The resident will generally only be contacted for a transfusion reaction report on the weekend or at night for one of the following conditions:
Do not delay investigation of a reported transfusion reaction because of incomplete paperwork. The paperwork can be completed later. We do not need a physician's signature to proceed.
For all acute reactions other than rash/urticaria alone or volume overload alone, we request the following:
VERY IMPORTANT: If at all possible, further transfusions should be delayed until completion of the transfusion reaction work-up. If a transfusion must be given right away, the patient must receive uncrossmatched group O RBCs issued on a blue card (or group AB plasma). We must assure the patient's ABO group is correct before issuing further ABO specific blood. Any ABO group specific units that have already been crossmatched (but not transfused) cannot be used unless they are group O. You must ask if any such units are present outside of the blood bank, e.g. in the OR or ICU refrigerator. If so, THESE UNITS MUST BE RETURNED TO THE BLOOD BANK IMMEDIATELY!!!! These units must not be transfused prior to completion of the work-up, and if they are left up on the floor, the temptation to transfuse them may be too great. The nursing staff/physicians may resist sending the units back, but you must be firm and assure them that they can have group O blood if emergency transfusion is necessary. We must assume they are ABO incompatible until proven otherwise.
This is a life-threatening EMERGENCY. It is almost always due to the transfusion of ABO-incompatible RBCs with resulting intravascular hemolysis, complement activation, and coagulopathy. Stop whatever else you are doing and make sure the clinicians know that there is evidence that incompatible blood was given, so that appropriate treatment can be rendered. Hopefully, they will already know, but please make sure. Do not assign blame at this point. If the clinicians ask for treatment advice, remember that vigorous hydration is the most important therapeutic step at this point. Lasix may be administered to preserve renal function. Supportive measures should be taken as appropriate (e.g. pressors). Document who you spoke to and when. Make sure a Transfusion Service faculty member knows about the reaction (as time allows).
If the incompatible blood was issued due to mislabelling of a patient cross-match sample, it is important to make sure we identify what patient is on the other end of that specimen switch. For example, if patient X is blood group A and patient Y is blood group B and their pretransfusion testing sample labels were switched, both patient X and patient Y are at risk of getting incompatible RBCs. Even in a case involving groups A and O, for example, one patient is at risk for incompatible RBCs and the other for incompatible plasma products.
This is defined as a rise in patient body temperature by greater than or equal to1oC with no other obvious explanation. We must always rule out the possibility of an acute hemolytic transfusion reaction, bacterial contamination of the bag, and fever due to pre-existing underlying disease. If no other explanation exists, fever may be due to the transfusion. Physicians should always take the presence of fever seriously, stop the transfusion, and send the bag and post-transfusion samples for work-up in the laboratory. Acute intravascular hemolysis may present as fever alone. If the fever is quite high or accompanied by hypotension, or if you are very suspicious of sepsis, make sure the blood bag is cultured. The blood bank techs will arrange this with the microbiology lab at your request.
Following the occurrence of one febrile reaction, we recommend the use of antipyretics (e.g. Tylenol) prior to future transfusions. Some physicians may already have used antipyretics, as they can make the patient feel much more comfortable during the transfusion. If so, continued use is suggested. If they choose not to administer antipyretics, that is their perogative. You might reassure a reluctant physician, however, that the use of antipyretics prior to transfusion should not mask the significant fever that would accompany a serious reaction such as acute hemolysis or sepsis. Multiply transfused patients especially benefit from pre-medication.
Generally, we do not start using leukocyte-reduced blood components for a patient until they have had two recorded febrile transfusion reactions. The statistics say that only 1 in 8 patients will ever have a second febrile reaction, therefore the use of expensive, leukoreduced blood is often unnecessary. However, you may want to make an exception to the rule in certain instances: For example, in a patient who is particularly ill who has had numerous transfusions already (so they are at relatively higher risk), or if the clinician is particularly insistent. Another instance might be a patient with a complicated serological picture in whom working up a febrile transfusion reaction would entail a lot of work. I would also probably issue leukoreduced blood if the patient has a history of febrile reactions, but they have not all been formally work-up by the blood bank, and thus are not documented by us.
DO NOT APPROVE THE USE OF WASHED RED BLOOD CELLS for the prevention of febrile reactions!!!! This is an outmoded practice. The clinicians may ask for washed blood, and some older texts may say to use it, but leuko-reduction filters are 100 to 1000 times more efficient and easier for the staff. Plus, there should be no delay obtaining a leukoreduced unit from inventory, where washing will take close to an hour to perform.
Patients having fever despite getting leukoreduced blood.
Occasionally a multitransfused patient will suffer a febrile reaction
despite receiving a leuko-reduced unit of blood. This may occur in
individuals with particularly high anti-leukocyte antibody titers.
Remember that leukoreduction still leaves behind somewhere in the
neighborhood of 100,000 WBCs in each unit. This situation does not
call for switching to the use of washed RBCs! As noted above, washing
is significantly less efficacious and will not improve the symptoms.
Similarly, the use of washed and leukoreduced RBCs is not
likely to improve the patient's symptoms because of the minimal
increased WBC removal of washing and has the downside of giving the
unit a 24 hour shelf life and loss of some of the RBCs, as well.
The presence of cytokines is one of the latest theories to explain
these reactions. If fevers persist in spite of the use of
leukoreduced blood, you may want to suggest that the freshest units
be selected for leukofiltration. Thus, fewer cytokines would
theoretically be present in these units.
Fever in a patient with no prior transfusion or pregnancy history. Patients having their first ever transfusion may experience fever even though they have had no opportunity to previously be sensitized to WBC antigens. This phenomenon may be explained by the presence of cytokines in transfused plasma.
Mild reactions involving the skin only (rash, urticaria, itching) do not need to be worked-up by the blood bank or even reported to us. The clinicians may administer an anti-histaminic agent (e.g. Benadryl) and if the allergic symptoms subside, the transfusion of that unit may continue. If the skin symptoms persist, we would suggest stopping that unit and trying a different one (in addition to the use of anti-histamines). If a mild, skin-only reaction is reported to the laboratory and specimens sent, we generally go ahead and complete a transfusion reaction investigation, although it does not accomplish anything in nearly every case.
If symptoms beyond skin involvement are reported, the transfusion should be stopped, and the remainder of that unit sent back to the laboratory. Examples to watch out for are facial swelling, itching of the throat, or dyspnea. These symptoms may be the first inkling of a more serious allergic reaction developing and should be taken seriously. Development of anaphylaxis is not uncommon and is a life-threatening emergency. You may be contacted when this occurs. Your job is to assess further transfusion needs and decide how to meet them. You may want to suggest a work-up of the recipient for IgA deficiency. The work-up should first involve a total IgA level and tryptase determinations (done in Immunology on a red top tube. The tryptase level should preferentially be collected within 2-3 hours of the reaction). If that is within normal limits, a more detailed evaluation for missing subtypes of IgA and the presence of corresponding antibodies may be indicated. This is a send-out test through Immunology. In the meantime, careful consideration should be given to additional transfusion needs. RBC components should be thoroughly washed, but plasma and platelet transfusions will be problematic. Close observation and slow infusion should be carried out in any case as well as premedication with anti-histamines and possibly steroids. If IgA deficiency is diagnosed, refer to the section on IgA deficiency for transfusion options.
When a patient has symptoms of high fever and shock or other symptoms suggestive of sepsis (e.g. DIC) during or within 90 minutes of ending the transfusion, consider the possibility that one of the transfused units of blood was contaminated with bacterial growth. RBC components are especially at risk for the growth of gram-negative, endotoxin-producing organisms such as Yersinia enterocolitica. These organisms thrive in a blood-rich medium at refrigerator temperatures. Their growth generally reaches significant levels in blood stored for 21 days or longer. Please remember to culture the blood bag (and have the recipient's blood cultured) if suspicion is high for this situation, such as in the following clinical situations:
A culture utilizing a sealed segment from the blood bag is not adequate, as the segments may not show bacterial growth. Ask for a gram stain of the remaining blood to be performed immediately, if possible, to get immediate information about possible bacterial presence. Gram-negative sepsis from transfusion can be devastating, and is fatal within hours in a high percentage of patients. Initial treatment involves managing the septic shock, which may include immediate i.v. administration of broad spectrum antibiotics and the use of steroids and vasopressor drugs, such as dopamine. Antibiotic therapy concurrent with the administration of the unit will not blunt the effects of the endotoxin. Platelet components may also be contaminated with bacteria, although these are more commonly gram-positive organisms that were skin contaminants on the donor.
The most significant feature of TRALI is bilateral pulmonary "white-out" on x-rays which is most likely caused by trapped donor white cell antibodies/recipient WBC agglutinates. Supportive care to maintain oxygenation as all that is required for treatment. The infiltrates will slowly resolve with no harmful sequela.
You may be contacted if the blood bank discovers that a delayed hemolytic transfusion reaction has taken place. Please make certain that the clinical team knows of the diagnosis and will monitor the patient carefully for signs of ongoing hemolysis and worsening anemia. Otherwise, no action is generally required.
See appendix 7 in paper supplement for estimates of risk.
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