Pulmonary transfusion reactions

Investigation of the patients with recurrent acute transfusion reactions: A single tertiary medical centre experience

OBJECTIVE

To assess the spectrum of patients who developed recurrent acute transfusion reactions (TRs) and to characterize these recurrent TRs.

METHODS

This retrospective study included patients who developed ≥2 acute TRs between April 2017 and March 2020 in a tertiary medical centre.

RESULTS

Among 216 TRs that occurred after 2024 transfusions in 87 patients, 66 (75.9%) patients reported a history of transfusions before the first TR and 70 (80.5%) patients received further transfusions after the last TR; with the same type of TR and reaction to the same type of blood product observed in 59 (67.8%) patients and 56 (64.4%) patients, respectively. TRs were most commonly associated with packed red blood cell (PRBC) transfusions and a febrile non-haemolytic transfusion reaction (FNHTR) was the most common type of TR. However, leukocyte reduced (LR) PRBCs were less common than LR platelets among transfusions with TR (22.7% [27/119] versus 75.0% [57/76], respectively) and premedication was prescribed before 196 of 216 (90.7%) transfusions with TR.

CONCLUSION

Most patients with recurrent TRs received repeated transfusions in addition to transfusions with TR. Instead of considering premedication, an increase in the use of LR might be the strategy to reduce the recurrence of TR.

Biological investigations of transfusion reactions: contribution of symptom-based decisional algorithms

OBJECTIVES

While transfusion is a common and safe therapeutic procedure in health care facilities, transfusion reactions can occur, whether acute or delayed, mild or life-threatening. In face of these reactions, the biological analysis laboratory plays a central role in their diagnosis. The objective of this article is to develop decisional algorithms for laboratory tests to be performed according to the clinical symptoms developed by the patient during or after transfusion.

METHODS

Based on the information collected by reviewing the literature and the procedures used in our hospital, we then developed biological investigation algorithms according to the symptoms presented by the patient, rather than the presumed reaction.

RESULTS AND CONCLUSION

We have developed symptom-based algorithms for acute transfusion reactions management that streamline laboratory testing and simplify the differential diagnosis.

Development of the Chinese Haemovigilance Network and reporting of adverse transfusion reactions from 2018 to 2020

BACKGROUND AND OBJECTIVES

To advance blood transfusion safety, the Chinese Haemovigilance Network (CHN) was put into operation in 2018. This report describes the development of the CHN and evaluates its role by analysing reported adverse transfusion reactions (ATRs) from 2018 to 2020.

MATERIALS AND METHODS

All data in this study were obtained from the CHN online reporting platform. A timeline of CHN development is presented, and the activities of CHN-enrolled facilities are analysed by year. The reported ATRs were analysed in detail for ATR types, blood components involved and adherence to case definition, severity and imputability criteria. Incidence rates were calculated and compared with international examples.

RESULTS

During 2018-2020, a total of 3061 ATRs were reported through the CHN online reporting system. The rate of reported ATRs in all facilities and the 10 highest reporting facilities was 0.7‰ and 1.8‰, respectively. When analysed by year, the incidence rate showed an increasing trend from 2018 to 2020. Allergic (68.2%) and febrile non-haemolytic transfusion reaction (27.1%) were the most common. The vast majority of ATRs (92.0%) were not serious, but serious cases of transfusion-associated circulatory overload, transfusion-associated dyspnoea and hypotensive reaction were common. Most (86.0%) of reported cases were definitely or probably associated with transfusion.

CONCLUSION

Under-reporting of ATRs occurs in many Chinese hospitals, but the establishment of CHN has increased ATR recognition and management. More effort will be needed in the future to detect transfusion problems and improve transfusion practice in China.

Random allogeneic blood transfusion in pigs: characterisation of a novel experimental model

Background

Organ cross-talk describes interactions between a primary affected organ and a secondarily injured remote organ, particularly in lung-brain interactions. A common theory is the systemic distribution of inflammatory mediators that are released by the affected organ and transferred through the bloodstream. The present study characterises the baseline immunogenic effects of a novel experimental model of random allogeneic blood transfusion in pigs designed to analyse the role of the bloodstream in organ cross-talk.

Methods

After approval of the State and Institutional Animal Care Committee, 20 anesthetized pig were randomized in a donor and an acceptor (each n = 8): the acceptor animals each received high-volume whole blood transfusion from the donor (35–40 ml kg⁻¹). Four animals received balanced electrolyte solution instead of blood transfusion (control group; n = 4). Afterwards the animals underwent extended cardiorespiratory monitoring for eight hours. Post mortem assessment included pulmonary, cerebral and systemic mediators of early inflammatory response (IL-6, TNF-alpha, iNOS), wet to dry ratio, and lung histology.

Results

No adverse events or incompatibilities occurred during the blood transfusion procedures. Systemic cytokine levels and pulmonary function were unaffected. Lung histopathology scoring did not display relevant intergroup differences. Neither within the lung nor within the brain an up-regulation of inflammatory mediators was detected. High volume random allogeneic blood transfusion in pigs neither impaired pulmonary integrity nor induced systemic, lung, or brain inflammatory response.

Conclusion

This approach can represent a novel experimental model to characterize the blood-bound transmission in remote organ injury.

Transfusion-associated circulatory overload-a systematic review of diagnostic biomarkers

BACKGROUND

Transfusion‐associated circulatory overload (TACO) is the leading cause of transfusion‐related major morbidity and mortality. Diagnosing TACO is difficult because there are no pathognomonic signs and symptoms. TACO biomarkers may aid in diagnosis, decrease time to treatment, and differentiate from other causes of posttransfusion dyspnea such a transfusion‐related acute lung injury.

STUDY DESIGN AND METHODS

A systematic review of literature was performed in EMBASE, PubMed, the TRIP Database, and the Cochrane Library, from inception to June 2018. All articles discussing diagnostic markers for TACO were included. Non‐English articles or conference abstracts were excluded.

RESULTS

Twenty articles discussing biomarkers for TACO were included. The majority investigated B‐type natriuretic peptide (BNP) and the N‐terminal prohormone cleavage fragment of BNP (NT‐proBNP), markers of hydrostatic pressure that can be determined within 1 hour. The data indicate that a post/pretransfusion NT‐proBNP ratio > 1.5 can aid in the diagnosis of TACO. Posttransfusion levels of BNP less than 300 or NT‐proBNP less than 2000 pg/mL, drawn within 24 hours of the reaction, make TACO unlikely. Cut‐off levels that exclude TACO are currently unclear. In critically ill patients, the specificity of natriuretic peptides for circulatory overload is poor. Other biomarkers, such as cytokine profiles, cannot discriminate between TACO and transfusion‐related acute lung injury.

CONCLUSION

Currently, BNP and NT‐proBNP are the primary diagnostic biomarkers researched for TACO. An NT‐proBNP ratio greater than 1.5 is supportive of TACO, and low levels of BNP or NT‐proBNP can exclude TACO. However, they are unreliable in critically ill patients. Other biomarkers, including cytokines and pulmonary edema fluid‐to‐serum protein ratio have not yet been sufficiently investigated for clinical use.

Incidence of transfusion reactions: a multicenter study utilizing systematic active surveillance and expert adjudication

BACKGROUND

Prevalence estimates of the serious hazards of transfusion vary widely. We hypothesized that the current reporting infrastructure in the United States fails to capture many transfusion reactions and undertook a multicenter study using active surveillance, data review, and adjudication to test this hypothesis.

STUDY DESIGN AND METHODS

A retrospective record review was completed for a random sample of 17% of all inpatient transfusion episodes over 6 months at four academic tertiary care hospitals, with an episode defined as all blood products released to a patient in 6 hours. Data were recorded by trained clinical research nurses, and serious reactions were adjudicated by a panel of transfusion medicine experts.

RESULTS

Of 4857 transfusion episodes investigated, 1.1% were associated with a serious reaction. Transfusion-associated circulatory overload was the most frequent serious reaction noted, being identified in 1% of transfusion episodes. Despite clinical notes describing a potential transfusion association in 59% of these cases, only 5.1% were reported to the transfusion service. Suspected transfusion-related acute lung injury/possible transfusion-related acute lung injury, anaphylactic, and hypotensive reactions were noted in 0.08, 0.02, and 0.02% of transfusion episodes, respectively. Minor reactions, including febrile nonhemolytic and allergic, were noted in 0.62 and 0.29% of transfusion episodes, respectively, with 30 and 50% reported to the transfusion service.

CONCLUSION

Underreporting of cardiopulmonary transfusion reactions is striking among academic, tertiary care hospitals. Complete and accurate reporting is essential to identify, define, establish pathogenesis, and mitigate/treat transfusion reactions. A better understanding of the failure to report may improve the accuracy of passive reporting systems.

Analysis of leucocyte antibodies, cytokines, lysophospholipids and cell microparticles in blood components implicated in post-transfusion reactions with dyspnoea

BACKGROUND AND OBJECTIVES

Post-transfusion reactions with dyspnoea (PTR) are major causes of morbidity and death after blood transfusion. Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) are most dangerous, while transfusion-associated dyspnoea (TAD) is a milder respiratory distress. We investigated blood components for immune and non-immune factors implicated in PTR.

MATERIAL AND METHODS

We analysed 464 blood components (RBCs, PLTs, L-PLTs, FFP) transfused to 271 patients with PTR. Blood components were evaluated for 1/antileucocyte antibodies, 2/cytokines: IL-1β, IL-6, IL-8, TNF-α, sCD40L, 3/lysophosphatidylcholines (LysoPCs), 4/microparticles (MPs) shed from plateletes (PMPs), erythrocytes (EMPs) and leucocytes (LMPs).

RESULTS

Anti-HLA class I/II antibodies or granulocyte-reactive anti-HLA antibodies were detected in 18.2% of blood components (RBC and FFP) transfused to TRALI and in 0.5% of FFP transfused to TAD cases. Cytokines and LysoPCs concentrations in blood components transfused to PTR patients did not exceed those in blood components transfused to patients with no PTR. Only EMPs percentage in RBCs transfused to patients with TRALI was significantly higher (P < 0.05) than in RBCs transfused to patients with no PTR.

CONCLUSION

Immune character of PTR was confirmed mainly in 1/5 TRALI cases. Among non-immune factors, only MPs released from stored RBCs are suggested as potential mediators of TRALI. Our results require further observations in a more numerous and better defined group of patients.

Transfusion associated circulatory overload

Transfusion associated circulatory overload (TACO) is an established, but grossly under diagnosed and underreported complication of blood transfusion. We present the case of a 46-year-old diabetic and hypertensive patient admitted to our hospital for recurrent episodes of urinary retention. Over initial 3 days of the admission, the patient received multiple units of packed red blood cells (RBC) and fresh frozen plasma, uneventfully. However, the patient developed signs and symptoms suggestive of TACO with only small amount of the 4(th) unit of RBC. The patient had to be shifted to the Intensive Care Unit for further management of this complication. Etiology of TACO is more complex than a mere circulatory overload and is still not completely understood. TACO leads to a prolonged hospital stay and morbidity in the patients developing this complication. TACO thus needs to be suspected in patients at risk for this complication.

Transfusion associated circulatory overload: a critical incident

Transfusion associated circulatory overload (TACO) is a serious but under-recognised complication of blood transfusion. While the exact incidence rate is unknown the associated morbidity and mortality make this a transfusion reaction worthy of attention. This article provides details of a critical incident involving TACO followed by a literature review and discussion written from the perspective of a student ODP. The goal of this article is to raise awareness of TACO amongst hospital staff to facilitate faster recognition and earlier intervention in future events.

Post-partum sequential occurrence of two diverse transfusion reactions (transfusion associated circulatory overload and transfusion related acute lung injury)

Transfusion associated circulatory overload (TACO) and transfusion related acute lung injury (TRALI) are two dissimilar pathological conditions associated with transfusion of blood products where the time course of the events and clinical presentation overlap leading to uncertainty in establishing the diagnosis and initiating the treatment, which otherwise differs. We encountered a case where a patient of post-partum hemorrhage developed TACO in the immediate post-operative period due to aggressive resuscitative attempts with blood products. The patient's condition was appropriately diagnosed and was managed according to the clinical scenario, and the condition abated. Subsequently, on the third post-operative day the patient again required blood product transfusions following which the patient developed TRALI, the diagnosis of which was also established and adequate treatment strategy was undertaken.

Anemia, bleeding, and blood transfusion in the intensive care unit: causes, risks, costs, and new strategies

The definition of anemia is controversial and varies with the sex, age, and ethnicity of the patient. Anemia afflicts half of hospitalized patients and most elderly hospitalized patients. Acute anemia in the operating room or intensive care unit is associated with increased morbidity as well as other adverse outcomes, including death. The risks of anemia are compounded by the added risks associated with transfusion of red blood cells, the most common treatment for severe anemia. The causes of anemia in hospitalized patients include iron deficiency, suppression of erythropoietin and iron transport, trauma, phlebotomy, coagulopathies, adverse effects of and reactions to medications, and stress-induced gastrointestinal bleeding. The types and causes of anemia and the increased health care utilization and costs associated with anemia and undetected internal bleeding are described. The potential benefits and risks associated with transfusion of red blood cells also are explored. Last, the strategies and new tools to help prevent anemia, allow earlier detection of internal bleeding, and avoid unnecessary blood transfusions are discussed.

[Transfusion-related acute lung injury]

Transfusion-related acute lung injury (TRALI) developed into the leading cause of transfusion-related morbidity and mortality after the first description by Popovsky et al. approximately three decades ago. It was the most frequent reason for transfusion-related fatalities worldwide before implementation of risk minimization strategies by donor selection. Plasma-rich blood products, such as fresh frozen plasma and apheresis platelets seem to be the leading triggers of TRALI. Hypoxemia and development of pulmonary edema within 6 h of transfusion are the diagnostic criteria for TRALI. The differentiation between cardiac failure and other transfusion-related lung injuries, such astransfusion-associated circulatory overload ( TACO) is difficult and causal treatment is not available. Therapy is based on supportive measures, such as oxygen insufflationor mechanical ventilation. The exactly pathogenesis is still unknown but the most propagated hypothesis is the two-event-model. Neutrophils are primed by the underlying condition, e.g. sepsis or trauma during the first event and these primed neutrophils are activated by transfused leukoagglutinating antibodies (immunogen) or bioreactive mediators (non-immunogen) during the second-event. Transfusion of leukoagglutinating antibodies from female donors with one or more previous pregnancies is the most frequent reason. No more TRALI fatalities were reported after implementation of the donor selection in Germany in 2009.

IgE- and IgG mediated severe anaphylactic platelet transfusion reaction in a known case of cerebral malaria

Background:

Allergic reactions occur commonly in transfusion practice. However, severe anaphylactic reactions are rare; anti-IgA (IgA: Immunoglobulin A) in IgA-deficient patients is one of the well-illustrated and reported causes for such reactions. However, IgE-mediated hypersensitivity reaction through blood component transfusion may be caused in parasitic hyperimmunization for IgG and IgE antibodies.

Case Report:

We have evaluated here a severe anaphylactic transfusion reaction retrospectively in an 18year-old male, a known case of cerebral malaria, developed after platelet transfusions. The examination and investigations revealed classical signs and symptoms of anaphylaxis along with a significant rise in the serum IgE antibody level and IgG by hemagglutination method. Initial mild allergic reaction was followed by severe anaphylactic reaction after the second transfusion of platelets.

Conclusion:

Based on these results, screening of patients and donors with mild allergic reactions to IgE antibodies may help in understanding the pathogenesis as well as in planning for preventive desensitization and measures for safe transfusion.

Blood transfusion determines postoperative morbidity in pediatric cardiac surgery applying a comprehensive blood-sparing approach

OBJECTIVE

Recently we suggested a comprehensive blood-sparing approach in pediatric cardiac surgery that resulted in no transfusion in 71 infants (25%), postoperative transfusion only in 68 (24%), and intraoperative transfusion in 149 (52%). We analyzed the effects of transfusion on postoperative morbidity and mortality in the same cohort of patients.

METHODS

The effect of transfusion on the length of mechanical ventilation and intensive care unit stay was assessed using Kaplan-Meier curves. To assess whether transfusion independently determined the length of mechanical ventilation and length of intensive care unit stay, a multivariate model was applied. Additionally, in the subgroup of transfused infants, the effect of the applied volume of packed red blood cells was assessed.

RESULTS

The median length of mechanical ventilation was 11 hours (interquartile range, 9-18 hours), 33 hours (interquartile range, 18-80 hours), and 93 hours (interquartile range, 34-161 hours) in the no transfusion, postoperative transfusion only, and intraoperative transfusion groups, respectively (P < .00001). The corresponding median lengths of intensive care unit stay were 1 day (interquartile range, 1-2 days), 3.5 days (interquartile range, 2-5 days), and 8 days (interquartile range, 3-9 days; P < .00001). The multivariate hazard ratio for early extubation was 0.24 (95% confidence interval, 0.16-0.35) and 0.37 (95% confidence interval, 0.25-0.55) for the intraoperative transfusion and postoperative transfusion only groups, respectively (P < .00001). In addition, the cardiopulmonary time, body weight, need for reoperation, and hemoglobin during cardiopulmonary bypass affected the length of mechanical ventilation. Similar results were obtained for the length of intensive care unit stay. In the subgroup of transfused infants, the volume of packed red blood cells also independently affected both the length of mechanical ventilation and the length of intensive care unit stay.

CONCLUSIONS

The incidence and volume of blood transfusion markedly affects postoperative morbidity in pediatric cardiac surgery. These results, although obtained by retrospective analysis, might stimulate attending physicians to establish stringent blood-sparing approaches in their institutions.

Effects of a comprehensive blood-sparing approach using body weight-adjusted miniaturized cardiopulmonary bypass circuits on transfusion requirements in pediatric cardiac surgery

OBJECTIVES

Transfusion-free pediatric cardiac surgery remains a challenge, mainly owing to the mismatch between the cardiopulmonary bypass (CPB) priming volume and the infants' blood volume. Within a comprehensive blood-sparing approach, we developed body weight-adjusted miniaturized CPB circuits with priming volumes of 95, 110, and 200 mL for, respectively, infants weighing less than 3 kg, 3 to 5 kg and 5 to 16 kg. We analyzed the effects of this approach on transfusion requirements and risk factors predisposing for blood transfusion.

METHODS

A total of 288 children with body weights between 1.7 and 15.9 kg were included and divided into 3 groups: No transfusion, postoperative transfusion only, and intraoperative and postoperative transfusion. Groups were compared by analysis of variance or analysis of variance on ranks. Risk factors predisposing for transfusion were identified by multivariate logistic regression.

RESULTS

Of the infants, 24.7% required no transfusion, 23.6% received postoperative transfusion only and 51.7% received intraoperative and postoperative transfusion. Groups differed by age, body weight, and size and by duration of surgery, CPB, and aortic crossclamp (P<.00001). Body weight (P<.00001), CPB duration (P<.00001), and persisting cyanosis (P=.03) were predictors of intraoperative and postoperative transfusion, whereas body weight (P=.00095), reoperations (P=.0051), and cyanotic heart defects (P=.035) were associated with postoperative transfusion only.

CONCLUSIONS

Our blood-sparing approach allows for transfusion-free surgery in a substantial number of infants. The strongest predictors of transfusion requirement, body weight and complexity of surgery as reflected by CPB duration, are not amenable to further improvements. Better preservation of the coagulatory system might allow for reduction of postoperative transfusion requirements.

Risks of transfusion

Each year, more than 4 million patients receive a blood transfusion in the United States to control symptoms associated with anemia, coagulopathy, thrombocytopenia, or some combination thereof. In each of these cases, the physician and the patient must weigh the potential benefits of the transfusion along with the associated risks. To assess accurately the risk:benefit ratio and to discuss this with the patient, the physician must be familiar with the range of adverse transfusion outcomes and the current estimates of their frequency. Most important, during the past decade the risk profile of transfusion has changed significantly. Transfusion-transmitted disease, although still a rare outcome of transfusion, is no longer an overriding concern in transfusion safety considerations; however, risks such as hemolysis, transfusion-related lung injury, and anaphylaxis continue to represent significant concerns and are relatively more common than the transmission of infectious diseases after transfusion. Against this background, the development of a national hemovigilance system, designed to evaluate more accurately transfusion adverse outcomes in the United States, will require greater precision and reliability in the assessment of adverse transfusion outcomes by clinicians if the proposed benefits of this system are to be realized.