Basically made for ICU nurses to help them understand different kinds of blood transfusion reactions and how to diagnose and manage them in ICU

1. Dr. Muhammad Asim Rana
MBBS, MRCP(UK), FCCP, SF-CCM
, EDIC
Critical Care Medicine

2. • Bed no 1 is a 68 yrs old chronic case for
tracheostomy and the Hb% is 8.5
• ENT and Ansthesia has demanded Hb% of
10.0
• What will you do?

3. PRBCs Ideal for patients requiring red cells
but not volume replacement. Increase
O2 carrying capacity
• Transfusion trigger (HCT<30% ;
HB<10g/dl)
• 1 Unit increases 3% HCT or 1g/dl
• Shelf life =42 d (1-6 ℃)

4. • Bed no 14 Medical ICU, a 35 yrs old
female case of Sickle Cell Anemia has
been admitted with chest pain and
cough, has anemia Hb% is 6.0, your
consultant advised therapeutic exchange.
• What will be your plan?

5. • Bed no 34 surgical ICU, a 25 yrs old male
victim of RTA admitted with severe abdominal
injury with ruptured spleen and tear in liver is
admitted post OR.
• His Hb% pre OR was 3.0 he received 10
PRBCs in OR as he was massively bleeding
during surgery
• Came hypotensive, hypothermic, oozing from
wounds and active bloody out put from drains
• What will be your plan?

6. • His resuscitation started with PPF, Hessteril and PRBCs but his bleeding is not
stopped
• GS has no plan to re-explore him
• His labs showed that he is in severe DIC
• Why?
• What is the solution now?

7. • Bed no 50 surgical ICU, a 55 yrs old male
ESRD on haemodialysis admitted post
fixation of his fracture femur.
• You found he has a constant ooz from the
incision so that his Hb% dropped to 6.0
• What will be your plan?
• What is the cause of constant oozing in
this pt?

8. • Bed no 23 a 65 yrs old female, case of
hydrocephalus due to TBM is going for
EVD insertion and you see that she has
very low platlets around 30,000
(thrombocytopenia)
• What will be your plan?
• What is the risk in this pt?

9. • Consists of formed elements (cells)
suspended & carried in plasma (fluid part)
• Total blood volume is about 5L
• Plasma is straw-colored liquid consisting of
H20 & dissolved solutes
• Includes
ions, metabolites, hormones, antibodies

10. PRBCs Ideal for patients requiring red cells but not volume replacement.
Increase O2 carrying capacity
Transfusion trigger (HCT<30% ; HB<10g/dl)
1 Unit increases 3% HCT or 1g/dl
Shelf life =42 d (1-6 ℃)
Platelets
Thrombocytopenia (< 5,000)
Platelet dysfunction
Each unit increase 5,000 PLTs after 1hr
FFP ( initial therapeutic dose : 10-15 ml/kg ) and used in
Isolated factor deficiencies
Reverse warfarin therapy
Correction of coagulopathy associated with liver disease
Massive blood transfusion with microvascular bleeding
(>1 BV/ 24 hrs or > 50 % BV within 3 hrs or > 150 ml/min)
Antithrombin III deficiency
TTP ( Thrombotic thrombocytopenic purpura )

11. Christian Zagado (1665)
First human blood transfusion
Dr. James Blundell, a British
obstetrician (1825)
Austrian Karl Landsteiner (1900)
Discovery of ABO type
Oswald Hope Robertson
US Army Capt 1916
First Blood Bank World War 1

12. Erythrocytes (RBCs)
• RBCs are flattened biconcave discs
• Shape provides increased surface area
for diffusion
• Lack nuclei & mitochondria
• Each RBC contains 280 million
hemoglobins
13-9

13. • Have nucleus, mitochondria, & amoeboid ability
• Granular leukocytes help detoxify foreign substances & release
heparin
• Include eosinophils, basophils, & neutrophils
• Agranular leukocytes are
phagocytic
& produce antibodies
,Include
lymphocytes &
monocytes
13-10

14. • Are smallest of formed elements, lack
nucleus
• Are fragments of megakaryocytes
• Constitute most of mass of blood clots
• Release serotonin to vasoconstrict &
reduce
blood flow to clot area
• Secrete growth factors to maintain
integrity of blood vessel wall
• Survive 5-9 days
13-12

15. • Constitute 7-9% of the plasma
• Three types : albumins, globulins, & fibrinogen
Albumin accounts for 60-80%
• Creates colloid osmotic pressure that draws H20
from interstitial fluid into capillaries to maintain blood
volume & pressure
Globulins carry lipids. Gamma globulins are
antibodies
Fibrinogen serves as clotting factor
Serum is fluid left when blood clots
13-8

16. 
Whole Blood；

Blood Component；RBC PLT FFP Leukocyte
concentrate

Plasma Substitutes；
Use of whole blood is considered to be waste of
resources
Indications
•
Acute massive blood loss;
•
Anaemia and hypoalbuminemia
•
Overwhelming Infection
•
Dysfunction of Coagulation;

17. 
Approach Route: PVL, CVL

Filtration before Transfusion

Velocity of Transfusion： 5-10ml/min

Double Check: Name, Type and Cross-match

Storage Time

Pre-heat

No any other Medication

Observation during / after Transfusion

18. • The pt of bed 1 is receiving 2 units of PRBCs for
possible tracheostomy. After his 1st unit of blood he
developed a temp of 38.3 °C (101.0°F). He has no other
symptoms.
On exam he appears anxious but his vital signs are
stable with BP 120/70mmHg, HR 80bpm RR18 Sat O2
98% on Room Air
he has no skin rash and his urine color is amber
What is your diagnosis?
How would you manage this patient ?

19. •
•
Most common, usually benign without sequelae
Concerning because initial presentation is similar to
more adverse reactions. i.e. fever, chills +/- mild
dyspnea.
15% will have a recurrence in the future with
subsequent transfusion
•
Management
•
•
•
Discontinue transfusion, rule out hemolysis i.e.
check labels, repeat type and cross
match, coombs test
Antipyretics +/- meperidine for chills and rigors
Although antihistamine premedication is widely
used there are no evidence to support that their
use actually prevents reaction.

20. • A 35-year-old woman with sickle cell disease, she is
receiving 2 units of PRBC. Her 1st unit of blood was
transfused without events but 5minutes into her 2nd
unit, She complains of new flank pain and fever.
On exam she appears very anxious, diaphoretic and in
acute distress, she is febrile to 38.8C with BP
100/60mmHg, HR101/m RR 22/m, Pulse Ox 98% 0n RA
She has no skin rash but is oozing out of IV sites and her
urine color is now reddish brown.
Labs: elevated Bun/creat, increased PTT, PT and
decreased HCT.
What is the diagnosis and how would you manage this
patient?

21. • Medical emergency
• Occurs due to rapid transfused RBC destruction by
preformed recipients Abs
• Mostly due to ABO incompatibility
• Most common causes are clerical or procedural errors
• Complications includes DIC, shock, ARF secondary to
ATN
Clinical presentation
• Classic presenting triad of Fever, flank pain and
reddish brown urine from hemoglobinuria are rarely
seen
• DIC may be presenting mode
• Positive Direct Coombs

22. • People with Type A blood
make antibodies to Type
B RBCs, but not to Type
A
• Type B blood has
antibodies to Type A
RBCs but not to Type B
• Type AB blood doesn’t
have antibodies to A or B
• Type O has antibodies to
both Type A & B
• If different blood types
are mixed, antibodies will
cause mixture to

23. • If blood types don't
match, recipient’s
antibodies agglutinate
donor’s RBCs
• Type O is “universal
donor” because lacks A
& B antigens
• Recipient’s antibodies
won’t agglutinate donor’s
Type O RBCs
• Type AB is “universal
recipient” because
doesn’t make anti-A or
anti-B antibodies
• Won’t agglutinate donor’s
Insert fig. 13.6 •

24. Management
1. Stop transfusion, alert blood bank to start search for
clerical error since another patient may be at risk
, repeat type and cross matching
2. Supportive care; ABC +/-pressors
3. Cardiac monitoring because of risk of hyperkalemia
4. Infuse N/S to maintain BP and promote diuresis, avoid
LR and dextrose because calcium in LR will promote
clotting in IV line and dextrose will increase hemolysis.
Maintain urine output >100-200ml/hour
5. With DIC early heparinization 10u/kg/hr may be
beneficial

25. life threatening emergency
•Occurs within a few seconds to minutes
following transfusion
•Characterized by rapid onset of anaphylaxis
•Can occur with all blood products
•Incidence ; 1 in 20-50 thousand
•Presence of class specific IgG and anti IgA abs
in patients who are IgA deficient
•Treatment: Epinephrine , ABC +/- pressor

26. After 3days of treatment, he had improved however, he developed a
cough and a temperature of 38.3°C , with increasing FiO2 requirement
O/E, BP is 120/80 mm Hg. There is no rash . he is tachycardic . Oxygen
saturation is 80% on FiO2 of 85%, and a blood gas study shows an
arterial PO2 of 45 mm Hg. A chest radiograph reveals diffuse
opacifications of both lungs.
Which of the following is the most likely cause for this patient's
reaction?
1. Pulmonary embolism
2. Antileukocyte antibodies
3. Allergy to donor plasma proteins
4. Circulatory overload

27. • New acute lung injury occurring during or within 6 hour of blood
product transfusion
• 1 case for every 1000-2400 units transfused with 6-9% mortality rate
• Abs against HLA
Clinical presentation
• Acute onset of respiratory distress (hypoxemia) during or shortly after
blood transfusion.
• Fever, tachycardia, tachypnea, +/-hypotension
• In intubated pts; elevated peak airway pressures, pink frothy airway
secretion
• CXR bilateral patchy alveolar infiltrates, normal cardiac picture
Management
• Mostly supportive with abrupt resolution in symptoms within a few
days
• A majority of patients may require mechanical ventilation

28. Immune mediated transfusion reactions
• Febrile non hemolytic transfusion
reactions
• Acute and delayed hemolytic reactions
• Anaphylactic transfusion reaction
• Urticarial transfusion reaction
• Post-transfusion purpura
• GVHD
• TRALI (Transfusion Related Acute Lung
Injury)

29. • Physical reactions: thermal i.e. heat or cold
induced
• Infectious; Hepatitis B/C, malaria, HIV, CMV, West
Nile virus
• Chemical; citrate toxicity, hypo/hyperkalemia, iron
overload
• Acute hypotensive reaction: mediated by
bradykinins and occurs in patients with faulty
bradykinin metabolism on ACE I
• Osmotic injury

30. • Transfusion reactions are mostly due to
documentation errors and can range from benign
reactions to life threatening emergencies
• Early detection, discontinuation of transfusion
and instituting supportive care are key to
management.
• Reporting of all reactions helps to improve
standard practices and reduce future
occurrences.

31. Dr. Asim Rana