3

due to haemolysis and renal failure in a group A patient. ABO-incompatible transfusion occurs in around 1 in 180 000 red cell units transfused. It is usually caused by human error when taking or labelling pre-transfusion blood samples, collecting components from the blood bank or satellite refrigerator and/or failing to perform a correct identity check of blood pack and patient at the bedside (see Chapter 4). If red cells are transfused to the wrong patient, there is around a 30% chance they will be ABO incompatible. Major morbidity (requiring intensive care or renal dialysis) occurs in up to 30% of cases and 5–10% of episodes contribute to the death of the patient. Conscious patients often become very unwell within the first few minutes of transfusion, complaining of flushing, loin and abdominal pain and ‘a feeling of impending doom’. If the patient is unconscious, Transfusion Handbook / 5: Adverse effects of transfusion page 4 of 17 anaesthetised or cannot communicate, the first indication of a reaction may be tachycardia, hypotension and bleeding into the skin or from needle wounds, emphasising the importance of careful monitoring of vital signs. Immediate clinical management of patients with suspected severe acute haemolytic transfusion should follow the steps outlined in Figure 5.1 and the investigations in Table 5.1. After disconnecting the transfusion pack and starting resuscitation: Maintain venous access with physiological saline and call for urgent medical support. Check the compatibility label on the blood pack against the patient’s ID band (and seek confirmation of identity from the patient, parent or carer if possible). Inform the transfusion laboratory urgently. If the wrong blood has been transfused, another patient may be at risk. Return the (sealed) transfusion pack and giving-set for investigation. Seek early support and advice from critical care and haematology teams and admit the patient to an intensive care unit if possible. Figure 5.1 Clinical flowchart for the management of acute transfusion reactions (reproduced from BCSH Guideline on the Investigation and Management of Acute Transfusion Reactions, 2012, with kind permission of British Committee for Standards in Haematology) Transfusion Handbook / 5: Adverse effects of transfusion page 5 of 17 Table 5.1 Investigation of moderate or severe acute transfusion reactions (adapted from BCSH Guideline on the Investigation and Management of Acute Transfusion Reactions, 2012) Symptoms Investigations Transfusion Handbook / 5: Adverse effects of transfusion page 6 of 17 Fever (>2°C rise or >39° C) and/or chills, rigors, myalgia, nausea or vomiting and/or loin pain Standard investigationsa Samples for repeat compatibility testing, direct antiglobulin test (DAT ), lactate dehydrogenase (LDH) and haptoglobins Blood cultures from patient Coagulation screen Do not discard implicated unit If febrile reaction sustained, return blood component to laboratory, repeat serological investigations (compatibility testing, antibody screen and DAT), measure haptoglobins and culture blood component. Contact a Blood Service consultant to discuss the need for recall of components from same donation. Mucosal swelling (angioedema) Standard investigationsa Measure IgA level – if 30 mm Hg resulting in a level 2°C above baseline), hypotension and rapidly developing shock and impaired consciousness. Immediate management and investigation follows the principles outlined in Figure 5.1 and Table 5.1. In particular: Inspection of the pack may show abnormal discoloration, aggregates or offensive smell, but many packs appear normal. Blood cultures should be taken from the patient and treatment immediately started with an intravenous broad spectrum antibiotic combination covering gram negative and gram positive bacteria (the local empirical antibiotic regimen used in patients with neutropenic sepsis is appropriate). Implicated components must be sealed to avoid leakage or contamination and returned to the transfusion laboratory for further investigation. The blood transfusion centre must be contacted immediately so that any associated components from the implicated donation can be urgently identified and withdrawn from hospital blood banks. National Blood Services provide comprehensive bacterial testing and typing of strains (to confirm identity of contaminating bacteria with those isolated from the patient’s blood cultures). Both SHOT and BCSH recommend that, wherever possible, implicated component packs are returned to the Blood Service for testing rather than sampled and cultured in local hospital laboratories. 5.2.2.3: Severe allergic or anaphylactic reactions Shock or severe hypotension associated with wheeze (bronchospasm), stridor from laryngeal oedema or swelling of face, limbs or mucous membranes

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19