Blood transfusion

Key Information

Appropriate Tests

Donor testing

Donor suitability is determined initially by questionnaire ± interview.

Mandatory testing:

  • ABO and RhD Blood group, Blood group antibody screen
  • Syphilis testing (serum)
  • Viral screening for:
  • HIV Ab and Ag combination and HIV-1 RNA
  • HBV (Hepatitis B serology) and HBV DNA
  • HCV (Hepatitis C serology) and HCV DNA (Hepatitis C nucleic acid)
  • HTLV Ab
  • All platelet donations are screened for bacterial contamination 24 hours post donation
  • When required, additional donor testing is performed, including confirmatory testing, CMV screening, and malarial antibody screening.
The same testing is required for donors of autologous and directed blood transfusions.

See transfusion.com.au for further information.

Recipient testing

Meticulous attention to patient identification and specimen labelling is required. (See current Guidelines for pretransfusion testing, ANZSBT).

ABO and RhD Blood group, red cell antibody screen, compatibility testing (Crossmatch) against group compatible donor cells.

See transfusion.com.au.

Red cell phenotyping may be required (eg, for patients on chronic transfusion programme).

Complications of transfusion

For information on risks and management of adverse events, see transfusion.com.au.

Febrile nonhaemolytic transfusion reactions (FNHTR)

0.1 to 1% of transfusions with leucocyte depletion*

Defined as an unexpected rise in temperature ( ≥38 degrees, or  ≥1 degree above baseline when baseline is  ≥37degrees).

Investigations: Acute haemolytic reaction and transfusion associated sepsis may need exclusion. Direct antiglobulin test, Full blood count and ABO Blood group and Blood culture may be indicated.

In patients with repeated FNHTR, investigation for HLA antibodies may be useful.

Minor allergic reaction

1-3% of transfusions*

Generally no investigations are required. If more than simple urticarial, Haemolysis should be excluded. Direct antiglobulin test (DAT), Full blood count and repeat ABO Blood group may be indicated.

Severe allergic (anaphylactoid or anaphylactic) reaction

1:20,000-50,000 transfusions*

Diagnosis usually made on clinical features. Investigations may include Direct antiglobulin test, Full blood count and repeat ABO Blood group. Consider testing recipient pretransfusion sample for IgA deficiency and anti-IgA antibodies.

See also Anaphylaxis.

ABO incompatibility

~1:76,000 transfusions

Cease transfusion immediately; resuscitate, maintaining IV access, intravascular volume and urine output and investigate. Check patient's identity against the identification information on the blood pack and transfusion form. Return blood pack and giving set to transfusion laboratory.

Testing: repeat patient ABO Blood group, Blood group and antibody screen, compatibility testing (Crossmatch) in pre- and post-transfusion samples. Also test Direct antiglobulin test and Indirect Coombs test, Full blood count, Blood film, renal function, Liver function tests, Coagulation profile and tests for Haemolysis. See also DIC.

Delayed haemolytic transfusion reaction

1:2500 -11,000 transfusions

Usually due to previous sensitisation to red cell antigens (eg, prior transfusion, transplantation, pregnancy); the antibody may be at low titre and undetectable in the initial blood group antibody screen.

Usually occurs 2-14 days post transfusion.

Investigations: Full blood count, Blood film, Blood group and antibody screen (on pre and post-transfusion sample if available), Reticulocyte count; Direct antiglobulin test, Liver function tests, Lactate dehydrogenase and markers of haemolysis (Haptoglobin).

Transfusion-related acute lung injury (TRALI)

1:2000-190,000 transfusions

Clinical features include respiratory distress, tachycardia and fever, hypoxaemia during or within 6 hours of transfusion.

Investigations: acute haemolytic reaction or transfusion associated sepsis should also be excluded. Consider Direct antiglobulin test, Blood group and Full blood count. Once TRALI is clinically suspected, donor and recipient serum should be tested for HLA and HNA antibodies and HLA typing of the recipient. This requires liaison with the Blood Service. See transfusion.com.au for more information.

Massive transfusion (MT)

Complications of MT include:

  • Hypothermia
  • Hypocalcaemia
  • Dilutional coagulopathy
  • Lactic acidosis

Monitor temperature, pH, base excess, Lactate, Calcium, Full blood count and Coagulation profile.

Transfusion-transmissible infections 

The Australian Red Cross Blood Service provides estimates of residual risk estimates of transfusion-transmissible infections based on conservative estimates that are updated annually, including:

  • Viral infection
  • Bacterial infection
  • Malarial infection
  • Other infectious diseases
  • Variant Creutzfeldt Jakob disease (vCJD)

Please see transfusion.com.au for more information

Investigations: directed by clinical assessment and suspected infection. Also consult the Blood Service.

Transfusion associated Graft versus host disease (TA-GVHD) 

Rare transfusion adverse reaction due to engraftment and proliferation of allogeneic T lymphocytes:

Clinical features include rash, fever and diarrhoea occurring 1-2 weeks post transfusion with associated pancytopenia, and liver function abnormalities. Immunocompromised recipients are at a higher risk, however TA-GVHD has been reported in recipients with intact immune systems. Directed donations are routinely irradiated before administration to prevent in vivo T cell proliferation.

Investigations: HLA typing (HLA B27) on donor and recipient and skin biopsy.

Post-transfusion purpura

Rare.

Profound thrombocytopenia approximately 1 week after transfusion due to presence of antibodies in recipient to common platelet antigen/s for which the recipient’s platelets are negative.

Investigations: Platelet antigen testing, Platelet Ab (recipient). Refer to transfusion.com.au for further information.

Transfusion-associated sepsis 

1:75,000 platelet transfusions and 1:500,000 red cell transfusion

Investigations: Blood cultures from recipient and culture and Gram stain on remainder of blood component. Keep the blood bag and giving set (sealed) for further investigation. Confirmation of transfusion-related sepsis is based on culturing the same organism from the patient and blood component.

Iron overload

Evidence of iron overload may occur after 10-20 red cell units in chronically transfused patients. Evidence of iron overload with organ dysfunction may occur after transfusion of 50 to 100 units.^

Investigations: liver biopsy or iron quantification by MRI are superior than serum ferritin in determining the degree of iron overload. End organ dysfunction should be assessed with specific organ tests..

References:

* Roback JD (ed). Non-infectious complications of blood transfusion. AABB Technical Manual. 17th edition. Bethesda: AABB, 2011; Chapter 17.

# National Blood Authority. Patient Blood Management Guidelines: Module 1 – Critical Bleeding/Massive Transfusion. http://blood.gov.au.

^ Australian Red Cross Blood Service, Residual risk estimates for transfusion- transmissible infections. www.transfusion.com.au.

Australian and New Zealand Society of Blood Transfusion. Guidelines for pretransfusion laboratory practice, 5th edition, March 2007.

Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. Sydney: ACSQHC, 2011.