Transfusion complication

vi) Oxygen Affinity Changes

• 2,3 DPG is greatly reduced in RBC’s after about 3 weeks of storage, this increases hemoglobin’s affinity for oxyen and adversely affects oxygen delivery to tissues.

vii) Acute Respiration.’ Distress C’yndronte  viii)Coagulation Factor Depletion 

Banked blood has a pH of 6.8 and is acidotic.

After massive transfusion citrate in the stored blood is converted into bicarbonate resulting in metabolic alkalosis.

The most common reaction after blood transfusion is Febrile Non Hemolytic Transfusion Reaction (FNHTR).

These reactions are characterized by chills and rigors and ≥1 degree celsius rise in temperature.

FNHTR is diagnosed when other causes of fever in the transfused patient are ruled out.

Ref: Harrison’s Principles of Internal Medicine, 16th Edition, Page 665

Ans:A.)Hypokalemia.

Complications usually seen with massive blood transfusion are

• 1) hyperkalemia,
• 2) hypocalcemia,
• 3)hypomagnesemia
• 4) hyperammonemia,
• 5) hypothermia,
• 6) Acidosis
• 7)dilutional coagulopathies and DIC (most worrisome problem after massive transfusion and is the usual cause of death after massive blood transfusion) and
• 8) ARDS.

Ans. is ‘None’

Ans. is `b’ i.e., Type II hypersensitivity

Ans. is ‘a’ i.e., Blood transfusion reaction

Ans. is ‘d’ i.e., Blood transfusion 

“Children usually acquire infection indirectly, through parenteral route from hepatitis B contaminated blood transfusion”.

Other modes of transmission in children : –

i)    Sharing of contaminated hypodermic needles used for multiple doses of infection.

ii)     Shaving razors.

iii)      Sexual contact Adolescent boy & girls.

B i.e. Excessive bleeding

Mismatched blood transfusion is anesthetized patient present as:

1. General oozing from wound (excessive bleeding)Q
2. Severe & progressive hypotensionQ
3. Tachycardia
4. LIrticarial rashQ
5. BronchospasmQ, raising airway pressure on intermittent positive pressure ventilation
6. Later jaundice & oliguria (5-10%)

Answer is ‘b’ i.e. Hypotension & bleeding from site of wound

“If the patient is awake, the most common symptoms of acute transfusion reactions are pain at the site of transfusion, facial flushing, and back and chest pain. Associated symptoms include fever, respiratory distress, hypotension, and tachycardia. In anesthetized patients, diffuse bleeding and hypotension are the hallmarks.”- Schwartz

 Also remember

• Most common symptom of hemolytic transfusion reaction in a conscious patient — sensation of heat and pain along the vein into which the blood is being transfused.
• Most common sign of hemolytic tranfsusion reaction in a conscious patient –> oliguria > hemoglobinuria [Ref:Schwartz Pretest 7/e, Q no. 87]

Ans. is ‘a’ i.e. Hypokalemia 

Hyperkalemia and not hypokalemia is a major complication of massive transfusion.

This is because the plasma potassium concentration of stored blood increases because of RBC leakage and lysis.

 Hyperkalemia is generally not a problem unless very large amount of blood are given quickly.

Massive Blood Tranfusion

• Definition – it is defined as transfusion greater than patient’s total blood volume in 24 hrs or as acute administration of more than 10 units of blood over a few hours.

• Complications

The complications of massive transfusion are those of any blood transfusion plus :

1. Volume overload
2. Hypothermia
3. Dilutional thrombocytopenia – it occurs as platelet function declines to zero after only few days of storage
4. Oxygen affinity changes – as 2, 3 DPG is greatly reduced in RBCs after about 3 weeks of storage, this increases hemoglobin’s affinity for oxygen and adversely affects oxygen delivery to the tissues.
5. Hyperkalemia – the plasma potassium concentration of stored blood is high due to RBC leakage
6. Hypocalcemia – d/t binding of ionized calcium by citrate used as anticoagulant in stored blood.
7. vii.    Hypomagnesemia – d/t binding by citrate [Ref: Various internet sites; Transfusion Practices by American College of Anaesthetics]
8. Acid/Base disturbances – even though stored RBCs and whole blood have an acid pH (- 6.3), alkalosis is the usual result of massive blood transfusion (as sodium citrate is metabolised by liver into sodium bicarbonate)
9. Acute Respiratory Distress Syndrome
10. Coagulation factor depletion

Ans. Thwo options are correct i.e., ‘a, b

Ans. is ‘b’ i.e., Dilutional thrombocytopenia 

Answer is D (All of the above)

Decreased haptaglobin levels may occur in all cases of hemolysis.

Although decreased haptaglobin levels are more characteristic of intravascular hemolysis, decreased levels are also seen in cases of extravascular hemolvsis.

Heptaglobin levels and hemolysis (Hematology for Student’s by Mackinney (2003)/78, 79

• Normal plasma contains haptoglobin, an a2- globulin that can bind free haemolglobin
• During intravascular hemolysis as levels of free haemoglobin rise significantly, the levels of serum haptoglobin are observed to be very low or absent
• Even in Extravascular hemolysis, enough haemoglobin levels leaks out of the macrophages to bind with and deplete haptaglobin

Therefore

A low serum haptaglobin concentration is a good test of hemolysis butt is not specific for intravascular hemolysis.

Answer is D (All of the above)

DIC may be associated with all of the options provided in the question.

Common Clinical causes of Disseminated Intravascular Coagulation:

Sepsis

• Bacterial
• Staphylococci, streptococci, pneomococci, meningococci, gram-negative bacilli
• Viral
• Mycotic
• Parasitic
• Rickettsial

Immunologic disorders

• Acute hemolytic transfusion reaction
• Organ or tissue transplant rejection
• Graft-versus-host disease

Trauma and tissue injury

• Brain injury (gunshot)
• Extensive burns
• Fat embolism
• Rhabdomyolysis

• Giant hemangiomas (Kasabach-Merrit syndrome)
• Large vessel aneurysms (eg. Aorta)

Obstetric complications

• Abruptio placentas
• Amniotic fluid embolism
• Dead fetus syndrome
• Septic abortion

Answer is A (Complement mediated Hemolysis is seen)

Acute Hemolytic Transfusion reactions following Blood transfusion are Type II hypersensitivity reactions caused most often by complement mediated hemolysis. These reactions are often life threatening and complications include Oliguria and acute renal failure (decreased renal blood flow).

Treatment involves immediate termination of transfusion.

Answer is A (Febrile Non Hemolytic Reaction)

The most frequent reactions associated with the transfusion of cellular blood components is a Febrile Non Hemolytic Transfusion Reaction (F N H T R).

Febrile Non Hemolytic Transfusion Reactions (F N H T R)

Clinical presentation

• These reaction are characterized by chills and rigors and 1°C rise in temperature
• Diagnosis is usually made by excluding other causes of fever in a transfused patient

Prevention and Treatment

• Most reactions are mild and do not require any further investigations or treatment
• Their incidence and severity may be reduced by:

–    Use of leucocyte reduced blood products

–    Premedication with acetaminophen or other antipyretic agents

Answer is None or C (None >> EBV)

Parvovirus B-I9, Hepatitis G, Cytomegalovirus and Epstein Bar virus may all be transmitted by blood transfusion. Transfusion transmitted EBV is however a rare event and may hence be selected as the single best answer by exclusion.

EBV and Blood Transfusion (Morbidity following EBV Transfusion is Rare)

`EBV infection may also follow blood transfusion or marrow transfusion but these are rare events’-Ananthanarayan 8th/131 `Although transfusion associated EBV is rare, it is nevertheless well documented’

Answer is D (Metabolic Acidosis)

Massive blood transfusion is usually associated with metabolic alkalosis rather than metabolic acidosis Hyperkalemia, Citrate toxicity and Hypothermia are established complications of massive blood transfusion

Metabolic acidosis / Alkalosis after Massive Blood Transfusion

Banked / stored blood is acidic because of accumulated red cell metabolites. However the actual acid load to the patient is minimal. The acid load on massive blood transfusion is quickly countered by the effect of citrate infusion as citrate is normally metabolized to sodium bicarbonate. It is therefore more common for massively transfused patients to exhibit metabolic alkalosis rather than metabolic acidosis.

Patients with massive transfusion may present with initial metabolic acidosis, however metabolic alkalosis is more frequent once citrate is metabolized in liver to bicarbonate.

Answer is A (1-lypokalemia):

Massive transfusions are associated with risk of hyperkalemia and not hypokalemia.

Hvperkalemia, Hypocalcemia & H^ypomagnesemia: Transfusion Practices by American College of Anaesthetics

The potential metabolic problems resulting from blood transfusion are hyperkalemia, hypocalcemia and hypomagnesemia’ – Transfusion Practice – American society of Anesthesiologists

• Hyperkalemia: Potassium increases in the plasma of stored blood as potassium leaves viable erythrocytes.

However, hyperkalemia is rarely a problem in adults for two reasons:

• there is very little plasma in Red Blood Cells and
• the potassium that is present leaves the intravascular space of the recipient and rapidly moves intracellularly. Neonates and patients in renal failure are at increased risk of hypokalemia.
• Hypocalcemia: Citrate present in anticoagulant preservative solutions chelates calcium and causes hypocalcemia
• Hypomagnesemia:
• Citrate also has an affinity for the magnesium ion and the occurrence of hypomagnesemia in the setting of massive transfusion has been reported.
• Alkalosis/Acidosis
• Stored blood is acidic (pH of 6.6 to 6.9) due to citric acid in the antocoagulant and the accumulation of carbondioxide and lactic acid from erythrocyte metabolism.
• Citrate Toxicity:
• Citrate toxicity occurs when ionized calcium is significantly reduced by citrate present in anticoagulant preservative solutions and thereby inhibits the coagulant cascade.

Metabolic acidosis / Alkalosis after Massive Blood Transfusion

Banked / stored blood is acidic because of accumulated red cell metabolites. However the actual acid load to the patient is minimal. The acid load on massive blood transfusion is quickly countered by the effect of citrate infusion as citrate is normally metabolized to sodium bicarbonate. It is therefore more common for massively transfused patients to exhibit metabolic alkalosis rather than metabolic acidosis.

Patients with massive transfusion may present with initial metabolic acidosis, however metabolic alkalosis is more frequent once citrate is metabolized in liver to bicarbonate.

Ans. C i.e. Hyperthermia

Hypothermia is seen and hence blood should be warmed before infusion

Ans. A: Hypokalemia

• Citrate toxicity: Citrate is the anticoagulant used in blood products. It is usually rapidly metabolised by the liver. Rapid administration of large quantities of stored blood may cause hypocalcaemia and hypomagnesaemia when citrate binds calcium and magnesium. This can result in myocardial depression or coagulopathy. Patients most at risk are those with liver dysfunction or neonates with immature liver function having rapid large volume transfusion.
• Potassium Effects: Stored red cells leak potassium proportionately throughout their storage life. Irradiation of red cells increases the rate of potassium leakage. Clinically significant hyperkalaemia can occur during rapid, large volume transfusion of older red cell units in small infants and children
• Iron accumulation: Iron accumulation is a predictable consequence of chronic RBC transfusion. Organ toxicity begins when reticuloendothelial sites of iron storage become saturated. Liver and endocrine dysfunction creates significant morbidity and the most serious complication is cardiotoxicity which causes arrhythmias, and congestive heart failure.

Ans: C i.e. Alkalosis, hypothermia, hyperkalemia

The complications usually seen with massive blood transfusion are: i) hyperkalemia, ii) Hypocalcemia, iii) Hyperammonemia, iv) Hypothermia, v) Metabolic alkalosis, vi) Dilutional coagulopathies, DIC & vii) ARDS.

Ans. B i.e. Hypercalcemeia

Complications of blood transfusion

• Hyperkalemia,
• Citrate toxicity,
• Hypothermia,
• ARDS

Ans. B: Excessive bleeding from the surgical site

In anaesthesized individual, haemolytic (transfusion) reaction manifests as tachycardia, hypotension (so minute to minue BP monitoring during early transfusion is necessary) and oozing from surgical site (more specific)

Ans. B: Dilutional thrombocytopenia

Massive blood transfusion causes dilutional coagulopathies especially dilutional thrombocytopenia (stored blood has no platelets and concentration of other clotting factors is also very less)

Ans. A: Alkalosis, hypothermia, coagulopathy

Ans. is ‘B’ i.e., Hypernatremia.

Complications usually seen with massive blood transfusion are

• 1) hyperkalemia,
• 2) hypocalcemia,
• 3)hypomagnesemia
• 4) hyperammonemia,
• 5) hypothermia,
• 6) Acidosis
• 7)dilutional coagulopathies and DIC (most worrisome problem after massive transfusion and is the usual cause of death after massive blood transfusion) and
• 8) ARDS.

Ans. is ‘a’ i.e., Human error

The most common cause resulting in complications from blood transfusion is human error

Acute hemolytic reaction resulting from ABO incompatibility is the most serious complication of blood transfusion.