Complication and hazard of Blood transfusions

Mr. Topesh Patle

Introduction

  • Blood transfusion is a life-saving medical procedure widely used in anemia, trauma, surgery, obstetric emergencies, hematological disorders, and critical care.

  • Advances in transfusion medicine, such as component therapy, donor screening, and improved laboratory testing, have significantly increased transfusion safety.

  • Despite these advances, blood transfusion is not completely risk-free.

  • Blood is a complex biological product containing red cells, white cells, platelets, plasma proteins, electrolytes, and immunologically active substances.

  • Transfusion of donor blood can trigger immune, infectious, metabolic, and circulatory complications in the recipient.

  • Transfusion reactions may range from mild febrile or allergic reactions to severe life-threatening complications, such as:

    • Acute hemolytic transfusion reaction

    • Transfusion-related acute lung injury (TRALI)

    • Transfusion-associated circulatory overload (TACO)

    • Transfusion-transmitted infections

  • A large proportion of transfusion hazards occur due to human and system-related errors, including:

    • Incorrect patient identification

    • Improper blood grouping or cross-matching

    • Inappropriate indication for transfusion

    • Inadequate monitoring during transfusion

  • Therefore, prevention of transfusion hazards is a critical component of safe transfusion practice.

  • Prevention requires a multilevel approach, involving:

    • Proper donor selection and screening

    • Strict blood bank protocols

    • Rational clinical decision-making

    • Careful patient monitoring

Classification

Transfusion hazards are broadly classified based on time of onset and mechanism:

  1. Immediate (Acute) Complications

  2. Delayed Complications

  3. Infectious Complications

  4. Metabolic and Hemodynamic Complications

  5. Immunological Complications

  6. Complications Related to Massive Transfusion

 

Immediate (Acute) Transfusion Complications

These occur during transfusion or within 24 hours.

A. Acute Hemolytic Transfusion Reaction (AHTR)

Cause

  • ABO incompatibility (most commonly due to clerical or labeling errors)

  • Preformed IgM antibodies activate complement

Pathophysiology

  • Rapid destruction of donor red cells

  • Release of free hemoglobin

  • Activation of inflammatory mediators

Clinical Features

  • Sudden fever and chills

  • Severe back pain

  • Chest tightness

  • Hypotension

  • Hemoglobinuria

  • Oliguria or anuria

Complications

  • Acute renal failure

  • Disseminated intravascular coagulation (DIC)

  • Shock

  • Death

Management

  • Immediate stoppage of transfusion

  • Maintain urine output

  • Supportive therapy

B. Febrile Non-Hemolytic Transfusion Reaction (FNHTR)

Cause

  • Cytokines released from donor leukocytes

  • Recipient antibodies against donor white cells

Clinical Features

  • Rise in temperature ≥1°C

  • Chills and rigors

  • Headache

Importance

  • Common but usually benign

  • Must be differentiated from hemolysis or sepsis

Prevention

  • Leukoreduced blood components

C. Allergic and Anaphylactic Reactions

Mild Allergic Reaction

  • Caused by plasma proteins

  • Urticaria, itching, flushing

Severe Anaphylaxis

  • Seen in IgA-deficient recipients

  • Bronchospasm

  • Hypotension

  • Angioedema

Management

  • Antihistamines (mild)

  • Epinephrine and airway support (severe)

D. Transfusion-Related Acute Lung Injury (TRALI)

Cause

  • Donor anti-HLA or anti-neutrophil antibodies

Onset

  • Within 6 hours of transfusion

Features

  • Acute respiratory distress

  • Hypoxemia

  • Non-cardiogenic pulmonary edema

Significance

  • Leading cause of transfusion-related mortality

E. Transfusion-Associated Circulatory Overload (TACO)

Cause

  • Rapid or excessive volume transfusion

High-Risk Groups

  • Elderly

  • Pediatric patients

  • Cardiac or renal disease

Features

  • Dyspnea

  • Raised JVP

  • Pulmonary edema

  • Hypertension

 

Delayed Transfusion Complications

These occur days to weeks after transfusion.

A. Delayed Hemolytic Transfusion Reaction

Cause

  • Secondary immune response to minor RBC antigens

Features

  • Mild anemia

  • Jaundice

  • Fall in hemoglobin

B. Alloimmunization

Definition

  • Formation of antibodies against donor antigens

Clinical Importance

  • Makes future transfusions difficult

  • Increases risk of hemolytic reactions

Common in

  • Thalassemia

  • Sickle cell disease

C. Transfusion-Associated Graft Versus Host Disease (TA-GVHD)

Mechanism

  • Viable donor T lymphocytes attack recipient tissues

Symptoms

  • Fever

  • Skin rash

  • Diarrhea

  • Pancytopenia

Mortality

  • Very high (>90%)

Prevention

  • Irradiated blood products

 

Infectious Complications of Blood Transfusion

Despite screening, window period infections can occur.

A. Viral Infections

  • HIV

  • Hepatitis B

  • Hepatitis C

  • HTLV

B. Bacterial Contamination

Most Common With

  • Platelet concentrates (stored at room temperature)

Features

  • High fever

  • Hypotension

  • Septic shock

C. Parasitic Infections

  • Malaria

  • Babesiosis

  • Trypanosomiasis

 

Metabolic Complications

A. Citrate Toxicity

  • Citrate binds calcium

  • Leads to hypocalcemia

Features

  • Tingling

  • Tetany

  • Arrhythmias

B. Hyperkalemia

  • Potassium leaks from stored RBCs

  • Risk in neonates and massive transfusions

C. Hypothermia

  • Rapid transfusion of cold blood

  • Causes arrhythmias and coagulopathy

 

Complications of Massive Blood Transfusion

Definition

  • Replacement of one blood volume within 24 hours

Complications

  • Dilutional coagulopathy

  • Thrombocytopenia

  • Metabolic acidosis

  • Electrolyte imbalance

 

Iron Overload

Cause

  • Repeated transfusions

Organ Damage

  • Liver (cirrhosis)

  • Heart (cardiomyopathy)

  • Endocrine glands (diabetes, hypogonadism)

 

Prevention of Transfusion Hazards

1. Prevention at the Donor Level

A. Proper Donor Selection

  • Detailed medical history and physical examination

  • Exclusion of donors with:

    • Recent infections

    • High-risk behavior

    • Chronic diseases

  • Ensures safety for both donor and recipient

B. Mandatory Screening of Donor Blood

Each donated unit must be tested for:

  • HIV 1 & 2

  • Hepatitis B (HBsAg)

  • Hepatitis C

  • Syphilis

  • Malaria

Nucleic Acid Testing (NAT) further reduces the window period and risk of transfusion-transmitted infections.

2. Prevention at the Blood Bank Level

A. Proper Blood Grouping and Cross-Matching

  • Accurate ABO and Rh typing

  • Antibody screening

  • Compatibility testing between donor and recipient

 Most fatal transfusion reactions occur due to clerical errors, not lab errors.

B. Component Therapy Instead of Whole Blood

  • Use only the required component:

    • Packed RBCs

    • Platelets

    • Fresh Frozen Plasma (FFP)

  • Reduces volume overload and unnecessary exposure

C. Leukoreduction

  • Removal of donor leukocytes

  • Prevents:

    • Febrile non-hemolytic reactions

    • CMV transmission

    • HLA alloimmunization

D. Irradiation of Blood Products

  • Inactivates donor lymphocytes

  • Prevents Transfusion-Associated Graft-Versus-Host Disease (TA-GVHD)

  • Indicated in:

    • Immunocompromised patients

    • Neonates

    • Bone marrow transplant recipients

E. Proper Storage and Handling

  • Maintain correct temperature:

    • RBCs: 2–6°C

    • Platelets: 20–24°C with agitation

  • Avoid expired or improperly stored units

  • Prevent bacterial contamination

3. Prevention at the Patient Level

A. Strict Patient Identification

  • Verify:

    • Patient name

    • Hospital ID

    • Blood group

  • Match with blood unit label and compatibility report

This is the most critical step in preventing acute hemolytic reactions.

B. Rational Indication for Transfusion

  • Transfuse only when clearly indicated

  • Avoid unnecessary transfusions

  • Follow restrictive transfusion thresholds when possible

C. Informed Consent

  • Explain:

    • Benefits

    • Risks

    • Alternatives

  • Obtain written consent prior to transfusion

4. Prevention During Transfusion

A. Proper Administration

  • Use standard transfusion sets with filters

  • Do not add drugs to blood

  • Start transfusion slowly (first 15 minutes critical)

B. Close Monitoring of Patient

  • Monitor:

    • Pulse

    • Blood pressure

    • Temperature

    • Respiratory rate

  • Especially during initial 15–30 minutes

C. Early Recognition of Adverse Reactions

Stop transfusion immediately if:

  • Fever or chills

  • Breathlessness

  • Chest or back pain

  • Rash or itching

  • Hypotension

5. Prevention of Metabolic and Volume-Related Hazards

A. Prevention of TACO

  • Slow transfusion rate

  • Use diuretics in high-risk patients

  • Avoid unnecessary volume

B. Prevention of Citrate Toxicity

  • Monitor calcium levels

  • Calcium supplementation during massive transfusion

C. Prevention of Hyperkalemia

  • Use fresh blood in neonates

  • Monitor electrolytes in massive transfusion

D. Prevention of Hypothermia

  • Use blood warmers during rapid transfusion

6. Post-Transfusion Prevention Measures

A. Post-Transfusion Monitoring

  • Observe patient for delayed reactions

  • Monitor hemoglobin and vital signs

B. Documentation and Reporting

  • Document transfusion details

  • Report adverse reactions to:

    • Blood bank

    • Hospital transfusion committee

C. Hemovigilance Programs

  • Continuous monitoring of transfusion safety

  • Helps identify system errors and improve practices

7. Institutional and Policy-Level Prevention

    • Standard operating procedures (SOPs)

    • Regular staff training

    • Transfusion audits

    • National hemovigilance systems