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Overview of Adverse Events and Outcomes After Transfusion
Transfusion of blood products can lead to number of adverse events and outcomes in recipients, ranging from subclinical infection with a virus that can remain undiagnosed for decades, to acute immune hemolysis or acute septic reaction resulting in rapid onset of hypotension, shock, and ultimately death. A number of classification schemes exist to categorize adverse events and outcomes, including groupings by pathogenesis (immune vs. nonimmune; infectious [termed transfusion-transmitted infections, TTI] vs. noninfectious [termed noninfectious serious hazards of transfusion, NiSHOTs]), reaction type (febrile or allergic), and time to development. Acute transfusion reactions occur within 24 hours of transfusion, and delayed reactions occur more than 24 hours after transfusion, and both can range from mild to life-threatening ( Table 60.1 ).
Table 60.1
Transfusion Reactions
| Name | Temporal Relationship | Severity |
|---|---|---|
| Acute Transfusion Reactions | ||
| Acute hemolytic | 0–24 hours | Mild–severe |
| Anaphylactic | 0–1 hours | Severe |
| Febrile | 0–4 hours | Mild |
| Hypotensive | 0–1 hours | Mild–moderate |
| Metabolic complications | 0–4 hours | Mild–moderate |
| Septic | 0–6 hours | Mild–severe |
| TACO | 0–6 hours | Mild–severe |
| TRALI | 0–6 hours | Mild–severe |
| TAD | 0–24 hours | Mild |
| Urticarial/allergic | 0–4 hours | Mild–moderate |
| Delayed Transfusion Reactions | ||
| Alloimmunization | Days–months | None–severe |
| Delayed hemolytic | Days | Mild–severe |
| Iron overload | Years | Mild–severe |
| PTP | Week–weeks | Moderate–severe |
| TA-GVHD | Week–weeks | Severe |
| TA-MC | Months–years | Unknown |
| TRIM | Week–weeks | Mild–moderate |
| TTD | Days–years | None–severe |
Serious Hazards of Transfusion
As serious infectious hazards of transfusion including human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B virus (HBV) are increasingly rare, attention has turned more to NiSHOTs.
NiSHOTs include transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), and hemolytic transfusion reactions (HTRs). Occurrence of such reactions is not uncommon, as evidenced by FDA data ranking these three entities as the leading causes of transfusion-associated death in the United States in 2015. The latest information (2016) from the UK hemovigilance scheme, serious hazards of transfusion (SHOT) with 20 years of follow-up regarding adverse events and reactions showed that acute transfusion reactions together with failure to administer anti-D globulin and handling and storage errors (HSEs) ranked highest followed by incorrect blood component transfused (IBCT; equals “mistransfusion”). Importantly, longitudinal analysis of hemovigilance data from the United Kingdom also suggests that as focused steps are taken to mitigate SHOTs, such as TRALI and bacterial contamination of blood components, somewhat less-well-defined entities such as HSE are now taking lead in transfusion-associated morbidity.
Leading Causes of Transfusion-Associated Death
As stated above, the three leading causes of transfusion-associated death in the United States are TRALI, TACO, and HTR ( Chapter 63, Chapter 65, Chapter 66 ). Significant strides have been made to develop prevention strategies for these NiSHOTs in the past few years.
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