on MAO inhibitors             

l  Antihistaminics: not indicated

Tx should not be restarted for 30 min.