Page 2022 - Hematology_ Basic Principles and Practice ( PDFDrive )

Chapter 119 Transfusion Reactions to Blood and Cell Therapy Products 1793

24 hours after the incompatible transfusion, the episode can be Acute Hemolytic Transfusion Reaction
considered to be over, with serious sequelae unlikely. The direct
antiglobulin test (DAT) becomes positive in an immune hemolytic A 15-year-old blood group O male with sickle cell disease presents for
reaction (if tested before all the incompatible RBCs are destroyed). routine simple transfusion for primary prevention of stroke. He has no
Preparation of an antibody eluate is often necessary to identify the history of red blood cell (RBC) alloimmunization and his pretransfusion
presence of an offending IgG antibody. An elution is a procedure that compatibility testing shows a negative screen for RBC alloantibodies.
chemically separates the bound antibody from the RBCs and con- Seven minutes into the transfusion, the patient reports not feeling well.
centrates it so that it may be identified. He quickly develops chills, abdominal pain, flank pain, and pain at the
Initial therapy consists of immediately stopping the transfusion, infusion site. The transfusion is stopped. Vital signs show a 15-mm Hg
administering intravenous fluids, cardiorespiratory support, and drop in systolic blood pressure from baseline value, pulse of 130, and
ensuring a brisk diuresis. Increasing renal blood flow is the best way a temperature increase from afebrile pretransfusion to 38.9°C. Gross
hematuria is seen in a subsequent urine sample. Reinspection of the
to prevent acute oliguric renal failure. Usually, 0.9% NaCl is infused blood unit shows that it is group A and labeled with the name of the
to maintain a urine output of 100 mL/hour for approximately 24 child receiving blood in the infusion chair next to him. The patient is
hours. Diuresis can be achieved with loop diuretics or mannitol. transferred to the emergency room where he is evaluated for renal
Mannitol, if chosen, must be used with caution; if acute tubular failure and DIC.
necrosis (ATN) occurs before mannitol infusion, pulmonary edema Recognition of the signs and symptoms at an acute hemolytic transfu-
may occur as a result of the acute increase in intravascular volume sion reaction are paramount for transfusion safety. Stopping transfusion
secondary to fluid expansion. Maintaining hydration and diuresis at the first sign of incompatibility, usually fever, is critical for preventing
can be complicated in the setting of heart failure and underlying severe sequelae. Although almost all febrile reactions to blood transfu-
renal disease. The mechanisms responsible for the beneficial effect sion are not caused by blood incompatibility, it is impossible to exclude
this possibility at the bedside. All transfusion reactions need to be
of increased renal blood flow likely include increased clearance of reported to the blood bank to exclude incompatibility.
free hemoglobin and a return of more physiologic control of renal
vasodilation. Creatinine and blood urea nitrogen (BUN) should
be monitored; dialysis may be necessary for treatment of oliguric
acute renal failure. Support of blood pressure and respiration may
require the use of vasopressors, bronchodilators, or intubation. DIC
can occur in severe cases. The prothrombin time, activated partial
thromboplastin time, and fibrinogen level should be monitored (see MILD ALLERGIC
FNHTR
box on Workup of an Acute Intravascular Hemolytic Transfusion FLUID OVERLOAD
Reaction).
Hyperhemolysis is a specific type of acute intravascular hemolysis 100
of bystander RBCs that do not express the antigen to which an
immune-mediated hemolysis is directed. Hyperhemolysis occurs in
1,000
TRALI
ANAPHYLAXIS
TABLE Types of Acute Transfusion Reactions HEMOLYTIC
119.1
10,000
Reaction Type Presenting Signs and Symptoms 1/INCIDENCE
SEPTIC
Acute hemolytic Fever, chills, dyspnea, vomiting, hypotension,
tachycardia, infusion site pain, back pain,
hemoglobinuria, hemoglobinemia, indirect 100,000
hyperbilirubinemia, renal failure, DIC FATAL
REACTION
Febrile reaction Fever, chills, rigors
Allergic Urticaria, pruritus, flushing, angioedema, 1,000,000
dyspnea, bronchospasm stridor, PTP
hypotension, tachycardia, abdominal T-GVHD
cramping
Hypervolemic Dyspnea, tachycardia, hypertension, 10,000,000
headache, jugular venous distention
Septic Fever, chills, hypotension, tachycardia,
vomiting Fig. 119.1 APPROXIMATE RISK OF VARIOUS TRANSFUSION
Transfusion-related Dyspnea, hypoxemia, fever, hypotension COMPLICATIONS. FNHTR, Febrile nonhemolytic transfusion reaction;
acute lung injury PTP, posttransfusion purpura; t-GVHD, transfusion-associated graft-versus-
host disease; TRALI, transfusion-related acute lung injury.

TABLE Hemolytic Transfusion Reactions: Serologic Presentation
119.2
Type Antibody Detectable Initially Primary Antibody Type Degree of Complement Binding Example
Acute intravascular Yes IgM Full (C1-9) ABO system
Acute extravascular Yes IgG None/partial Rh system
Delayed intravascular No IgG Full (C1-9) Kidd system
Delayed extravascular No IgG None/partial Duffy system