Acute NON-Haemolytic Transfusion Reactions (bsh 2012)
SHOT receives approx. 30-40 reports of anaphylactic reactions per year
Management of ATR’s is guided by signs and symptoms, rather than classification
Acute Transfusion Reaction – SHOT Definition:
Reactions occurring within 24 hours of administration of blood or blood components excluding incorrect component transfusion, haemolytic reactions, TRALI, TACO and bacterial contamination.
More useful clinically to use a wider definition including the above complications
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 in predicting ATR.
Clinical Assessment of ATR
Staff/Patient Recognition of ATR
Patients must be monitored throughout transfusion
Give patient contact card if day case and advise to call if any symptoms within 24 hours of the transfusion.
Fever, chills, rigors, flushing
Myalgia or bone pain
Hyper or hypo-tension
Respiratory distress, Collapse
General malaise or nausea
Acute onset bleeding diathesis
Stop transfusion and maintain IV access with Saline
Assess ABC and call for help if indicated
Check patient identity against component being transfused
Examine component for clumps / discolouration
Then manage as per mild, moderate severe reaction protocols.
E.g. pyrexia >38oC + rise of 1-2oC from baseline with or without rash
Continue transfusion with appropriate treatment and direct observation.
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.
All other cases that are not mild or moderate + in keeping with underlying condition
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
Laboratory Investigation of ATR
Standard Ix for All Patients
FBC U&E, LFT
Urine assessment for haemoglobin
Further testing dependent of clinical signs and symptoms
Implicated unit returned to transfusion lab for further testing
Patient sampling for cultures and repeat compatibility testing
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 was beneficial prior to universal leukodepletion
Trial of pre-med paracetamol but no good evidence
Trial of washed blood components if continues to react
Recurrent Allergic Reactions
No trials assessing pre-med use of hydrocortisone + chlorphenamine
Pooled SD-FFP reduces rates of reaction for FFP transfusions
Severe IgA Deficiency with Anti-IgA Antibodies and history of Allergic Transfusion Reaction
IgA-deficient donors should be used
If not available in a clinically relevant time frame, washed components can be given under direct observation with access to resus facilities.
Patient incidentally identified as IgA deficient
Experience suggests serious reactions are still very rare in this group
Discuss with transfusion haematologist or immunologist.
Washed components can be tried in cases of unexplained recurrent hypotensive episodes
ACEI should be stopped if thought due to bradykinin-release
Legal requirement to report to MHRA (BSQR is the UK responsible body)
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.