Paediatrics: Blood transfusion reactions

Blood transfusion reactions

Major blood incompatibability

An example is group A blood being transfused to a child with blood group O. Signs and symptoms of intravascular haemolysis may appear after only 5–10mL blood infusion with:

·  Pain at venepuncture site.

·  Agitation, flushing, chest/abdominal/flank pain.

·  Fever, hypotension, haemoglobinaemia, haemoglobinuria, renal failure.

Treatment

·  Stop transfusion immediately.

·  Keep IV line open with saline.

·  Monitor vital signs and urine output.

·  Recheck patient and blood unit ID number.

·  Give supportive care. Watch for hypotension, respiratory and renal failure.

·  Inform the blood bank.

Minor incompatibilities (i.e. group O+ blood given to an O- child) will not cause intravascular haemolysis but will cause sensitization and problems for future transfusions, in particular in females during later pregnancies.

Bacterial infected blood products

Most serious reactions are seen with platelets (kept at room temperature where bacteria can multiply and produce toxins). At its most severe there is sudden hypotension, fever, rigors, systemic collapse, and DIC.

Treatment

Give IV broad-spectrum antibiotics (unlikely to help as the reaction is toxin mediated but will stop the development of further sepsis), inotropic support, and intensive care support as required. Delayed reaction after a platelet transfusion, i.e. not immediate, but within a few hours, must raise the suspicion of an infected product, requiring immediate blood cultures, broad spectrum antibiotics. Alert the blood bank immediately.

Transfusion-related acute lung injury (TRALI)

Rapid onset cough and shortness of breath occur (may mimic fluid over-load). TRALI is caused by donor antibodies to recipient leucocytes. There is an ARDS-like picture, with bilateral infiltrates on CXR. Respiratory sup-port is required.

Febrile, non-haemolytic reactions

These are due to recipient anti-HLA or granulocyte antibodies, or cytokines in infused blood product. Reactions are secondary to red cell al-loimmunization. Less frequent since the universal leucodepletion of blood products started in the UK in 1999. Fever and rigors occur within few hours of starting or completing the transfusion. To treat, slow transfusion rate and give paracetamol and antihistamines.

Circulatory overload

Results in pulmonary oedema, dyspnoea, headache, venous distension, signs of cardiac failure. To treat slow transfusion rate and give IV fruse-mide.

Transfusion-associated graft vs host disease (TaGVHD)

This occurs in patients with impaired cellular immunity. Lymphocytes in donor unit ‘engraft’ leading to rash, diarrhoea, liver impairment, and bone marrow failure. There is no effective treatment. Prevention is by prior irra-diation of blood products. Mortality is >90%.

Transfusion safety

UK rates of infection from blood products per transfused component:

·Hepatitis B: 1 in 1.5 million.

·Hepatitis C: 1 in 100 million.

·HIV: 1 in 5 million.

·Malaria: 0.5 in 1 million (US data only).

·Bacterial infection: 2 in 1 million for RBC, higher for platelet transfusion (up to 1 in 2000).

·Variant Creutzfeldt-Jakob disease (CJD): unknown (4 cases reported in UK up to 2010 in patients receiving non-leucocyte-depleted blood between 1996–1999).