Question 13

Outline the adverse consequences of a blood transfusion. (75% of marks)

Define massive blood transfusion and list the adverse consequences associated with a massive blood transfusion. (25% of marks)

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College Answer

In general this question was well answered; however candidates often had difficulty differentiating 
specifically for a massive blood transfusion (defined as replacement of circulating volume in 24 hours, or greater than 4 units blood transfused in 1 hour of continuing blood loss, or loss of 50% circulating volume in 3 hours). Responses to the first part of the question generally lacked depth. It is suggested that candidates take a systematic approach (e.g. use of categories such as immune, infectious, storage, etc.) when answering these type of questions. Candidates are reminded that when asked to “outline”, that the expectation for them to include a description that reflects understanding, and not just “dotpoints”.


Acute immunological complications

  • Acute hemolytic transfusion reactions due to wrong crossmatch
  • Febrile nonhemolytic transfusion reactions due to cytokine release
  • Tranfusion-associated lung injury (TRALI) - mainly due to the presence of donor leukocytes, as well as cytokine-induced pulmonary capillary leak
  • Allergic reactions to blood products

Acute non-immunological complications

  • Transfusion-associated circulatory overload (TACO) due to rapid increase of the venous volume
  • Bacterial sepsis due to contaminated blood products

Delayed immunological complications

  • Delayed hemolytic transfusion reactions
  • Transfusion-related immune modulation (TRIM)  
  • Microchimerism - the persistence of an allogeneic cell population of leucocytes
  • Posttransfusion graft-vs-host disease (due to non-leukodepleted PRBCs)
  • Posttransfusion purpura

Delayed non-immunological complications

  • Transfusion-transmitted diseases, eg. HIV, Hep C 
  • Iron overload (in the case of frequent transfusions)
  • Creutzfeld-Jacob disease (very rare, and largely preventable by donor screening)

Massive transfusion: 

  •  defined by the volume of blood lost.
    • The replacement of one's entire blood volume in 24 hrs
    • The replacement of half of one's blood volume over 4 hours\
    • Or, bleeding-defined criteria (rate of blood loss in excess of 150ml/min).
  • Additional complications from MASSIVE transfusion:
    • Hypocalcemia due to citrate used to prevent clotting in storage
    • Hyperkalemia due to high PRBC K+ content
    • Acidosis due to high PRBC lactate content
    • Hypothermia due to use of recently refrigerated PRBCs
    • Dilutional coagulopathy due to inappropriate blood product replacement proportions
    • Dilutional thrombocytopenia due to lack of platelet replacement


Goodnough, Lawrence T., Jerrold H. Levy, and Michael F. Murphy. "Concepts of blood transfusion in adults." The Lancet 381.9880 (2013): 1845-1854.

Spahn, Donat R., and Lawrence T. Goodnough. "Alternatives to blood transfusion." The Lancet 381.9880 (2013): 1855-1865.

There is also a rescinded document from the NHMRC (2001) which has been used to guide practice: Clinical Practice Guidelines on the Use of Blood Components.

To some extent this document has been superceded by the Australian and New Zealand Society of Blood Transfusion GUIDELINES FOR THE ADMINISTRATION OF BLOOD PRODUCTS.

The Patient Blood Management Guidelines from the National Blood Authority of Australia is another series of documents worth looking at - it contains several important modules which have been reviewed and which act as successors to the 2001 NHMRC guidelines.

Treleaven, Jennie, et al. "Guidelines on the use of irradiated blood components prepared by the British Committee for Standards in Haematology blood transfusion task force." British Journal of Haematology 152.1 (2011): 35-51.

Aoun, Elie, et al. "Transfusion‐associated GVHD: 10 years’ experience at the American University of Beirut—Medical Center." Transfusion 43.12 (2003): 1672-1676.

Heddle, Nancy M., and Morris A. Blajchman. "The leukodepletion of cellular blood products in the prevention of HLA-alloimmunization and refractoriness to allogeneic platelet transfusions [editorial]." Blood 85.3 (1995): 603-606.

Sharma, R. R., and Neelam Marwaha. "Leukoreduced blood components: Advantages and strategies for its implementation in developing countries."Asian journal of transfusion science 4.1 (2010): 3.

Dzik, Walter H. "Leukoreduction of blood components." Current opinion in hematology 9.6 (2002): 521-526.

Corwin, Howard L., and James P. AuBuchon. "Is leukoreduction of blood components for everyone?." JAMA 289.15 (2003): 1993-1995.

Blajchman, M. A. "The clinical benefits of the leukoreduction of blood products."Journal of Trauma-Injury, Infection, and Critical Care 60.6 (2006): S83-S90.

Rosenbaum, Lizabeth, et al. "The reintroduction of nonleukoreduced blood: would patients and clinicians agree?." Transfusion 51.12 (2011): 2739-2743.

Bilgin, Y. M., L. M. van de Watering, and A. Brand. "Clinical effects of leucoreduction of blood transfusions." Neth J Med 69.10 (2011): 441-450.

Australian Red Cross - Blood Service Policy on "The Age of Red Cells"

Hess, John R. "Red cell changes during storage.Transfusion and Apheresis Science 43.1 (2010): 51-59.

Bennett-Guerrero, Elliott, et al. "Evolution of adverse changes in stored RBCs."Proceedings of the National Academy of Sciences 104.43 (2007): 17063-17068.

Sihler, Kristen C., and Lena M. Napolitano. "Complications of massive transfusion." CHEST Journal 137.1 (2010): 209-220.