Mediated by immune or nonimmune factors, a transfusion reaction accompanies or follows I.V. administration of blood components. Its severity varies from mild (fever and chills) to severe (acute renal failure or complete vascular collapse and death), depending on the amount of blood transfused, the type of reaction, and the patient’s general health.
Hemolytic reactions follow transfusion of mismatched blood. Transfusion of serologically incompatible blood triggers the most serious reaction, marked by intravascular agglutination of red blood cells (RBCs). The recipient’s antibodies (immunoglobulin [Ig] G or IgM) attach to the donated RBCs, leading to widespread clumping and destruction of the recipient’s RBCs and, possibly, the development of disseminated intravascular coagulation (DIC) and other serious effects.
Transfusion of Rh-incompatible blood triggers a less serious reaction within several days to 2 weeks. Rh reactions are most common in females sensitized to RBC antigens by prior pregnancy or by unknown factors (such as bacterial or viral infection) and in people who have received more than five transfusions. (See Understanding the Rh system.)
Allergic reactions are fairly common but only occasionally serious. In this type of reaction, transfused soluble antigens react with surface IgE molecules on mast cells and basophils, causing degranulation and release of allergic mediators. Antibodies against IgA in an IgA-deficient recipient can also trigger a severe allergic reaction (anaphylaxis).
Febrile nonhemolytic reactions, the most common type of reaction, apparently develop when cytotoxic or agglutinating antibodies in the recipient’s plasma attack antigens on transfused lymphocytes, granulocytes, or plasma cells.
Although fairly uncommon, bacterial contamination of donor blood can occur during donor phlebotomy. Offending organisms are usually gram-negative, especially Pseudomonas species, Citrobacter freundii, and Escherichia coli.
Contamination of donor blood with viruses, such as hepatitis, cytomegalovirus, and malaria, is also possible.
Immediate effects of a hemolytic transfusion reaction develop within a few minutes or hours after the start of the transfusion and may include chills, fever, urticaria, tachycardia, dyspnea, nausea, vomiting, tightness in the chest, chest and back pain, hypotension, bronchospasm, angioedema, and signs and symptoms of anaphylaxis, shock, pulmonary edema, heart failure, and renal failure. In a surgical patient under anesthesia, these symptoms are masked, but blood oozes from mucous membranes or the incision site.
Delayed hemolytic reactions can occur up to several weeks after a transfusion, causing fever, an unexpected fall in serum hemoglobin (Hb) level, and jaundice.
Allergic reactions are typically afebrile and characterized by urticaria and angioedema, possibly progressing to cough, respiratory distress, nausea, vomiting, diarrhea, abdominal cramps, vascular instability, shock, and coma.
The hallmark of febrile nonhemolytic reactions is mild to severe fever that may begin at the start of transfusion or within 2 hours after its completion.
Bacterial contamination produces a high fever, nausea, vomiting, diarrhea, abdominal cramps and, possibly, shock. Symptoms of viral contamination may not appear for several weeks after transfusion.
If you suspect such a reaction, have the patient’s blood retyped and crossmatched with the donor’s blood. After a hemolytic transfusion reaction, laboratory tests will show increased indirect bilirubin levels, decreased haptoglobin levels, increased serum Hb levels, and Hb in the urine. As the reaction progresses, tests may show signs of DIC (thrombocytopenia, increased prothrombin time, and decreased fibrinogen level) and acute tubular necrosis (increased blood urea nitrogen and serum creatinine levels).
A blood culture to isolate the causative organism should be done when bacterial contamination is suspected.
At the first sign of a hemolytic reaction, stop the transfusion immediately. Depending on the nature of the patient’s reaction, prepare to:
❑ monitor vital signs every 15 to 30 minutes, watching for signs of shock
❑ maintain a patent I.V. line with normal saline solution; insert an indwelling catheter and monitor intake and output
❑ cover the patient with blankets to ease chills, and explain what’s happening
❑ deliver supplemental oxygen at low flow rates through a nasal cannula or bag-valve-mask (handheld resuscitation bag)
❑ give drugs as ordered: an I.V. antihypotensive drug and normal saline solution to combat shock, epinephrine to treat dyspnea and wheezing, diphenhydramine to combat cellular histamine released from mast cells, corticosteroids to reduce inflammation, and mannitol or furosemide to maintain urinary function. Administer parenteral antihistamines and corticosteroids for allergic reactions. (Severe reactions such as anaphylaxis may require epinephrine.) Administer antipyretics for nonhemolytic febrile reactions and appropriate I.V. antibiotics for bacterial contamination.
❑ Remember to fully document the transfusion reaction on the patient’s chart, noting the transfusion’s duration, the amount of blood absorbed, and a complete description of the reaction and of any interventions.
❑ To prevent a hemolytic transfusion reaction, make sure you know your hospital’s policy about giving blood before you give a blood transfusion. Then make sure you have the right blood and the right patient. Check and double-check the patient’s name, hospital number, ABO blood group, and Rh status. If you find even a small discrepancy, don’t give the blood. Notify the blood bank immediately and return the unopened unit.
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Title: Professional Guide to Diseases (Eighth Edition)
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2005
ISBN: 1-58255-370-X
» Next page: Photosensitivity reactions (Professional Guide to Diseases (Eighth Edition))
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