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Complications of Blood Transfusion: An Overview

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Title: Complications of Blood Transfusion: An Overview


1
Complications of Blood TransfusionAn Overview
  • Clinical Pathology Conference
  • Dean Fong, DO
  • January 6, 2006

2
Case Presentation
  • 63 y/o male status post AVR 2 to AS on 11/18.
  • Developed fevers, weakness, sternal erythema, SOB
    ? readmitted on 12/3.
  • BC
  • Echo ? vegetations c/w endocarditis
  • 12/10 AM
  • Received 2U FFP 2 ? PT and PTT

3
Case Presentation
  • Approximately 20 minutes after transfusion, pt.
    developed
  • Shaking/rigors
  • Tachycardia
  • Hypoxia
  • No change in tempterature during transfusion
  • Pt. was given benadryl, lasix, intubation and
    ventilatory support
  • Pt. improved and was extubated later that
    afternoon

4
Case Presentation
  • PMH AVR S/P AS, endocarditis, left arm septic
    thrombophlebitis
  • CXR
  • 12/9 ? fluid overload, unchanged, LLL
    consolidation, pneumonia R base
  • 12/10 (AM after transfusion) ? bibasilar
    atelectasis/consolidation
  • 12/10 (later AM) ? ? pulmonaty edema, unchanged
    LLL consolidation)
  • 12/11 ? no change

5
Case Presentation
  • Labs
  • HCT 11/20 32.8
  • 12/10 27.6 (1600)
  • 12/10 34.7 (2000)
  • 12/12 34.7
  • Haptoglobin 100 mg/dl (30-200 mg/dl)
  • Blood bank
  • Pt. is O, DAT
  • Backtype on both units FFP
  • Gram stain -, cultures (after 7 days)
  • Donor information
  • 33 y/o female, O, G2, CMV
  • 64 y/o male, O, CMV

6
Case Presentation
  • DIFFERENTIAL DIAGNOSIS?

7
Differential Diagnosis
  • Circulatory overload
  • Pulmonary embolism
  • Anaphylactic reaction
  • TRALI
  • Bacterial/Sepsis

8
Complications of Transfusion
  • Transfusion reactions occur in 2 of units or
    within 24 hours of use.
  • Most common adverse side effects are usually mild
    and non-life-threatening
  • Two categories
  • Infectious complications
  • i.e HIV and HCV ? 1 transmission/2 million
    transfusion
  • Non-infectious complications

9
Non-infectious Complications of Transfusions
  • Technical Manual
  • Acute (lt 24)
  • Immunologic
  • Non-immunologic
  • Delayed (gt 24)
  • Immunologic
  • Non-immunologic

10
Acute (lt 24) Immunologic
  • Hemolytic
  • Fever/chills, non-hemolytic
  • Urticarial/Allergic
  • Anaphylactic

11
Acute (lt 24) Non-Immunologic
  • Hypotension associated with ACE inhibition
  • Transfusion-related acute lung injury (TRALI)
  • Circulatory overload
  • Nonimmune hemolysis
  • Air embolus
  • Hypocalcemia
  • Hypothermia

12
Delayed (gt 24) Immunologic
  • Allo-immunization
  • RBC antigens
  • HLA
  • Hemolytic
  • Graft-versus-host disease (GVHD)
  • Post-transfusion purpura
  • Immuno-modulation

13
Delayed (gt 24) Non-Immunologic
  • Iron overload

14
Acute (lt 24) Immunologic
  • Hemolytic
  • Fever/chills, non-hemolytic
  • Urticarial/Allergic
  • Anaphylactic

15
Hemolytic
  • Most severe hemolytic rxns. occur when transfused
    RBCs interact w/ preformed aby
  • Transfused aby rxns. w/ recipients RBCs rarely
    cause sxs.
  • May cause accelerated RBC destruction
  • Can occur after infusion of as little as 10-15 mL
    ABO-incompatible blood
  • Etiology
  • 138,000 to 170,000
  • Clerical and other human error most common causes
    of ABO-incompatible transfusion
  • CAP survey 3601 institution
  • 834 HTR over 5 year period w/ 50 (6) fatality
  • Mortality estimated to be 11,000,000 transfusion

16
Hemolytic
  • Highly variable in acuity and severity
  • Severe
  • Fevers and/or chills
  • Hypotension
  • Dyspnea
  • Tachycardia
  • Pain
  • DIC
  • ARF
  • Shock

17
Hemolytic
  • Pathophysiology
  • Intravascular hemolysis, opsonization, generation
    of anaphylotoxins
  • Complement activation ? classical pathway
  • IgM and IgG
  • C1q binds to Ig
  • C3 activation ? cleavage of C3 leads to C3a being
    released into plasma and C3b deposition onto RBC
    membrane
  • C3a ? proinflammatory effects
  • C3b ? erythrophagocytosis
  • C5 cleaved ? C5a into plasma
  • C5a ? proinflammatory (100-fold more potent than
    C3a)
  • Assembly of remaining components of the MAC then
    occurs on RBC surface
  • Lysis of RBC
  • Cytokines activation
  • TNF, IL-1, IL-6, IL-8
  • Coagulation activation
  • Bradykinin

18
Hemolytic
  • Laboratory findings
  • Hemoglobinemia
  • Hemoglobinuria
  • ? LDH
  • Hyperbilirubinemia
  • ? Haptoglobin
  • ? BUN, creatinine in ARF
  • DAT

19
Hemolytic
  • Differential diagnosis
  • AIHA
  • Nonimmune hemolysis
  • Microangiopathic hemolytic anemia
  • Drug-induced
  • Infections
  • Any causes of hemolysis

20
Hemolytic
  • Treatment/Prevention
  • Stop transfusion
  • Supportive care to maintain renal function
  • Goal of urine O/P 100 mL/hr. in adults for at
    least 18-24 hours
  • Low dose dopamine
  • Treatment of DIC
  • ? Heparin direct anticomplement effect
  • Prevention of clerical/human errors

21
Acute (lt 24) Immunologic
  • Hemolytic
  • Fever/chills, non-hemolytic
  • Urticarial/Allergic
  • Anaphylactic

22
Fevers/chills, non-hemolytic (FNHTR)
  • Defined as a rise in temperature of 1C or
    greater.
  • Incidence
  • 43-75 of all transfusion rxn.
  • PRBCs 0.5-6
  • Plts 1-38
  • Signs/Symptoms
  • Chills/rigor
  • HA
  • Vomitting

23
Fevers/chills, non-hemolytic (FNHTR)
  • Etiology
  • Reaction
  • Between recipient WBC antibodies (HLA, WBC
    antigens) against transfused WBC in product
  • Cytokines that accumulates in blood bag during
    storage
  • Differential Diagnosis
  • Other causes of fever ruled out
  • Hemolytic
  • Bacterial/Septic
  • Treatment/Prevention
  • Discontinue transfusion?
  • Acetaminophen/meperidine
  • Leukoreduced blood component

24
Acute (lt 24) Immunologic
  • Hemolytic
  • Fever/chills, non-hemolytic
  • Urticarial/Allergic
  • Anaphylactic

25
Uritcarial/Allergic
  • Continuum
  • Mild urticarial
  • Anaphylactoid
  • Severe anaphylactic
  • Incidence
  • 1-3 of all transfusion rxn.
  • Signs/Symptoms
  • Uriticarial/hives upper trunk and neck
  • Fever
  • Pulmonary signs (10) hoarseness, stridor,
    lump in throat, bronchoconstriction
  • No cutaneous involvement
  • GI N/V, abd. pain, diarrhea
  • Circulatory tachycardia, hypotension

26
Uritcarial/Allergic
  • Etiology
  • Circulating aby against soluable material in the
    blood
  • Proteins in donor plasma
  • Binds to preformed IgE aby on mast cells
  • Release of histamine
  • Vasoactive substances
  • C3a, C5a, leukotrienes
  • Differential Diagnosis
  • Hemolytic
  • Bacterial
  • TRALI
  • Treatment/Prevention
  • Discontinue transfusion
  • Antihistamine/steroids
  • Washing of blood products, pretreatment,leukoreduc
    tion?

27
Acute (lt 24) Immunologic
  • Hemolytic
  • Fever/chills, non-hemolytic
  • Urticarial/Allergic
  • Anaphylactic

28
Anaphylactic
  • Rare
  • Incidence
  • 118,000 to 170,000
  • Plt 11598-9630
  • FFP 128,831
  • RBCs 123,148-57,869
  • Signs/Symptoms
  • In addition to uritcarial/allergic
  • Cardiovascular instability
  • Cardiac arrhythmia
  • Shock
  • Cardiac arrest
  • More pronounced respiratory involvement

29
Anaphylactic
  • Etiology
  • IgA aby (IgE, IgG, IgM) in IgA deficiency
  • Serum IgA lt 5 mg/dL
  • Estimated 1 in 342 blood donors
  • C4 aby
  • Aby against nonbiologic origin
  • Haptoglobin deficiency (IgG or IgE
    anti-haptoglobin)
  • ?
  • Differential Diagnosis
  • Hemolytic
  • Bacterial
  • TRALI
  • Circulatory overload

30
Anaphylactic
  • Treatment/Prevention
  • Discontinue transfusion
  • Supportive care
  • Epinephrine
  • Antihistamine/steroids
  • In IgA deficient pts. ? IgA-deficient product,
    wash blood product

31
Acute (lt 24) Non-Immunologic
  • Hypotension associated with ACE inhibition
  • Transfusion-related acute lung injury (TRALI)
  • Circulatory overload
  • Nonimmune hemolysis
  • Air embolus
  • Hypocalcemia
  • Hypothermia

32
Hypotension associated with ACE inhibition
  • Pt. on ACEI ? receiving albumin during plasma
    exchange
  • Etiology
  • Inhibition of bradykinin catabolism by ACEI
  • Bradykinin activation by activator (low level
    prekallikrein) in albumin
  • Bradykinin activation by prekallikrein in plasma
    protein
  • Differential diagnosis
  • Rule out hemolysis
  • Treatment/Prevention
  • Withdraw ACEI/supportative care
  • Avoid albumin
  • Avoid bedside leukofiltration

33
Acute (lt 24) Non-Immunologic
  • Hypotension associated with ACE inhibition
  • Transfusion-related acute lung injury (TRALI)
  • Circulatory overload
  • Nonimmune hemolysis
  • Air embolus
  • Hypocalcemia
  • Hypothermia

34
Transfusion-related acute lung injury (TRALI)
  • What Is TRALI?
  • Transfusion related noncardiogenic pulmonary
    edema
  • Differential Diagnosis
  • Circulatory overload (TACO)
  • Allergic/Anaphylactic
  • Bacterial
  • Acute hemolytic reaction
  • Clinical presentation (classic, severe form)
  • Acute respiratory distress
  • Pulmonary edema
  • Hypoxemia
  • Hypotension
  • Transfusion usually within 6 hours (majority of
    cases during transfusion or within 2 hours of
    transfusion)

35
TRALI
  • Clinical criteria
  • Insidious, acute onset of pulmonary insufficiency
  • Profound hypoxemia ? PaO2/FiO2 lt 300 mmHg
  • CXR ? b/l fluffy infiltrates c/w pulmonary edema
  • Cardiac ? PA wedge pressure ? 18 mmHg
  • No clinical evidence of LA HTN

36
TRALI
  • Definition
  • TRALI w/out clinical risk factors for ALI
  • New ALI temporally related to transfusion
  • Worsening of pre-existing pulmonary insufficiency
    temporally related to transfusion
  • TRALI in pts. w/ clinical risk factor for ALI
  • New ALI temporally related to transfusion
  • New ALI thought to be mechasnistically related to
    the transfusion
  • Worsening of pre-existing pulmonary insufficiency
    temporally related to transfusion

37
TRALI
  • Syndrome of TRALI (Weber KE et. al., Transfusion
    Med Rev, 2003)
  • Very common
  • Dyspnea, hypoxemia, pulmonary edema, hypotension,
    fever (1-2C increase)
  • Common
  • Tachycardia, cyanosis
  • Uncommon
  • Hypertension
  • ?
  • Leukopenia, hypocomplements, monocytopenia

38
TRALI
  • Implicated Blood Products
  • RBCs, FFP, apheresis platelets, platelet
    concentrates
  • Rare cases of IVIG, cryo-
  • No cases of albumin reported

39
TRALI
  • Clinical Course
  • 100 TRALI patients require O2 and 72 require
    ventilation support
  • 81 resolves within 4 days and 17 resolve within
    7 days
  • Most pts. recover with 72 hours
  • Mortality rate 6 (subsequent series up to
    14-25)
  • No long term sequela
  • Treatment
  • Respiratory support
  • No role for treatment w/ steroids or diuretics

40
TRALI
  • Why Is TRALI Important?
  • Between 2001 2003, FDA report on causes of
    transfusion related deaths
  • TRALI 16.3
  • ABO/Hemolytic transfusion reaction 14.3
  • Bacterial contamination 14.1
  • UK SHOT Data 7 years experience (from 1996)
  • Total 155 cases
  • 32 Deaths

41
TRALI
  • Why Is TRALI Important? (cont.)
  • UK SHOT Data 7 years experience (from 1996)

2001/2002 Red cells 2.7 million Platelets
250K Fresh frozen plasma 385K Cryoprecipitate
88K TOTAL 3.4 million
42
TRALI
  • Pathogenesis
  • Two current working model hypothesis
  • Both models are directed against increase in
    pulmonary microvascular permeability

Bioactive Lipids Two-Hit Model
Leukocyte Antibody
? Pulmonary Microvascular Permeability
Pulmonary Edema
43
TRALI
  • UK and SHOT (7 Year Experience)
  • Data between 1996 to 2003
  • Define TRALI as Acute dyspnea, hypoxia,
    bilateral pulmonary infiltrates within 24 hours
    after transfusion with no other apparent causes
  • 1996 lt 10 cases
  • 2003 ? 40 cases
  • Total 155 cases
  • 138 cases examined, others were excluded

94 Fully Recovered
4 Partial Recovery
32 Deaths
11 Other Demise
44
TRALI
1 or more donors positive 71
  • UK and SHOT (cont.)
  • Serological testing
  • Leukocyte antibody investigation
  • 71 cases of leukocyte antibodies

Patient positive 8
Donor and patient negative 19
16 HNA
50 HLA Class I or II
5 HLA and HNA
Incomplete samples or not done 2
18 Crossmatched 14 Antibody only in donor 18
Multiple antibodies
45
TRALI
  • UK and SHOT (cont.)
  • Products implicated
  • 45/139 FFP/Cryo-
  • 34/139 RBCs
  • 27/139 Platelets
  • Estimation
  • FFP/Platelet 1 in 50-60K
  • RBC/Cryo- 1 in 500-600K
  • Frequency 1 in 1,000-2,500 patients transfused
  • Would expect to see 300-750 cases/year

46
TRALI
  • UK and SHOT
  • What UK is doing
  • October 2003 Male donor ONLY for FFP
  • 2004 Import FFP for children
  • April 2004 Previously transfused donors
    excluded
  • Future Considerations
  • ? Male plasma only to suspend platelet pools
  • ? Female apheresis platelet donor for leukocyte
    antibody
  • ? Effects of decreased plasma (additive solution)
    in platelet concentrates/apheresis platelets
  • ? Mild TRALI. Does it exist?

47
Acute (lt 24) Non-Immunologic
  • Hypotension associated with ACE inhibition
  • Transfusion-related acute lung injury (TRALI)
  • Circulatory overload
  • Nonimmune hemolysis
  • Air embolus
  • Hypocalcemia
  • Hypothermia

48
Circulatory overload
  • Acute pulmonary edema due to volume overload
  • Incidence
  • One of the most common complications of
    transfusion
  • Young children and elderly at risk
  • Cardiac and pulmonary compromise
  • Chronic anemia with expanded plasma volume
  • Infusion of 25 albumin
  • Shifts large volume of extravascular fluid into
    the vascular space
  • Signs/Symptoms
  • Dyspnea, cyanosis, orthopnea, severe HA, HTN, CHF
    during or soon after transfusion

49
Circulatory overload
  • Differential diagnosis
  • TRALI
  • Allergic rxn.
  • Other causes of CHF
  • Treatment/Prevention
  • Stop transfusion
  • Supportive care
  • Phlebotomy
  • Diuretic
  • Slow transfusion
  • Usually 4 hours, can be extended to 6 hours
  • Other strategies

50
Acute (lt 24) Non-Immunologic
  • Hypotension associated with ACE inhibition
  • Transfusion-related acute lung injury (TRALI)
  • Circulatory overload
  • Nonimmune hemolysis
  • Air embolus
  • Hypocalcemia
  • Hypothermia

51
Nonimmune hemolysis
  • Lysis of RBCs as a result of storage, handling,
    or transfusion condition
  • Incidence
  • Rare
  • Signs/Symptoms
  • Transient hemodynamic
  • Pulmonary impairment
  • Renal impairment
  • Hemoglobinemia and hemoglobinuria
  • Hyperkalemia (renal failure)
  • Fever

52
Nonimmune hemolysis
  • Differential diagnosis
  • Hemolytic
  • Autoimmune
  • Bacterial/sepsis
  • PNH, drug-induced, oxidative stress, etc.
  • Diagnosis of exclusion
  • Treatment/Prevention
  • Stop transfusion
  • Investigation of blood bag and tubing
  • Investigate for hemolytic transfusion rxn.
  • Check serum K
  • Supportive care
  • Maintain urine O/P (except for contraindicationi.
    e. renal failure)

53
Acute (lt 24) Non-Immunologic
  • Hypotension associated with ACE inhibition
  • Transfusion-related acute lung injury (TRALI)
  • Circulatory overload
  • Nonimmune hemolysis
  • Air embolus
  • Hypocalcemia
  • Hypothermia

54
Air embolus
  • Air infusion via line
  • Rare
  • Cough, dyspnea, chest pain, shock
  • If suspected
  • Pt. placed on left side with head down
  • Displace air bubble from pulmonary valve

55
Hypocalcemia
  • Large volumes of FFP, whole blood, plts.
    transfused rapidly ? plasma citrate levels may
    rise ? binds iCa2
  • Citrate rapidly metabolized ? manifestations
    transient
  • Prolonged apheresis
  • Periorbal/peripheral tingling paresthesias,
    shivering, lightheadedness, tetanic sxs.,
    hyperventilation, depressed cardiac function
  • Ca2 replacement

56
Hypothermia
  • Rapid infusion of large volumes of cold blood
  • Ventricular arrhythmias
  • More likely via central catheters
  • Increased toxicity of hypocalcemia and
    hyperkalemia
  • Impaired hemostasis
  • Increase caloric requirement
  • Blood warmer

57
Delayed (gt 24) Immunologic
  • Allo-immunization
  • Hemolytic
  • Graft-versus-host disease (GVHD)
  • Post-transfusion purpura
  • Immuno-modulation

58
Allo-immunization
  • Occurs weeks to months after transfusion
  • Incidence
  • 1-1.6 to RBC antigens
  • 10 to HLA
  • Signs/Symptoms
  • PRBCs ? hemolysis
  • Plts. ? refractoriness
  • Treatment/Prevention
  • Plts.
  • Leukoreduction
  • Cross-matched and/or HLA-matched plts.

59
Delayed (gt 24) Immunologic
  • Allo-immunization
  • Hemolytic
  • Graft-versus-host disease (GVHD)
  • Post-transfusion purpura
  • Immuno-modulation

60
Hemolytic
  • Once allo-immunization has occurred, abys may
    diminish to undetectable levels
  • Especially Kidd system (anti-Jka and anti-Jkb)
  • Hemolysis typically extravascular
  • Anamnestic response
  • W/in hours or days (up to 6 weeks), IgG aby
    reacts with transfused red cells
  • Prospective study
  • 58 of 2082 (2.8) RBC recipients were found to
    have alloabys (previous undetected) w/in 7 days
    of transfusion
  • Incidence
  • Based on above study, only 1 recipient w/ new aby
    w/in 7 days of transfusion was shown to have
    hemolysis
  • Estimated rate
  • 1 in 2082 recipients
  • 1 in 11,328 units
  • Other reports at 0.02 to 0.009

61
Hemolytic
  • Signs/Symptoms
  • Fever
  • Declining Hb
  • Mild jaundice
  • Hemoglobinuria
  • ARF uncommon
  • Check for alloaby in both serum and RBC
  • Treatment/Prevention
  • Rarely necessary
  • May need to monitor urine O/P, renal function,
    coagulation functions
  • IVIG
  • Appropriate units for transfusion

62
Delayed (gt 24) Immunologic
  • Allo-immunization
  • Hemolytic
  • Graft-versus-host disease (GVHD)
  • Post-transfusion purpura
  • Immuno-modulation

63
Graft-versus-host disease (GVHD)
  • Fatal complication cause by engraftment and
    clonal expansion of donor lymphocytes in
    susceptible host
  • Attack recipient tissues
  • Immunocompromised pts.
  • Hematologic malignancies or certain solid tumors
    receiving chemotherapy radiation
  • Stem cell transplant
  • Recipients of HLA matched products or familial
    blood donation
  • Lupus or CLL requiring fludarabine
  • Not reported in AIDS pts.
  • 2-30 days after transfusion
  • Incidence
  • Rare (0.002-0.005)

64
GVHD
  • Signs/Symptoms
  • Appears w/in 10-12 days of transfusion
  • Skin whole body erythroderma, desquamation
  • GI ? N/A, diarrhea
  • Liver
  • BM ? failure leading to pancytopenia
  • Treatment/Prevention
  • No effective treatment
  • Gamma irradiation
  • Render T-cells incapable of replication
  • FDA requirement
  • Minimum of 2500 cGy target to the midline of the
    container
  • Minimum of 1500 cGy target to all other part of
    component

65
Delayed (gt 24) Immunologic
  • Allo-immunization
  • Hemolytic
  • Graft-versus-host disease (GVHD)
  • Post-transfusion purpura
  • Immuno-modulation

66
Post-transfusion Purpura (PTP)
  • Characterized by abrupt onset of severe
    throbocytopenia (lt 10K)
  • Average of 9 days (range 1-24 days)
  • PRBCs or whole blood
  • Reported in plts., plasma, frozen deglycerolized
    PRBCs
  • Incidence
  • Rare
  • Over 200 cases published
  • MaleFemale 15
  • Median age 51 years (range 16-83)
  • Clinical course
  • Usually self-limited, recovery w/in 21 days
  • 10-15 mortality
  • Intracranial hemorrhage

67
PTP
  • Signs/Symptoms
  • Profound thrombocytopenia
  • Purpura
  • Bleeding
  • Fever (reported)
  • Etiology
  • Plt. specific IgG aby that are auto-aby
  • All HPA implicated but HPA-1a most common
  • 3 mechanisms
  • Immune complex pt. aby and donor antigen
  • Concersion of antigen- autologous plts. to aby
    targets to antigen in transfused components
  • Cross-reactivity of pts. autoaby w/ autologous
    plts.

68
PTP
  • Differential diagnosis
  • ITP
  • TTP
  • Alloimmunization
  • Sepsis
  • DIC
  • BM failure
  • Drug-induced
  • Treatment/Prevention
  • Steroids controversial
  • Plasma exchange achieves plts. counts to 20K in
    1-2 days (up to 12 days)
  • IGIV recovery of plts. Counts of 100K w/in 3-5
    days
  • Block aby-mediated clearance
  • Splenectomy refractory pts., high risk of
    life-threatening hemorrhage
  • Plts. transfusion not effective
  • Antigen-negative blood product

69
Delayed (gt 24) Immunologic
  • Allo-immunization
  • Hemolytic
  • Graft-versus-host disease (GVHD)
  • Post-transfusion purpura
  • Immuno-modulation

70
Immuno-modulation
  • ? Increases risk of recurrent cancer and
    bacterial infection
  • WBCs ? cytokines during storage ? interfere w/
    immune function
  • Uncertain clinical significance
  • Leukoreduction of blood products

71
Delayed (gt 24) Non-Immunologic
  • Iron overload

72
Iron overload
  • Each unit of PRBC ? 200-225 mg of Fe
  • Chronic transfusion
  • gt 50-100 units of PRBC
  • Storage in RE sites ? saturation ? other sites
  • Heart, liver, endocrine glands (pancreas)
  • Removal of Fe
  • Desferoxamine Fe-chelating agent
  • Chronic transfusion in hemoglobinopathy
  • Prolong intertransfusion interval or PRBC exchange

73
Case Presentation
  • Follow-up

74
Case Presentation
  • Donor FFP from 33 y/o female (G2)
  • Anti-HLA aby resulted positive for several
    anti-HLA aby
  • Recipient
  • Positive anti-HLA aby, HLA Class II antigen, HLA
    DQ1
  • But
  • Pt. had received 11 units PRBCs and 2 units Plts.
    Over plast 1 month
  • Conclusion
  • ? TRALI
  • Pt. was transfused with 2 U FFP over a 6 hour
    period w/out incident
  • ? Other
  • Recommendation
  • ? What to do with donor
  • ? What to do with patient

75
References
  • Brecher ME et. al., Technical Manual, 14th Ed.,
    AABB Press, 2002.
  • Davenport RD, Pathophysiology of Hemolytic
    Transfusion Reactions Seminars in Hematology
    2005 42 165-168.
  • Gilstad CW, Anaphylactic transfusion reactions,
    Current Opinion in Hematology 2003 10 419-423.
  • Kuriyan M, Carson JL, Blood transfusion risks in
    the intensive care unit, Crit Care Clin 2004
    20 237-253.
  • MacLennan S, Barbara JAJ, Risks and side effects
    of therapy with plasma and plasma fractions,
    Best Practice and Research Clinical Haematology
    2006 19(1) 169-189.
  • Mintz PD, Transfusion Therapy Clinical Principles
    and Practice, AABB Press, 2005.
  • Shander A, Popovsky MA, Understanding the
    Consequences of Transfusion-Related Acute Lung
    Injury, Chest 2005 128 598-604.
  • Silliman CC, McLaughlin NJD, Transfusion-related
    acute lung injury, Blood Reviews 2005 article
    in press.
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