Blood transfusion generally carries some risk of reaction. Sometimes, the blood or blood components may act as a foreign protein or antigen that prompts immediate or delay immune response or tissue reaction reason why compatibility testing is one of the most important and confirmatory test done before blood transfusion. The following are some unfavourable reaction thay me occurs during or after blood transfusion.
Blood transfusion reactions and complications
- Haemolytic transfusion reaction
- Non-haemolytic (Febrile) reaction
- Allergic reaction
- Circulatory overload
Haemolytic transfusion reactions
It is an agglutination of the donors red blood cells followed by haemolysis, which normally occurs as a result of blood incompatibility. Haemolytic transfusion reaction is often refer to as Alloimmunization and is characterized by antibodies within the recipients blood attacking the donors red blood cells, white cells or platelets. Haemoglobin and other products of the haemolysis are circulated throughout the body.
Blood transfusion carries a risk of alloimmunization to the many ‘foreign’ antigens present on red cell surface, leukocytes, platelets and plasma proteins. This may also occur during pregnancy to fetal antigens inherited from the father and not shared by the mother known as Haemolytic disease of the Newborn.
Alloimmunization does not usually cause clinical problems with the first transfusion but may occur with subsequent transfusions. There may also be delayed consequences of alloimmunization, such as Haemolytic Disease of the Newborn (HDN) and the rejection of tissue transplantation.
Immediate Blood transfusion reaction
It is the most serious complication of blood transfusion and is usually occurs due to ABO incompatibility. There is complement activation by the antigen-antibody reaction, usually caused by the largest immunoglobulin that is Ig M antibodies, leading to lumbar pain,rigors, dyspnoea, hypotension, renal failure and haemoglobinuria.
Initial symptoms or reactions may occur few minutes after starting the transfusion. Activation of coagulation may also occur and bleeding due to disseminated intravascular coagulation (DIC) which is a bad prognostic sign. Emergency treatment may be needed to maintain the blood pressure and renal function.
Some signs and symptoms of immediate or Early haemolytic reactions
- local pain at the site of infusion
- headache or full feeling in the head
- Pain in the kidney area (backache)
- Difficulty in breathing (dyspnoea)
- Tachycardia (fast heart beat)
- Palpitation (feeling of your heart beating)
- Anaphylactic shock: this manifests with cold and clammy, increased difficulty in breathing, pulse becomes weak.
- Chest pain
haemolytic reaction is always difficult to detect with patient that have been anaesthetized
It may occur in patients alloimmunized by previous transfusions or pregnancies. The antibody level is too low to be detected by pretransfusion compatibility testing, but a secondary immune response occurs after transfusion, resulting in destruction of the transfused cells, usually by Immunoglobulin G antibodies which is the only immunoglobulin capable of crossing the placenta.
Haemolysis is usually extravascular as the antibodies are IgG, and the patient may develop anaemia and jaundice about a week after the blood transfusion, although most of these are clinically asymptomatic. A romanowsky stain of the blood film will shows spherocytosis and reticulocytosis. The direct antiglobulin test (DAT) is positive and detection of the antibody is usually straightforward.
Signs and symptoms of Late or Delayed haemolytic reactions
- Haemoglobinuria (urine becomes red)
- Acute renal failure
Treatment of Haemolytic transfusion reactions
This reaction can be remedied by
- stopping the administration of blood or blood component is with the initial manifestation(s) of reaction. The normal saline is started again but slowly to maintain an open intravenous line in case medications may have to be administered intravenously.
- A prescription of adrenaline 1:1000 (0.5-1 ml) subcutaneously or intramuscularly If the patient complains of shortness of breath and tightness in the chest (Conditional)
- A marked fall in blood pressure (hypotension) may be treated by increasing the intravascular volume with a plasma substitute such as haemaccel which is an intravenous colloid used to prevent or treat of shock associated with reduction in effective circulating blood volume due to hemorrhage, loss of plasma, or loss of water and electrolytes from persistent vomiting and diarrhea
- The treatment is instituted to promote urinary output and reduce impairment or renal function by the haemoglobin released through haemolysis. The fluid intake and output must be accurately measured and recorded. An indwelling catheter may be passed so the urinary output may be measured hourly.
Also Fluids containing potassium must be avoided and intravenous solutions are administered and may include mannitol which is an osmotic diuretic. If the urinary output progressively decreases, the fluid intake is limited to insensible fluid loss and losses by other channels (vomiting, bowel elimination). Anuria and renal failure may develop, necessitating haemodialysis.
Non-haemolytic (Febrile) reaction of blood transfusion
Is a fairly common reaction to a transfusion is fever preceded by a rigor. It is attributed to the recipients sensitivity to the donors White blood cells (leukocytes), thrombocytes or plasma proteins. It may also develop as a result of a pyrogenic material in the equipment or solution used in the hospital.
The transfusion is slowed to relieve the discomfort of the febrile reaction and chills. If the person has had multiple transfusions or experienced this type of reaction before, hydrocortisone and chlorpheniramine also known as Piriton as Brand name which is an antihistamine, may be prescribed.
A febrile reaction may be the first sign of an acute haemolytic reaction or it may indicate that the blood or blood product was infected with live bacteria or bacterial toxins (Septicaemia).
Febrile reactions are a common complication of blood transfusion in patients who have previously been transfused or pregnant. The usual causes are the presence of leukocyte antibodies in an alloimmunized recipient acting against donor leukocytes in red cell concentrates leading to release of pyrogens, or the release of cytokines from donor leukocytes in platelet concentrates.
Some typical signs of Febrile reaction
- Chills and rigors.
- Fever (> 38C)
Aspirin may also be used to reduce the fever, although it should not be used with those patients with thrombocytopenia as it will increase the risk of bleeding.
In United Kingdom,The introduction of leucocyte-depleted blood in order to minimize the risk of transmission of variant Creutzfeldt-Jakob disease (vCJD) by blood transfusion, has reduced the incidence of febrile reactions.
Leukocyte antibodies in donors plasma, who are usually multiparous women(women who have carried pregnancy to term) , may cause severe pulmonary reactions (called transfusion-related acute lung injury abbreviated TRALI.
Some Signs of TRALI
- Dyspnoea (difficulty in breathing)
- Shadowing in the perihilar and lower lung fields on chest X-ray.
Allergic reaction of blood transfusion
A component of the donors blood may act as an antigen and initiate an allergic response. It is also suggested that the cause of an allergic reaction may be the response of the antibodies in the donors blood to an antigen within the recipient. These reactions are common but rarely severe;
The most common manifestations are urticarial and asthma. Severe bronchospasm and anaphylaxis occur less frequently. Anaphylaxis occurs in persons who are IgA deficient, who produce anti-IgA that reacts with IgA in the transfused blood. When such persons are sensitized, either by a previous pregnancy or transfusion, an anaphylactic reaction may occur with a transfusion of plasma containing blood products. Stopping or slowing the transfusion and administration of chlorphenamine (chlorpheniramine) or diphenhydramine hydrochloride (Benadryl), may provide relief. If the bronchospasm is severe or anaphylaxis develops, epinephrine (adrenaline) may be administered parenterally as well as a corticosteroid preparation; endotracheal intubation may be required. Patients who have had severe urticarial or anaphylactic reactions should receive either washed red cells, autologous blood, or blood from IgA-deficient donors for patients with IgA deficiency.
Circulatory overload Or Massive Blood transfusion
The giving of a transfusion too rapidly, or the administration of whole blood or plasma to someone with a normal intravascular volume or who has or is predisposed to cardiac or renal insufficiency, is dangerous. The resulting increased intravascular volume places too great a demand on the heart. Heart failure and pulmonary oedema ensue. The patient develops severe dyspnea, coughing, anxiety, weak pulse and cyanosis. A pink frothy sputum is expectorated.
Massive Blood transfusion leading to circulatory overload may be prevented by the slow administration of packed cells while the central venous pressure is monitored carefully.
Non-cardiogenic pulmonary oedema or adult respiratory distress syndrome (ARDS) may also occur. This is likely to be due to a reaction to the HLA antibodies in the donor plasma.
Infection during blood transfusion
Infected blood usually cause chest and abdominal pain.Also hypotension may occur (septicaemic shock). If this is suspected, antibiotic therapy is immediately prescribed to result the issue.
One of the most commonest infection disease associated to blood transfusion is Hepatitis .Donors blood is always screened in blood banks for the hepatitis B antigen, but the transmission of hepatitis is still a possibility. The onset of manifestations of the infection may occur many weeks after the transfusion.
Other like Syphilis, Malaria, AIDS and hepatitis B, non-A and non-B may also be transmitted by blood transfusion, but with a low probability if all pre-transfusing test are done properly.
Donor questionnaires can be used for recording of recent travel to exclude possible risks of West Nile virus (WNV) and severe acute respiratory syndrome (SARS). Recently, WNV has been the causal agent of meningoencephalitis transmitted by transfusion or transplantation in the United States of America.
In the UK the incidence of transmission of HIV by blood transfusion is extremely low fewer than 1 in 8 million units of blood transfused. Prevention is based on self-exclusion of donors in ‘high-risk’ groups and testing each donation for anti-HIV before blood is collected.
There is still a potential risk of viral transmission from coagulation factor concentrates prepared from large pools of plasma. Measures for inactivating viruses such as treatment with solvents and detergents are undertaken. Viral transmission via blood transfusion is still a major issue in the developing world.
Bacterial contamination of blood components is rare but it is one of the most frequent causes of death associated with transfusion. Some organisms such as Yersinia enterocolitica can proliferate in red cell concentrates stored at 4C, but platelet concentrates stored at 22C are a more frequent cause of this problem. Systems to avoid bacterial contamination include automated culture systems and bacterial antigen detection systems, but none are currently in routine use in the UK.
Transfusion-transmitted syphilis is very rare in the UK. Spirochaetes do not survive for more than 72 hours in blood stored at 4 C, and each donation is tested using the Treponema pallidum haemagglutination assay (TPHA). There continues to be concern about the risk of transmitting the prion protein causing vCJD by blood transfusion: a possible transmission occurred following a transfusion in 2003.
How to resolve blood transfusion reaction
When blood transfusion reaction occurs,the following actions should be done in order to resolve the situation
- Stop the transfusion promptly.
- Slow infusion of normal saline is resumed
- The remaining blood or blood component is returned in the container with the tubing to the blood bank for analysis and determination of the cause of the reaction.
- Blood specimens are taken from a vein other than the one that was used to administer the blood. They are sent to the laboratory for grouping and cross matching, culture and free haemoglobin estimation in the plasma.
- Vitals signs are monitored frequently and continuous assessment of the patient’s condition is necessary.
- Urine specimen is collected from the patient as soon as possible and sent t the laboratory for haemoglobin determination
There may be transfusion induced immunosuppression during blood transfusion but the mechanism of this process happens to be unknown.
Diseases transmitted through blood transfusion
The following are the most common diseases transmitted through blood transfusion
- South American Trypanosomiasis (Chagas disease)
- Hepatitis B viral infections
- Cytomegalovirus infection
- Hepatitis C viral infections
- West Nile virus
- Epstein Barr Virus
- Human T-Cell Leukaemia Virus type 1 (HTLV-1)
- Visceral Leishmaniasis (Kala Azar) this is rare but can be transmitted
- Prion vCJD
Blood transfusion ethics and Jehovah’s Witness
Although blood transfusion is a commonly-used therapeutic procedure to save life some religious beliefs are against this process.Refusal of blood and blood products on religious grounds is usually associated with the Jehovah’s Witnesses.
Their right has been recognized by most court However, it has usually been judged that parents and guardians do not have the right to refuse life-saving therapy (including blood transfusions) for their minor children and a court order may be applied to protect a child. Whenever it becomes apparent that a patient is a Jehovah’s Witness, the use of blood and blood products should be discussed with the patient, with a clear explanation of the consequences of refusing treatment. It is advisable to obtain a signed and witnessed statement or consent if treatment is refused.