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Sepsis

Sepsis occurs when bacteria enter the blood or blood product that is to be infused. Bacteria can enter at any point from the time of collection, during storage through to administration to the patient. Organisms implicated in transfusion-related sepsis include Gram-negative Pseudomonas, Yersinia and Flavobacterium (Provan et al. 2009). Septic reactions usually present with a fever, tachycardia and/or hypotension, and can lead rapidly to systemic inflammatory response syndrome (SIRS) (Porth 2005). This is a serious life-threatening condition, sometimes referred to as septic shock, and requires urgent medical attention.

Transfusion-related acute lung injury (TRALI)

Transfusion-related acute lung injury is most frequently associated with plasma-rich products such as whole blood, platelets and FFP (Federico 2009). TRALI is usually caused by anti- leucocyte antibodies reacting against donor leucocytes. This reaction can result in ‘leucoagglutination’. Leucoagglutinins can in turn become trapped in the pulmonary microvasculature, causing severe respiratory distress without evidence of circulatory overload or cardiac failure (Contreras and Navarrete 2009). TRALI presents with a rapid onset of breathlessness, a non-productive cough, distress, chills or fever, cyanosis, hypotension and coma. A chest X-ray will show bilateral nodular infiltrates in a characteristic ‘bat wing’ presentation (McClelland 2007).

Transfusion-related acute lung injury is usually treated as any adult respiratory distress syndrome (ARDS) and therefore patients who develop TRALI may require ventilatory support (SNBTS 2004) and should be treated as an emergency. Diuretics should not be administered as patients are generally hypotensive and hypovolaemic. Although the symptoms resemble ARDS, TRALI is self-limiting and with most patients improving over a 4-day period, without long-term consequences (Federico 2009). As TRALI is donor related, it is essential that cases are reported to the blood transfusion services so that donors can be contacted and removed from the donor panel (McClelland 2007).

Transfusion-related immune modulation

The infusion of foreign antigen during a packed red blood cell (PRBC) transfusion induces a non-specific immunosuppression, which is known as transfusion-associated immunomodulation. Allogeneic plasma components, white blood cells, fibrin and accumulants from the storage process have all been implicated (Englesbe et al. 2005).

Urticaria

This uncommon reaction is caused by the recipient reacting to protein in the donor plasma (Davies and Williamson 1998). Urticaria is characterized by localized oedematous plaques, hives and itching and is usually mediated by histamines (Porth 2005). Therefore urticarial reactions usually respond well to antihistamines and they should be administered once the patient has been assessed and antihistamine therapy has been prescribed (SNBTS 2004). The infusion can then be recommenced; however, if symptoms return, the infusion should be discontinued.

Transfusion reactions

In November 1996 the SHOT scheme was launched. This voluntary and anonymized reporting scheme collects data from participating hospitals across the UK and Ireland. The purpose of SHOT is to collect data on the serious morbidity related to the transfusion of blood and blood products. These data have since been utilized to inform education programmes, policy development and guideline development, ultimately improving hospital transfusion practice (SNBTS 2004).

Although the Blood Safety and Quality Regulations (2005) have now made the reporting of such events via SABRE mandatory, the SHOT scheme remains active and important and has presented yearly retrospective reports of data collected since its inception. These data demonstrate improved performance in recognizing reporting of transfusion-related incidents and continue to generate key recommendations to improve all transfusion practice (SNBTS 2004). Despite significant improvement in the reduction of risk from transfusion-transmitted