Complications of blood transfusion

Complications from a single transfusion:

1. Febrile non hemolytic transfusion reactions.

It is due to the antibodies to donor leucocytes (HLA antigen).

Risk factors: multiparous woman, conditions requiring multiple blood transfusions.

Management:

• Generally, do not require treatment.
• Paracetamol.
• Can be prevented by giving leucodepleted blood by using micro filter blood sets.

2. Allergic reactions.

It is due to plasma proteins and clinically presented as urticaria.

Management:

• Stop blood transfusion momentarily.
• Antihistaminic: Injection diphenhydramine IM, Pheniramine.
• Steroids: if necessary.
• Restart the infusion at slower rate.

3. Anaphylaxis

It is due to release of histamine.

Clinical features:

• Increased heart rate, decreased blood pressure. (Histamine → Vasodilation).
• Central cyanosis. (Due to laryngeal edema).
•  Strider, Ronchi.
• Pruritus.

Management:

• Stop transfusion.
• Manage as anaphylactic shock. Oxygen, steroids, antihistaminic, undiluted adrenaline (1:1000/0.5mg).

4. Acute hemolytic reactions.

It is due to mismatched transfusion, ABO incompatibility. It is an example of type II hypersensitivity reaction.

Clinical features:

• Fever; Rise in temperature (more than 1⁰C) with chills and rigors.
• Burning in the vein.
• Dyspnea, tachycardia, hypotension.
• Oozing from surgical site.
• Rashes.
• Chest pain, flank pain (due to hemolysis).
• Acute tubular necrosis (due to hemoglobin).
• Hemoglobinuria (black colored urine).

Investigations: 

• Haptoglobins: decreased.
• Lactate dehydrogenase: Increased.
• Coagulogram.
• Urine hemoglobin, platelet count, fibrinogen level.

Management:

• Stop transfusion.
• Recheck the details of blood.
• Send the remaining blood back to blood bank.
• Maintain the urine output to 1-2 ml/kg/hour by mannitol and fluid administration.
• Alkalize the urine.
• Hemodialysis.
• Assay urine hemoglobin, platelet count, fibrinogen level and replace blood components accordingly.

5. Delayed hemolytic reactions.

It is due to Rh system. Reaction is mild and management is supportive.

6. Graft vs. host disease.

Due to donor T8 leucocytes.

Clinical features:

• Post transfusion fever, diarrhea, obstructive jaundice, pruritus.
• Pancytopenia (in blood count).

It can be prevented by giving irradiated blood (2500 cGy).

7. TRALI (Transfusion related acute lung injury)

It is the most common cause of death after transfusion. The incidences are common within 6 hours of transfusion and common in Fresh frozen plasma (FFP) donation than whole blood transfusion.

Doner, being the person who has been transfused multiple times in the past (eg. Multiparous woman) contain these antibodies in their blood.

• Anti HLA-I antibody.
• Anti HLA-II antibody.
• Anti-neutrophil antibody.

There is release of cytokines when transfused with blood containing these antibodies. There is leucocyte aggregation in pulmonary capillaries of recipient causing ventilation/ perfusion imbalance. This leads to non-cardiogenic pulmonary edema.

Clinical features:

• Features of respiratory distress (Dyspnea, fever, cough).
• Bilateral fine crepitations.

Investigations and diagnosis:

• PaO₂ / FiO₂.
• CXR: Bilateral infiltrations.
• Normal BP, JVP and BNP.
• Evidence of absence of LA hypertension.

Management:

• Mechanical ventilation.
• TRALI is managed as ALI (Acute lung injury)/ ARDS.

8. TACO (Transfusion associated circulatory overload).

The symptoms of TACO appear within 6 hours.

Clinical features:

• Increased BP, JVP.
• Features of respiratory distress and pulmonary edema.
• Bilateral fine crepitations.

Investigations:

• Increased BNP
• CXR: Bilateral infiltration.

Management:

• Decreasing the rate of transfusion in at-risk patients.
• Stop transfusion.
• Treated with supplemental oxygen and diuretics.
• Therapeutic phlebotomy.

9. Infections

• Bacteria: Syphilis, Pseudomonas, Acinetobacter, Coliforms etc. FFP does not transmit bacteria; as FFP is devoid of cellular components.
• Virus: Hepatitis B, C, D (not hepatitis A). HIV, CMV, EBV, HSV etc.
• Parasites: Malaria, Kala-azar, Toxoplasmosis, Brucellosis.

10. Others

• Air embolism.
• Thrombophlebitis.

Complications from massive transfusion:

11. Electrolyte imbalance:

• Metabolic alkalosis.
• Hyperkalemia: As cellular components break down while storage of blood in blood bank.
• Hypocalcemia: Citrate in CDPA (Citrate dextrose phosphate adenine) bind to calcium and can cause hypocalcemic tetany.

12. Coagulopathy.

Citrate binds to calcium and inhibit coagulation.

13. Iron overload/ toxicity:

There is secondary hemochromatosis in recurrent transfusions. Recurrent transfusion can cause bronze diabetes in thalassemic patients. Iron overload can be treated with iron chelators like deferoxamine, deferiprone.

14. Immunosuppression.