Acute Transfusion Reactions (ATR) (bsh 2012, bsh 2023)

 

Intro

ATR Definition

  • Reactions occurring within 24 hours of administration of blood or blood component

  • Includes minor febrile reactions through to life-threatening anaphylaxis/haemolysis

Epidemiology

  • ATR rate approx. 0.5-3% of transfusions (data reliant on haemovigilance reporting)

  • 10yr SHOT data 2022:

    • 1 in 7,700 transfusions risk of febrile/allergic/hypotensive reactions

    • 1 in 57,000 transfusions risk of haemolytic reactions

    • 1 in 310,000 transfusions risk of ABO incompatible red cell transfusion (BSH2023-OR23)

    • 65% of reported transfusion-related deaths were due to pulmonary complications

    • Platelets associated with the highest rate of reported reactions

Pathophysiology

  • Many febrile reactions thought to result from reaction to donor white cells or accumulation of biological response modifiers during storage.

  • This is supported by the reduction of cases since the introduction of universal leukodepletion.

  • Recipient factors are also important (diagnosis, allergy history, age, physical characteristics etc)

Management Principle

  • Management should be guided by signs and symptoms, rather than classification

Clinical Assessment of ATR

 

Staff/Patient Recognition of ATR

Patients must be transfused in clinical areas where they can be directly observed, and where staff are trained in the management of transfused patients.

Recognition and early management of ATR should be part of local mandatory staff training requirements

Give patient contact card if day case and advise to call if any symptoms following transfusion (e.g. dark urine, jaundice, breathlessness).

 

Clinical Signs/Symptoms

Fever, chills, rigors, flushing

Itch, urticaria

Pain - muscle, bone, chest, abdomen

Hyper or hypo-tension, Tachycardia

Respiratory distress, Collapse

General malaise or nausea

Acute onset bleeding diathesis

 

Universal actions

Stop transfusion and maintain IV access with Saline

Assess ABC, Call for help and start resuscitation if indicated

Check patient identity against component being transfused

Examine component for clumps / discolouration

Then manage as per mild, moderate severe reaction protocols.

 

Mild Reactions

E.g. pyrexia <39oC + rise of 1-2oC from baseline with or without rash

Continue transfusion with appropriate treatment and direct observation.

 

Moderate Reactions

E.g. pyrexia >39oC or rise of >2oC and or other symptoms except for rash/itch only.

Medical review of likely cause

If consistent with underlying condition continue transfusion at slower rate under direct observation

If worsening/persistent symptoms, move to management of severe reactions

 

Severe Reactions

All other cases that are not mild or moderate + in keeping with underlying condition

In major haemorrhage, assess whether hypotension/tachycardia due to blood loss vs ATR

Anaphylaxis (Shock + Wheeze/Stridor/Hypotension)

  • Resuscitation + IM Adrenaline 0.5ml of 1:1000

Shock without anaphylaxis or fluid overload

  • Consider ABO incompatibility or bacterial contamination

  • Resuscitation + ITU and Renal Support

  • Correction of DIC / Coagulopathy

  • If ABO incompatibility due to component intended for another patient contact transfusion lab immediately to prevent a further incident.

  • If bacterial contamination, immediately inform lab + haematologist on-call to consider contacting blood service to withdraw associated units.

Breathlessness without shock

  • TRALI vs TACO vs TAD

—> Retain the blood unit, Report to transfusion lab, Perform Ix as below, report to SHOT+MHRA

 

Laboratory Investigation of ATR

 

Standard Ix for All Patients

  • FBC U&E, LFT

     

Moderate-Severe Febrile Reactions

  • Implicated unit returned to transfusion lab for repeat compatibility testing

  • Haptoglobin, LDH, G&S, DAT, Coag screen, Blood cultures

  • Urine assessment for haemoglobin

  • Contact Blood Service

Moderate-Severe Allergic Reactions

  • Measure IgA level

  • Isolated low IgA level —> confirmatory testing and IgA antibody detection

  • Discuss IgA deficiency with immunologist

  • Listen to this podcast with Blood Bank Guy for detailed discussion of limitations in testing for and diagnosing IgA-related anaphylactic transfusion reactions.

 

Management of Repeated Reactions

 

Recurrent febrile non-haemolytic transfusion reactions (FNHTR)

  • Plasma removal (‘Washed units’) was beneficial prior to universal leukodepletion

  • Trial of pre-med paracetamol or NSAIDs, but evidence is weak

  • Trial of washed blood components if continues to react

  • Do NOT use pre-med steroids

 

Recurrent Allergic Reactions

  • Mild reactions can be managed with slower rate of transfusion +/- antihistamine

  • Mod-Severe reactions: Consider SD-FFP and pooled platelets (suspended in PAS) +/- antihistamine

  • There is NO evidence to support pre-med steroids

 

Severe IgA Deficiency with Anti-IgA Antibodies and history of Allergic Transfusion Reaction

  • Discuss with transfusion specialist, options may include IgA-deficient donors and washed units.

Patient incidentally identified as IgA deficient

  • Serious reactions are still very rare in this group

  • If no history of reactions, should receive standard transfusion with higher frequency monitoring

 

Hypotensive Reactions

  • Washed components can be tried in cases of unexplained recurrent hypotensive episodes

  • ACEI should be stopped if thought due to bradykinin-release

 

Reporting ATR

 

Legal requirement to report to MHRA

(BSQR 2005 is the UK law regulating transfusion practice)

 

Professional responsibility to report to SHOT haemovigilance scheme

(also a lab accreditation and hospital quality assurance scheme requirement).

 

Reporting to NHSBT will protect other potential recipient of associated blood components.

 

Local reporting to Hospital Transfusion Team will aid in the above and allow for local intervention and audit.