Question 16

List the potential problems resulting from blood transfusion and methods used to
minimise them.

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College Answer

This question required a broad answer. It was generally well answered. Those candidates who scored well had a good structure to their answers e.g. grouping potential electrolyte disturbances together, and infectious risks together etc. and including methods used to minimise these risks in appropriate detail.

Discussion

Complication	Management strategy
Acute hemolytic transfusion reactions	Stop transfusion Re-crossmatch Maintain blood pressure with vasopressors (there may be cytokine shock) Maintain adequate urine output to prevent haem-associated ATN
Febrile nonhemolytic transfusion reactions	Stop transfusion Antipyretic agents
Allergic reaction to blood products	Stop transfusion Antihistamine and corticosteroid
Tranfusion-associated lung injury	Stop transfusion Ventilate like ARDS
Transfusion-associated circulatory overload	Stop transfusion Administer a diuretic Consider a venodilator (eg. GTN) to decrease preload Ventilate with a higher PEEP
Bacterial sepsis	Management of sepsis as per usual routine Inform blood bank regarding contaminated blood products Perform a blood culture and Gram stain on the bag of PRBCs Keep the bag and giving set
Hypocalcemia due to citrate	Calcium replacement
Hyperkalemia due to high PRBC K⁺ content	Routine management of hyperkalemia (eg. calcium gluconate, bicarbonate)
Acidosis	Tincture of time, if your liver is normal Dialysis, if the clearance mechanisms are impaired
Hypothermia	Aggressive rewarming You should have used a blood warmer
Dilutional coagulopathy	Blood products will need to be replaced - FFP and cryoprecipitate to start with
Dilutional thrombocytopenia	Platelet transfusion

Delayed hemolytic transfusion reactions	Maintain blood pressure with vasopressors (there may be cytokine shock) Maintain adequate urine output to prevent haem-associated ATN
Transfusion-related immune modulation	You should have used leukodepleted PRBCs
Microchimerism	Using leukodepleted PRBCs, surprisingly, is not protective. Monitor for GVHD and autoimmune diseases
Transfusion-transmitted diseases	Councelling of the affected Post-exposure prophylaxis, if relevant Antiviral therapies
Posttransfusion graft-vs-host disease	Immunosuppression
Posttransfusion purpura	IV immunoglobulin Plasmapheresis Generally, management resembles the management for TTP

References

NZBLOOD Transfusion Medicine Handbook (2008)

Bux, Jürgen, and Ulrich JH Sachs. "The pathogenesis of transfusion‐related acute lung injury (TRALI)." British journal of haematology 136.6 (2007): 788-799.

Fontaine, Magali J., et al. "Diagnosis of transfusion-related acute lung injury: TRALI or not TRALI?." Annals of Clinical & Laboratory Science 36.1 (2006): 53-58.

Kleinman, Steven, et al. "Toward an understanding of transfusion‐related acute lung injury: statement of a consensus panel." Transfusion 44.12 (2004): 1774-1789.

Gajic, Ognjen, Michael A. Gropper, and Rolf D. Hubmayr. "Pulmonary edema after transfusion: how to differentiate transfusion-associated circulatory overload from transfusion-related acute lung injury." Critical care medicine 34.5 (2006): S109-S113.

Vincent, E. Chris, and Tracy Willett. "Post-Transfusion Purpura." The Journal of the American Board of Family Practice 4.3 (1991): 175-177.

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