Overview
Definition:
Blood product administration involves the judicious transfusion of various blood components to patients with deficiencies or specific clinical needs
Transfusion reactions are adverse events occurring during or after blood component therapy, ranging from mild to life-threatening.
Epidemiology:
Transfusion reactions are relatively rare, with incidence varying by product and reaction type
Hemolytic reactions, though infrequent, are the most serious
Febrile non-hemolytic reactions are the most common
In India, blood banking practices and vigilant monitoring aim to minimize these events.
Clinical Significance:
For surgeons, understanding blood product indications and potential adverse events is critical for patient safety
Timely recognition and management of transfusion reactions can prevent significant morbidity and mortality, especially in trauma, perioperative, and critically ill patients.
Indications For Transfusion
Red Blood Cells:
Severe anemia (e.g., symptomatic Hb < 7-8 g/dL), acute blood loss exceeding compensatory mechanisms (e.g., >15% total blood volume), patients with significant comorbidities.
Platelets:
Thrombocytopenia (<10,000-20,000/µL) with bleeding risk, platelet dysfunction with active bleeding, surgical prophylaxis for procedures in patients with severe thrombocytopenia (<50,000/µL).
Fresh Frozen Plasma Ffp:
Coagulopathy with active bleeding or planned invasive procedures (INR > 1.5-2.0), disseminated intravascular coagulation (DIC), reversal of warfarin effect, deficiency of single coagulation factor when specific concentrate is unavailable.
Cryoprecipitate:
Fibrinogen deficiency (<100-150 mg/dL) with bleeding, Factor VIII deficiency, von Willebrand disease, Factor XIII deficiency.
White Blood Cells:
Rarely indicated
typically reserved for severe neutropenia (<0.5 x 10^9/L) with severe infection unresponsive to antibiotics, or for prophylaxis in specific cases like Graft-versus-Host Disease prophylaxis in bone marrow transplant.
Administration Protocols
Pre Transfusion Checks:
Verify patient identity (two identifiers)
Confirm ABO and Rh compatibility
Check crossmatch report
Inspect blood product bag for leaks, discoloration, or clots
Ensure correct product is for the correct patient
Two licensed healthcare professionals must perform these checks.
Infusion Guidelines:
Use a standard blood administration set with a filter
Start infusion slowly (e.g., 2 mL/min) for the first 15 minutes, monitoring closely for initial reaction
After 15 minutes, if no reaction, increase infusion rate according to product and clinical need
Red blood cells typically infused over 1-4 hours
Platelets and FFP over 30-60 minutes.
Monitoring:
Vital signs (temperature, heart rate, respiratory rate, blood pressure) should be checked before, 15 minutes after starting, and hourly during transfusion, and then post-transfusion
Monitor for signs and symptoms of a reaction
Document all aspects of the transfusion process.
Transfusion Reactions
Acute Hemolytic Reaction:
Caused by ABO incompatibility
rapid lysis of transfused RBCs
Symptoms: fever, chills, back pain, hypotension, hemoglobinuria, oliguria/anuria, DIC
Management: STOP TRANSFUSION IMMEDIATELY
Maintain IV fluids, diuresis
Support circulation
Renal support if needed
Reconfirm ABO type of patient and donor unit.
Febrile Non Hemolytic Reaction Fnhtr:
Most common
usually due to antibodies to donor leukocytes
Symptoms: fever, chills, headache, myalgia
Management: STOP TRANSFUSION
Administer antipyretics (e.g., acetaminophen)
Resume transfusion if symptoms mild and resolve
Consider leukoreduced products for future transfusions.
Allergic Reaction:
Due to recipient antibodies to donor plasma proteins
Symptoms: urticaria, pruritus, mild bronchospasm, angioedema
Management: STOP TRANSFUSION
Administer antihistamines (e.g., diphenhydramine)
If symptoms resolve, can resume transfusion
Severe anaphylaxis requires prompt management (epinephrine, steroids, oxygen).
Transfusion Related Acute Lung Injury Trali:
Acute onset of respiratory distress and pulmonary edema within 6 hours of transfusion, without signs of volume overload
Caused by donor antibodies against recipient neutrophils or vice versa
Management: Supportive care
mechanical ventilation, oxygen, diuretics
Transfusion stopped
Donor unit investigated.
Circulatory Overload Transfusion Associated Circulatory Overload Taco:
Transfusion given too rapidly or in excessive volume, especially in elderly or cardiac patients
Symptoms: dyspnea, orthopnea, elevated JVP, hypertension, pulmonary edema
Management: STOP TRANSFUSION
Place patient upright
Administer diuretics
Oxygen therapy
May require phlebotomy.
Bacterial Contamination Sepsis:
Rare but serious
due to contamination of blood product
Symptoms: high fever, chills, hypotension, shock
Management: STOP TRANSFUSION IMMEDIATELY
Blood cultures
Broad-spectrum antibiotics
Supportive care for sepsis and shock.
Delayed Hemolytic Reaction:
Occurs 1-14 days post-transfusion
due to alloimmunization
Symptoms: mild fever, jaundice, anemia
Management: Monitor hemoglobin
Usually self-limiting
Consider further transfusions with antigen-negative products if needed.
Graft Versus Host Disease Gvhd:
Rare but fatal
occurs when donor lymphocytes engraft in immunocompromised recipient
Symptoms: fever, rash, diarrhea, liver dysfunction, pancytopenia
Management: Supportive care
Immunosuppression
Irradiation of blood products is key for prevention in at-risk individuals.
Prevention And Management Strategies
Prevention Of Fnhtr Trali And Allergic Reactions:
Use of leukoreduced blood products is effective in reducing febrile reactions and potentially TRALI
Strict donor screening for antibodies.
Prevention Of Hemolytic Reactions:
Rigorous pre-transfusion compatibility testing (major and minor crossmatch)
Careful patient identification at all stages of administration
Use of electronic crossmatch where validated.
Prevention Of Gvhd:
Irradiation of blood products for immunocompromised recipients (e.g., bone marrow transplant recipients, neonates from carrier mothers, directed donations from first-degree relatives).
Management Of Suspected Reaction:
Immediate cessation of transfusion
Maintain IV access with normal saline
Assess patient vital signs and clinical status
Notify the blood bank and physician immediately
Collect blood and urine samples for investigation as per protocol
Send the remaining blood product and set back to the blood bank
Document thoroughly.
Key Points
Exam Focus:
Know the indications for each blood product
Master the symptoms, signs, and immediate management of the common transfusion reactions, especially acute hemolytic and FNHTR
Understand the principles of prevention.
Clinical Pearls:
Always perform bedside checks with two identifiers
Never transfuse from the same bag for two different patients
In any suspected reaction, the first and most crucial step is to STOP the transfusion.
Common Mistakes:
Failure to perform bedside checks leading to ABO incompatibility
Delaying the cessation of transfusion in a suspected reaction
Not notifying the blood bank promptly
Inadequate fluid resuscitation in hemolytic reactions.