Acute haemolytic transfusion reaction

This is an acute (<24 hours), immunological transfusion reaction.
 

When to suspect this adverse reaction?

It characteristically begins with an increase in temperature and pulse rate.

Symptoms may include chills, rigors, dyspnoea, chest and/or flank pain, discomfort at infusion site, sense of dread, abnormal bleeding and may progress rapidly to shock.

Instability of blood pressure is frequently seen. Transfused patients develop oliguria, haemoglobinuria and haemoglobinaemia.

In anaesthetised patients, hypotension and evidence of disseminated intravascular coagulation (DIC) may be the first sign. This may be a fatal reaction.
 

Usual causes?

Acute haemolytic transfusion reactions occur at an incidence of 1:76 000 transfusions(1) and may be associated with:

  • ABO/Rh mismatch
  • Red cell alloantibodies (non-ABO) as a result of patient immunisation from previous pregnancy or transfusion.(2)
  • Rare cases when Group O donor platelets with high titres of anti-A and/or anti-B are transfused to a non-Group O recipient.(2)

There is immunologic destruction of transfused red cells, due to incompatibility of antigen on transfused cells with antibody in the recipient circulation.

The most common cause is transfusion of ABO/Rh incompatible blood due to clerical errors or patient identification errors such as improper labelling of samples, administering blood to the wrong patient or testing errors.(2) As little as 10 mL of incompatible blood can produce symptoms of an acute haemolytic reaction (1). ABO/Rh incompatibility occurs in about 1:40 000 transfusions.(1)

Another cause of this type of transfusion reaction can be the presence of red cell alloantibodies (non-ABO) in the patient’s plasma which have not been previously identified. Occasionally a patient may have an antibody at levels below the detection capabilities of the antibody screening method or a clerical error occurs in the labelling of patient samples. Rarely is it caused by emergency uncrossmatched blood being given to an alloimmunised patient.
 

Investigation

Clinically assess patients for common features of haemolysis occurring within 24 hours of transfusion.

Check clerical records, such as ABO typing of patient and unit.

Repeat patient ABO grouping in both pre- and post-transfusion samples.

Perform Direct Antiglobulin Test (DAT) and Indirect Antiglobulin Test (IAT), renal function, and tests for haemolysis (eg serum haptoglobulin).
 

What to do?

Stop transfusion immediately and follow other steps for managing suspected transfusion reactions.

Seek urgent medical assistance.

Maintain blood pressure and renal output.

Induce diuresis with intravenous fluids and diuretics.

This may become a medical emergency so support blood pressure and maintain an open airway.

Do not administer additional blood packs until cleared by haematologist or Transfusion Service Provider.
 

References
  1. Roback JD (ed). Non-infectious complications of blood transfusion. Chapter 27, AABB Technical Manual, 17th edition. AABB, Bethesda, 2011.
  2. Callum JL, Lin Y, Pinkerton PH, Karkouti K, Pendergrast JM, Robitaile N et al. Chapter 5, Transfusion Reactions. Bloody Easy 3: Blood Transfusions, Blood Alternatives and Transfusion Reactions: A Guide to Transfusion Medicine, 3rd edition. Canada: Ontario Regional Blood Coordinating Network, 2011. [cited 2012 Sep 13]. Available from: http://transfusionontario.org/en/documents/?cat=bloody_easy