Acute NON-Haemolytic Transfusion Reactions (2012)

 

Intro

-       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

 

Cause

-       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.

 

Clinical Signs/Symptoms

-       Fever, chills, rigors, flushing

-       Itch, urticaria

-       Myalgia or bone pain

-       Hyper or hypo-tension

-       Respiratory distress, Collapse

-       General malaise or nausea

-       Acute onset bleeding diathesis

 

Universal actions

-       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.

 

Mild Reactions

-       E.g. pyrexia >38oC + 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.

 

 

Severe Reactions

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

-       Shock + Wheeze/Stridor/Hypotension

o   Anaphylaxis

o   Resuscitation + IM Adrenaline 0.5ml of 1:1000

-       Shock without anaphylaxis or fluid overload

o   Consider ABO incompatibility or bacterial contamination

o   Resuscitation + ITU and Renal Support

o   Correction of DIC / Coagulopathy

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

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

-       SOB without shock

o   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

 

Febrile Patients

-       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 à confirmatory testing and IgA antibody detection

-       Discuss IgA deficiency with immunologist

 

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.

 

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 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.