transfusion reaction (redirected from Hyperammonemia and lactic acid)

transfusion reaction,

a systemic response by the body to the administration of blood incompatible with that of the recipient. The causes include red blood cell incompatibility; allergic sensitivity to the leukocytes, platelets, plasma protein components of the transfused blood; or potassium or citrate preservatives in the banked blood. See also hemolysis.

observations Fever is the most common transfusion reaction; urticaria is a relatively common allergic response. Asthma, vascular collapse, and renal failure occur less commonly. A hemolytic reaction from red blood cell incompatibility is serious and must be diagnosed and treated promptly. Symptoms develop shortly after beginning the transfusion, before 50 mL has been given, and include a throbbing headache, sudden deep severe lumbar pain, precordial pain, dyspnea, and restlessness. Objective signs include ruddy facial flushing followed by cyanosis and distended neck veins; rapid, thready pulse; diaphoresis; and cold, clammy skin. Profound shock may occur within 1 hour.

interventions When a hemolytic reaction is suspected, the transfusion is promptly terminated and the infusion line kept open with a normal solution of IV fluid. The remaining bank blood is saved for a repeat type and crossmatch against a fresh sample of blood from the recipient. Direct and indirect antiglobulin tests are usually ordered to detect hemolytic antibodies, and a sample of urine is examined for free hemoglobin. Immediate treatment may include IV mannitol and a solution of 5% dextrose in water to maintain urine flow of more than 100 mL per hour. In the presence of oliguria, the possibility of acute renal failure is evaluated and the patient managed accordingly. Hypovolemia is corrected with saline or plasma expanders, but the administration of more whole blood is avoided, if possible.

nursing considerations The need for exceptional care to ensure that typed and crossmatched blood conforms to compatibility standards is emphasized. The identifying information on the blood container is always checked against the transfusion records and the patient's identification on the band. Questioning the patient about previous transfusions may elicit warning indications of possible adverse reactions. After the transfusion is started, the patient is watched for objective signs of a transfusion reaction and is questioned for subjective symptoms. Routine temperature checks are done to detect febrile reactions that can be controlled by antipyretic drugs.

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transfusion

the introduction of whole blood or blood components directly into the bloodstream. Among the elements transfused, in addition to whole blood, are packed red blood cells, plasma, platelets, granulocytes and cryoprecipitate, a plasma protein rich in antihemophilic factor VIII. See also autotransfusion.

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autologous blood transfusion

transfusion of the animal's own blood.

blood transfusion

whole blood is most often indicated to maintain or replace blood volume, to provide deficient blood elements and improve coagulation, to maintain or improve transport of oxygen, and in liver failure in which toxins accumulate in the blood, or in some other types of toxemia.

direct transfusion

transfer of whole blood from the donor through a tube, directly to the recipient.

exchange transfusion

blood is removed from the recipient at the same time and in the same amount as blood is being administered from the donor.

incompatible transfusion

see transfusion reaction (below).

transfusion reaction

a group of clinical signs due to antibody in the recipient's blood reacting with the transfused red blood cells when blood for transfusion is incorrectly matched, or when the recipient has an adverse reaction to some element of the donor blood. Most commonly, there is an immune-mediated hemolysis involving alloantibodies, which may be naturally occurring or the result of an earlier transfusion, in the recipient's serum and the donor's erythrocytes. In ruminants, signs appear during the transfusion, beginning with hiccough, then tremor, dyspnea, lacrimation, fever, ruminal tympany, hemoglobinuria and subsequent abortion. If death occurs, it is because of pulmonary edema. Similar signs are seen in other species. Urticaria and erythema sometimes occur in dogs and cats.

Nonimmunological transfusion reactions include cardiovascular overload, hypocalcemic tetany from citrate (used as the anticoagulant) overload, and disease transmission.

transfusion therapy

the administration of whole blood or blood components, usually in the treatment of bleeding disorders.

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transfusion reaction

Blood transfusion reaction, incompatibility reaction Transfusion medicine Any untoward response to the transfusion of non-self blood products, in particular RBCs, which evokes febrile reactions that are either minor–occurring in 1:40 transfusions and attributed to nonspecific leukocyte-derived pyrogens, or major–occurring in 1:3000 transfusions and caused by a true immune reaction, which is graded according to the presence of urticaria, itching, chills, fever and, if the reaction is intense, collapse, cyanosis, chest and/or back pain and diffuse hemorrhage Note: If any of above signs appear in a transfusion reaction, or if the temperature rises 1ºC, the transfusion must be stopped; most Pts survive if < 200 ml has been transfused in cases of red cell incompatibility-induced transfusion reaction; over 50% die when 500 ml or more has been transfused; TF mortality is ± 1.13/105 transfusions Clinical Flank pain, fever, chills, bloody urine, rash, hypotension, vertigo, fainting

Transfusion reactions

Immune, non-infectious transfusion reactions  

• Allergic Urticaria with immediate hypersensitivity

• Anaphylaxis Spontaneous anti-IgA antibody formation, occurs in ± 1:30 of Pts with immunoglobulin A deficiency, which affects 1:600 of the general population–total frequency: 1/30 X 1/600 = 1/18,000

• Antibodies to red cell antigens, eg antibodies to ABH, Ii, MNSs, P1, HLA

• Serum sickness Antibodies to donor's immunoglobulins and proteins

Non-immune, non-infectious transfusion reactions  

• Air embolism A problem of historic interest that occurred when air vents were included in transfusion sets

• Anticoagulant Citrate anticoagulant may cause tremors and EKG changes

• Coagulation defects Depletion of factors VIII and V; this 'dilutional' effect requires massive transfusion of 10 + units before becoming significant

• Cold blood In ultra-emergent situations, blood stored at 4º C may be tranfused prior to reaching body temperature at 37º C; warming a unit of blood from 4 to 37º C requires 30 kcal/L of energy, consumed as glucose; cold blood slows metabolism, exacerbates lactic acidosis, ↓ available calcium, ↑ hemoglobin's affinity for O₂ and causes K⁺ leakage, a major concern in cold hemoglobinuria

• Hemolysis A phenomenon due to blood collection trauma, a clinically insignificant problem

• Hyperammonemia and lactic acid Both molecules accumulate during packed red cell storage and when transfused, require hepatorenal clearance, of concern in Pts with hepatic or renal dysfunction, who should receive the freshest units possible

• Hyperkalemia Hemolysis causes an ↑ of 1 mmol/L/day of potassium in a unit of stored blood, of concern in Pts with poor renal function, potentially causing arrhythmia

• Iron overload Each unit of packed RBCs has 250 mg iron, potentially causing hemosiderosis in multi-transfused Pts

Microaggregates Sludged debris in the pulmonary vasculature causing ARDS may be removed with micropore filters

Pseudoreaction Transfusion reaction mimics, eg anxiety, anaphylaxis related to a drug being administered at the same time as the transfusion

Infections transmitted by blood transfusion

• Viruses B19, CMV, EBV, HAV, HBV, HCV, HDV, HEV, Creutzfeldt-Jakob disease, Colorado tick fever, tropical viruses–eg Rift Valley fever, Ebola, Lassa, dengue, HHV 6, HIV-1, HIV-2, HTLV-I, HTLV-II

• Bacteria Transmission of bacterial infections from an infected donor is uncommon and includes brucellosis and syphilis in older reports; more recent reports include Lyme disease and Yersinia enterocolitica  Note: Although virtually any bacteria could in theory be transmitted in blood, the usual cause is contamination during processing rather than transmission from an infected donor

• Parasites Babesiosis, Leishmania donovani, L tropica, malaria, microfilariasis–Brugia malayi, Loa loa, Mansonella perstans, Mansonella ozzardi, Toxoplasma gondii, Trypanosoma cruzi