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Transfusion Medicine IEY POIIII t(rY P0ll{rs . Donated whole blood is screened for hepatitis B and C . Women of childbearing age or younger who are Rh neg- viruses, HIV human T-cell lymphotropic virus I/ll, and ative and patients previously sensitized to Rh antigens West Nile virus; undergoes serologic testing for syphilis; should never receive Rh positive blood. and, in select regions ofthe country is tested for anti- . For procedures in which blood transfusion is not invari- bodies to Trypanosoma cruzi, Babesia. and Zika virus. ably needed, a type and screen showing no unexpected antibodies eliminates the need for routine preprocedure crossmatching of individual units. Blood Group Antigens, Pretransfusion Compatibi lity Blood Components Testing, and the Direct Packed Red Blood Cells Antiglobulin Test Packed red blood cells (PRBCs) are erythrocytes suspended in A type and screen comprises ABO/Rh blood group determi anticoagulant preservative solution at a hematocrit level of nation and a screening test for unexpected (non ABO) anti- 55% to 65%. Transfusion of one unit of PRBCs to an average bodies. For procedures in which blood transfusion is not sized, nonbleeding adult raises the hematocrit level by 3% and invariably needed, a type and screen showing no unexpected the hemoglobin level by 1 g/dl (10 g/L) (for transfusion prod- antibodies eliminates the need for specific crossmatching uct modiftcations, see Table 25). (compatibility testing); blood can be quickly crossmatched when and if the decision to transfuse is made. If unexpected Plasma antibodies are found, a specific crossmatch is performed to Plasma contains coagulation factors and all other plasma pro- ensure that erythrocytes in the selected unit do not express teins. Plasma transfusion is indicated to restore coagulation the antigen(s). Blood is always matched for Rh status in factors for which specific factor concentrates are not available women of childbearing potential and in patients with anti- or in the setting of multiple acquired deficiencies, as in warfa- RH antibodies but may not be matched for other patients rin overdose when 4 factor prothrombin complex concen requiring massive transfusion. Women of childbearing age or trates (PCCs) are unavailable. younger who are Rh negative and patients previously sensi- tized to Rh antigens should never receive Rh-positive blood. Cryoprecipitate A direct antiglobulin (Coombs) test is performed to look Cryoprecipitate is the fraction of plasma that precipitates when for IgG or complement coating a patient's erythrocytes and is fresh frozen plasma is thawed at 1.0 to 4.0 'C (33.8 39.2 'F). part of the investigation for suspected hemolltic transfusion It contains fibrinogen, von Willebrand factor. and factor Vlll reactions (acute or delayed), autoimmune hemolytic anemia, and is used to treat hypofibrinogenemia and disseminated and hemoll.tic disease of the newborn. intravascular coagulation (DIC). Cryoprecipitate is also used

IEY POIIII t(rY P0ll{rs . Donated whole blood is screened for hepatitis B and C . Women of childbearing age or younger who are Rh neg- viruses, HIV human T-cell lymphotropic virus I/ll, and ative and patients previously sensitized to Rh antigens West Nile virus; undergoes serologic testing for syphilis; should never receive Rh positive blood. and, in select regions ofthe country is tested for anti- . For procedures in which blood transfusion is not invari- bodies to Trypanosoma cruzi, Babesia. and Zika virus. ably needed, a type and screen showing no unexpected antibodies eliminates the need for routine preprocedure crossmatching of individual units. Blood Group Antigens, Pretransfusion Compatibi lity Blood Components Testing, and the Direct Packed Red Blood Cells Antiglobulin Test Packed red blood cells (PRBCs) are erythrocytes suspended in A type and screen comprises ABO/Rh blood group determi anticoagulant preservative solution at a hematocrit level of nation and a screening test for unexpected (non ABO) anti- 55% to 65%. Transfusion of one unit of PRBCs to an average bodies. For procedures in which blood transfusion is not sized, nonbleeding adult raises the hematocrit level by 3% and invariably needed, a type and screen showing no unexpected the hemoglobin level by 1 g/dl (10 g/L) (for transfusion prod- antibodies eliminates the need for specific crossmatching uct modiftcations, see Table 25). (compatibility testing); blood can be quickly crossmatched when and if the decision to transfuse is made. If unexpected Plasma antibodies are found, a specific crossmatch is performed to Plasma contains coagulation factors and all other plasma pro- ensure that erythrocytes in the selected unit do not express teins. Plasma transfusion is indicated to restore coagulation the antigen(s). Blood is always matched for Rh status in factors for which specific factor concentrates are not available women of childbearing potential and in patients with anti- or in the setting of multiple acquired deficiencies, as in warfa- RH antibodies but may not be matched for other patients rin overdose when 4 factor prothrombin complex concen requiring massive transfusion. Women of childbearing age or trates (PCCs) are unavailable. younger who are Rh negative and patients previously sensi- tized to Rh antigens should never receive Rh-positive blood. Cryoprecipitate A direct antiglobulin (Coombs) test is performed to look Cryoprecipitate is the fraction of plasma that precipitates when for IgG or complement coating a patient's erythrocytes and is fresh frozen plasma is thawed at 1.0 to 4.0 'C (33.8 39.2 'F). part of the investigation for suspected hemolltic transfusion It contains fibrinogen, von Willebrand factor. and factor Vlll reactions (acute or delayed), autoimmune hemolytic anemia, and is used to treat hypofibrinogenemia and disseminated and hemoll.tic disease of the newborn. intravascular coagulation (DIC). Cryoprecipitate is also used TABLE 25. CellularTransfusion Product Modifications Modification Notes Leukoreduction": decreases number Reduces class I HLA alloantibody production and subsequent platelet transfusion of leukocytes present in transfused refractori ness. erythrocytes or platelets Decreases febrile nonhemolytic transfusion reactions.

TABLE 25. CellularTransfusion Product Modifications Modification Notes Leukoreduction": decreases number Reduces class I HLA alloantibody production and subsequent platelet transfusion of leukocytes present in transfused refractori ness. erythrocytes or platelets Decreases febrile nonhemolytic transfusion reactions. Decreases transmission of CMV. Leukoreduction cannot be relied on to preventtransfusion-associated GVHD. lrradiation: prevents replication of Prevents transfusion-associated GVHD, which is mediated by donor lymphocytes. lymphocytes and circulating stem cells present in erythrocyte or platelet lndicated in patients with severe immunodeficiency, whether inherited or acquired or products fol lowing chemotherapy. lndicated in immunocompetent patients receiving HLA-matched platelets or transfusions from relatives. Washing: removes proteins remaining in Used in patients with a history of severe/recurrent allergic reactions, lgA deficiency (when the plasma of erythrocyte and platelet lgA-deficient donors are unavailable). products Reduces the amount of potassium transfused for patients who are at high risk for hyperkalemia. CMV = cltomegalovirus; GVHD = graft-versus host disease. "More than 80% of blood banks i n the United States adhere to universal leukoreduction. For those that do not, leukoreduction should be performed for patients who undergo celltransplant, and immunocompromised recipients who are CMV seronegative. 46

Transfusion Medicine empirically in uremic bleeding. Eight to 10 units of cryopre- elective invasive procedures, or in patients with chronic liver cipitate (from 8-10 donors) are pooled before transfusion. disease. PCCs contain residual heparin and are contraindi cated in patients with heparin-induced thrombocytopenia. Platelets Activated factor VII, which also has considerable pro- Platelet concentrates are derived from whole blood. Donations thrombotic risk, is used to manage hemophilia in patients by apheresis yield platelet products equivalent to approximately with high inhibitor titers and acquired hemophilia in some five platelet concentrates (platelets derived from whole blood patients. donation) and raise the platelet count by around 20,000 to rEY POIilIS 30,000/pL (ZO-So x 10e/L). Platelet transfusions are needed for patients with thrombocl.topenia undergoing general surgery o Recombinant factor concentrates (not containing any (platelet count <50,000/pL [50 x 10,/L]) or neurosurgery (plate donor plasma) are the standard of care for younger let count <100,000/prl h00 x 10,/Ll) or those who are actively patients with hemophilia A and B. bleeding. Platelets are also transfused to prevent spontaneous o Four-factor prothrombin complex concentrates are bleeding in most stable, afebrile patients whose platelet count is the preferred product for patients experiencing life less than 10,000/pL (10 x 10e/L) or in select circumstances, threatening bleeding while taking warfarin. such as in patients with acute promyelocytic leukemia with a platelet count less than 30,000 to 50,000/pL (30-50 x 10e/L). Platelets should generally not be used to treat patients with an Blood Management established diagnosis of thrombotic thrombocytopenic pur Patient blood management is a multidisciplinary strategr that pura and should be limited to managing life-threatening achieves a clinically relevant goal rather than corrects an bleeding in patients with immune thrombocytopenia (see abnormal Iaboratory finding, identifies and corrects specific Table 25 for platelet modifications). causes of anemia that eliminate the need for transfusion. and KEY POIl{TS reduces iatrogenic blood loss. o Transfusion of one unit of packed red blood cells to an A restrictive transfusion threshold of a hemoglobin level average-sized, nonbleeding adult raises the hematocrit less than 7 g/dL (7O glL) has been shown to be as safe and effec by 3% and the hemoglobin level by 1 g/dl (10 g/L); tive as more liberal thresholds, except in patients with acute transfusion to patients with anemia increases oxygen- coronary sl,ndrome or acute stroke. This restrictive threshold carrying capacity. does not apply to patients who are hemodynamically unstable . Cryoprecipitate contains a concentrated amount of or actively bleeding and should not be applied to symptomatic patients with rapidly decreasing hemoglobin concentrations. fibrinogen and is used to treat hypofibrinogenemia occurring in disseminated intravascular coagulation. KEY POINI o Platelets are not generally indicated in otherwise stable . A restrictive transfusion threshold (hemoglobin level patients with chronic thrombocytopenia until the <7 gldLlzO gtL)) provides equivalent outcomes as a platelet count decreases to less than 10,000 (10 x 10e/L). more liberal threshold in most patients; those with acute coronary qmdrome, acute stroke, acute slmptomatic anemia, or acute blood loss might require transfusion at a Plasma Derivatives and Recombinant higher hemoglobin level. Coagulation Factors Plasma pooled together from thousands of donors is fraction ated into derivatives such as albumin, Rh immune globulins, or coagulation factor concentrates (Table 26). Plasma deriva Transfusion Com plications tives are processed to reduce the risk of infectious disease Transfusion reactions occur in approximately 1% of transfusions. transmission. Recombinant f'actor concentrates (not contain Although fatal reactions are rare (incidence of1:200,000 400,000 ing any donor plasma) have become the standard of care for units), the leading causes are hemo$sis, transfusion related acute younger patients with hemophilia A and B (factor VIII and IX lung injury and transfusion associated circulatory overload. deficiency, respectively). Recombinant porcine factor VIII has been shown to provide effective hemostasis in patients with Hemolytic Reactions acquired hemophilia A. Acute Hemolytic Transfusion Reactions Four factor PCCs contain factors II, VII, IX and X and are Acute ABO-incompatible hemolytic transfusion reactions the preferred product for patients experiencing life-threaten- usually result from clerical errors at the time of specimen col- ing bleeding while taking warfarin. Although 3 factor PCCs Iection or blood administration. Electronic barcode systems are available, the 4 factor product is preferred. Inappropriate reduce such errors. Patient and specimen identification can be use of PCCs carries a thrombotic risk, so they should not be particular$ problematic in high turnover areas. Acute hemo- used in patients without life threatening bleeding, before lytic reactions manifest with fever and flank pain. This can

empirically in uremic bleeding. Eight to 10 units of cryopre- elective invasive procedures, or in patients with chronic liver cipitate (from 8-10 donors) are pooled before transfusion. disease. PCCs contain residual heparin and are contraindi cated in patients with heparin-induced thrombocytopenia. Platelets Activated factor VII, which also has considerable pro- Platelet concentrates are derived from whole blood. Donations thrombotic risk, is used to manage hemophilia in patients by apheresis yield platelet products equivalent to approximately with high inhibitor titers and acquired hemophilia in some five platelet concentrates (platelets derived from whole blood patients. donation) and raise the platelet count by around 20,000 to rEY POIilIS 30,000/pL (ZO-So x 10e/L). Platelet transfusions are needed for patients with thrombocl.topenia undergoing general surgery o Recombinant factor concentrates (not containing any (platelet count <50,000/pL [50 x 10,/L]) or neurosurgery (plate donor plasma) are the standard of care for younger let count <100,000/prl h00 x 10,/Ll) or those who are actively patients with hemophilia A and B. bleeding. Platelets are also transfused to prevent spontaneous o Four-factor prothrombin complex concentrates are bleeding in most stable, afebrile patients whose platelet count is the preferred product for patients experiencing life less than 10,000/pL (10 x 10e/L) or in select circumstances, threatening bleeding while taking warfarin. such as in patients with acute promyelocytic leukemia with a platelet count less than 30,000 to 50,000/pL (30-50 x 10e/L). Platelets should generally not be used to treat patients with an Blood Management established diagnosis of thrombotic thrombocytopenic pur Patient blood management is a multidisciplinary strategr that pura and should be limited to managing life-threatening achieves a clinically relevant goal rather than corrects an bleeding in patients with immune thrombocytopenia (see abnormal Iaboratory finding, identifies and corrects specific Table 25 for platelet modifications). causes of anemia that eliminate the need for transfusion. and KEY POIl{TS reduces iatrogenic blood loss. o Transfusion of one unit of packed red blood cells to an A restrictive transfusion threshold of a hemoglobin level average-sized, nonbleeding adult raises the hematocrit less than 7 g/dL (7O glL) has been shown to be as safe and effec by 3% and the hemoglobin level by 1 g/dl (10 g/L); tive as more liberal thresholds, except in patients with acute transfusion to patients with anemia increases oxygen- coronary sl,ndrome or acute stroke. This restrictive threshold carrying capacity. does not apply to patients who are hemodynamically unstable . Cryoprecipitate contains a concentrated amount of or actively bleeding and should not be applied to symptomatic patients with rapidly decreasing hemoglobin concentrations. fibrinogen and is used to treat hypofibrinogenemia occurring in disseminated intravascular coagulation. KEY POINI o Platelets are not generally indicated in otherwise stable . A restrictive transfusion threshold (hemoglobin level patients with chronic thrombocytopenia until the <7 gldLlzO gtL)) provides equivalent outcomes as a platelet count decreases to less than 10,000 (10 x 10e/L). more liberal threshold in most patients; those with acute coronary qmdrome, acute stroke, acute slmptomatic anemia, or acute blood loss might require transfusion at a Plasma Derivatives and Recombinant higher hemoglobin level. Coagulation Factors Plasma pooled together from thousands of donors is fraction ated into derivatives such as albumin, Rh immune globulins, or coagulation factor concentrates (Table 26). Plasma deriva Transfusion Com plications tives are processed to reduce the risk of infectious disease Transfusion reactions occur in approximately 1% of transfusions. transmission. Recombinant f'actor concentrates (not contain Although fatal reactions are rare (incidence of1:200,000 400,000 ing any donor plasma) have become the standard of care for units), the leading causes are hemo$sis, transfusion related acute younger patients with hemophilia A and B (factor VIII and IX lung injury and transfusion associated circulatory overload. deficiency, respectively). Recombinant porcine factor VIII has been shown to provide effective hemostasis in patients with Hemolytic Reactions acquired hemophilia A. Acute Hemolytic Transfusion Reactions Four factor PCCs contain factors II, VII, IX and X and are Acute ABO-incompatible hemolytic transfusion reactions the preferred product for patients experiencing life-threaten- usually result from clerical errors at the time of specimen col- ing bleeding while taking warfarin. Although 3 factor PCCs Iection or blood administration. Electronic barcode systems are available, the 4 factor product is preferred. Inappropriate reduce such errors. Patient and specimen identification can be use of PCCs carries a thrombotic risk, so they should not be particular$ problematic in high turnover areas. Acute hemo- used in patients without life threatening bleeding, before lytic reactions manifest with fever and flank pain. This can 47

Transfusion Medicine TAGLE ?tr" Piasma'DerivedTherapeutic Products Product lndication(s) for Use Fresh frozen plasma Replacement fluid for plasma exchange in thrombotic thrombocytopenic purpura Prevention and treatment of coagulopathy from massive transfusion Treatment of bleeding associated with multiple acquired clotting factor deficiencies (liver disease, disseminated intravascular coagulation, nonemergent warfarin toxicity) Cryoprecipitate Congenital or acquired fibrinogen deficiency Dysfibrinogenemia Factor Xlll deficiency Treatment of hemophilia A and von Willebrand disease when a specific factor concentrate is not available

TAGLE ?tr" Piasma'DerivedTherapeutic Products Product lndication(s) for Use Fresh frozen plasma Replacement fluid for plasma exchange in thrombotic thrombocytopenic purpura Prevention and treatment of coagulopathy from massive transfusion Treatment of bleeding associated with multiple acquired clotting factor deficiencies (liver disease, disseminated intravascular coagulation, nonemergent warfarin toxicity) Cryoprecipitate Congenital or acquired fibrinogen deficiency Dysfibrinogenemia Factor Xlll deficiency Treatment of hemophilia A and von Willebrand disease when a specific factor concentrate is not available lntravenous immune globulin Acquired or congenital hypogammaglobulinemia Autoimmune disorders Albumin Replacement fluid for plasma exchange Large-volume paracentesis Prothrombin complex concentratesa Major warfarin-associated hemorrhage Activated factor Vll Hemophilia with high-titer inhibitors; acquired hemophilia Factor Vlllb Hemophilia A, treatment and prevention of bleeding von Willebrand protein-rich factor Vlllb' von Willebrand disease, treatment and prevention of bleeding Factor lXb Hemophilia B, treatment and prevention of bleeding Fibrinogen concentrate Congenital fibrinogen deficiency, treatment o{ bleeding Thrombinb Topical application for small vessel bleeding despite standard surgical techniques or when surgical intervention is not feasible Protein C concentrate Severe congenital protein C deficiency (prevention and treatment of venous thrombosis and purpura fulminans) Antithrombinb Hereditary antithrombin deficiency (perisurgical and obstetric procedure prophylaxis and treatment of established venous thrombosis) o1-antitrypsin Congenital o1-antitrypsin deficiency (high-risk phenotype, cr1-antitrypsin level <1 1 pmol/1, >1 B years of age, and airflow obstruction by spirometry)

lntravenous immune globulin Acquired or congenital hypogammaglobulinemia Autoimmune disorders Albumin Replacement fluid for plasma exchange Large-volume paracentesis Prothrombin complex concentratesa Major warfarin-associated hemorrhage Activated factor Vll Hemophilia with high-titer inhibitors; acquired hemophilia Factor Vlllb Hemophilia A, treatment and prevention of bleeding von Willebrand protein-rich factor Vlllb' von Willebrand disease, treatment and prevention of bleeding Factor lXb Hemophilia B, treatment and prevention of bleeding Fibrinogen concentrate Congenital fibrinogen deficiency, treatment o{ bleeding Thrombinb Topical application for small vessel bleeding despite standard surgical techniques or when surgical intervention is not feasible Protein C concentrate Severe congenital protein C deficiency (prevention and treatment of venous thrombosis and purpura fulminans) Antithrombinb Hereditary antithrombin deficiency (perisurgical and obstetric procedure prophylaxis and treatment of established venous thrombosis) o1-antitrypsin Congenital o1-antitrypsin deficiency (high-risk phenotype, cr1-antitrypsin level <1 1 pmol/1, >1 B years of age, and airflow obstruction by spirometry) C1-esterase inhibitor Hereditary angioedema, acute attacks bRecombinant product available and preferred as a way of reducing the risk of transmissible nfections. 'Select plasma-derived factorVlll products are rich in von Willebrand protein.

lntravenous immune globulin Acquired or congenital hypogammaglobulinemia Autoimmune disorders Albumin Replacement fluid for plasma exchange Large-volume paracentesis Prothrombin complex concentratesa Major warfarin-associated hemorrhage Activated factor Vll Hemophilia with high-titer inhibitors; acquired hemophilia Factor Vlllb Hemophilia A, treatment and prevention of bleeding von Willebrand protein-rich factor Vlllb' von Willebrand disease, treatment and prevention of bleeding Factor lXb Hemophilia B, treatment and prevention of bleeding Fibrinogen concentrate Congenital fibrinogen deficiency, treatment o{ bleeding Thrombinb Topical application for small vessel bleeding despite standard surgical techniques or when surgical intervention is not feasible Protein C concentrate Severe congenital protein C deficiency (prevention and treatment of venous thrombosis and purpura fulminans) Antithrombinb Hereditary antithrombin deficiency (perisurgical and obstetric procedure prophylaxis and treatment of established venous thrombosis) o1-antitrypsin Congenital o1-antitrypsin deficiency (high-risk phenotype, cr1-antitrypsin level <1 1 pmol/1, >1 B years of age, and airflow obstruction by spirometry) C1-esterase inhibitor Hereditary angioedema, acute attacks bRecombinant product available and preferred as a way of reducing the risk of transmissible nfections. 'Select plasma-derived factorVlll products are rich in von Willebrand protein. Iead to hypotension, diffuse bleeding, DIC, hemoglobinuria, appreciated. Laboratory investigation will reveal a positive and death. Rarely, high titer A (or B) antibodies found in plate direct antiglobulin test, and the blood bank will be able to let units initiate hemolysis. Management requires abrupt identify the target antigen. Patients should be informed transfusion termination, because the degree of hemolysis is regarding their alloimmunization status so they can commu- proportional to the volume transfused. Volume expansion and nicate this information to other health care providers for sub supportive care for associated complications (DlC, acute kid sequent surgery or other care. Some jurisdictions outside the ney injury) are required. An investigation into the cause of the United States have translusion "antibody registries" for this reaction is initiated in each case. purpose.

Iead to hypotension, diffuse bleeding, DIC, hemoglobinuria, appreciated. Laboratory investigation will reveal a positive and death. Rarely, high titer A (or B) antibodies found in plate direct antiglobulin test, and the blood bank will be able to let units initiate hemolysis. Management requires abrupt identify the target antigen. Patients should be informed transfusion termination, because the degree of hemolysis is regarding their alloimmunization status so they can commu- proportional to the volume transfused. Volume expansion and nicate this information to other health care providers for sub supportive care for associated complications (DlC, acute kid sequent surgery or other care. Some jurisdictions outside the ney injury) are required. An investigation into the cause of the United States have translusion "antibody registries" for this reaction is initiated in each case. purpose. XEY POIilII Delayed Hemolytic Transfusion Reaction o Acute hemolytic transfusion reactions manifest with Antibodies to non-ABO blood group antigens occur after fever and flank pain, which can progress to hypotension, exposure through transfusion or pregnancy but may not be diffuse bleeding, and hemoglobinuria; discontinuing the detectable when transfusion is needed years later. Re exposure transfusion is the most important step in treatment. leads to an anamnestic response and delayed hemolysis of the . A delayed hemolytic transfusion reaction occurs 1 to transfused antigen positive ery.throc1tes, typically 7 to 14 days 2 weeks after transfusion and should be evaluated with after transfusion. The causative association between a decreas a direct antiglobulin test (the result will be positive). ing hematocrit and a previous transfusion is not always

XEY POIilII Delayed Hemolytic Transfusion Reaction o Acute hemolytic transfusion reactions manifest with Antibodies to non-ABO blood group antigens occur after fever and flank pain, which can progress to hypotension, exposure through transfusion or pregnancy but may not be diffuse bleeding, and hemoglobinuria; discontinuing the detectable when transfusion is needed years later. Re exposure transfusion is the most important step in treatment. leads to an anamnestic response and delayed hemolysis of the . A delayed hemolytic transfusion reaction occurs 1 to transfused antigen positive ery.throc1tes, typically 7 to 14 days 2 weeks after transfusion and should be evaluated with after transfusion. The causative association between a decreas a direct antiglobulin test (the result will be positive). ing hematocrit and a previous transfusion is not always 48

Transfusion Medicine Nonhemolytic Transfusion Reactions lnfectious Complications Transfusion-Associated Circulatory Overload Risk of infbction ranges from 1:300,000 fbr hepatitis B and Transfusion associated circulatory overload is an underrecog West Nile viruses to 1:1 million for infections such as hepatitis nized problem but may be the most common serious compli C virus and tllV. In addition to these int'ections. bacterial cation of blood transtusion, afl'ecting 1"/,, to B"/,, of transtusion contamination may occur, especially in platelet components recipients. Risk factors include older age, pre existing cardio that are stored at room temperature. Bacterial testing is per vascular or kidney disease, and rapid administration rate. formed befbre issuing the unit, but the risk is still reported to Signs and symptoms include respiratory distress within be 1:1000 to 1:3000 units. Erythrocyte components may 6 hours oftransfusion, positive fluid balance, elevated central rarely be inf'ected with Yersinio, which thrive in a cold, iron venous pressure, elevated B type natriuretic peptide. and rich environment. compatible radiographic findings of pulmonary eden.ra. Therapy consists of diuretics and a slower rate of blood Allergic Reactions and Anaphylaxis administration. Pruritus and urtic:rria occur in 1% to 5'1, of recipients during or after transfusion. Because the reaction may be donor specific, Transfusion-Related Acute Lung Injury prophylaxis with antihistamines or glucocorticoids for future Transfusion related acute lung injury (TRALI) is defined as transfusions is unwarranted. noncardiogenic pulmonary edema that occurs u'ithin 6 hours Anaphylactic or anaphylactoid reactions are rare. oftransfusion. Patients present with dyspnea, fever, and hypo Manifestations include angioedema, stridor. abdominal symp tension without signs olvolun.re overload. Radiographic find toms, and hypotension. Patients may require epinephrine, ings usually resemble acute respiratory distress syndrome. bronchodilators, or fluid resuscitation. Protein deficiency (lgA Most cases of TRALI occur because of HLA or neutrophil or haptoglobin) should be ruled out. Documentation of severe specific antibodies in donors that bind to and activate recipi' IgA deficiency with anti IgA antibodies necessitates using ent leukocy'tes in the pulmonary vasculature. Screening washed cellular blood components or plasma components donors for these antibodies reduces the incidence. Management from IgA deficient donors for future transfusions. is supportive and includes supplemental oxygen or mechanical ventilation. The prognosis is better. and the recovery is quicker ftY PorilTs than in patients with typical acute respiratory distress syn o No evidence supports the routine use of antihistamine drome. TRALI is unlikely to recur in subsequent transfusions. or glucocorticoid prophylaxis in patients with a history of mild allergic transfusion reactions. Febrile Nonhemolytic Transfusion Reaction . Manifestations of anaphylactic or anaphylactoid trans- Febrile nonhemolytic transfusion reaction is common, occur fusion reactions include angioedema, stridor, abdomi- ring in about lul, of transfusion episodes, and is mediated by nal symptoms, and hypotension and should prompt an proinflammatory cytokines elaborated by donor leukocytes investigation for an underlying protein deficiency (lgA during storage. Symptoms encompass a temperature increlse or haptoglobin). of 1.0 "C (t.A 'F) to greater than 38.0 'C (100.4 'F) within 4 hours oftransfusion or chills and rigors even in the absence Transfusion-Associated G raft-versus-Host Disease ofa fever. The differential diagnosis offever occurring in trsso Transfusion associated graft versus host disease is a rare but ciation with transfusion includes hemolysis and septic trans fatal complication in which donor lymphocytes in a cellular fusion reaction. The direct antiglobulin test result is negative. blood product (erythrocytes or platelets) engraft in an immu Antipyretics are used fbr treatment, but routine prophylaxis nocompromised recipient and cause toxic efTects in the bone with antipyretics is not warranted. Leukoreduction reduces marrow skin, liver, and gastrointestinal tract. Patients at risk the incidence. include those receiving chemotherapy lbr autoimmune disor- XEY POIf,Is ders or malignancy, patients with aplastic anemia or other . Signs and symptoms of transfusion-associated circula fbrms of immunodeficiency, patients who have undergone stem cell or other transplantation, recipients ol blood compo- tory overload include respiratory distress within nents from first degree relatives, and premature infants. 6 hours oftransfusion, positive fluid balance, elevated Prevention involves irradiation of cellular blood components. central venous pressure, elevated B-type natriuretic Patients who have undergone stem cell transplantation typi- peptide, and compatible radiographic findings of pul cally require irradiated blood components indefinitely. monary edema. r Transfusion-related acute lung injury is defined as non- rEY POI]II cardiogenic pulmonary edema that occurs within o Patients who have undergone stem cell transplantation 6 hours of transfusion and is managed similarly to other typically require irradiated blood products to prevent causes of acute respiratory distress syndrome. transfusion associated graft-versus-host disease.

Nonhemolytic Transfusion Reactions lnfectious Complications Transfusion-Associated Circulatory Overload Risk of infbction ranges from 1:300,000 fbr hepatitis B and Transfusion associated circulatory overload is an underrecog West Nile viruses to 1:1 million for infections such as hepatitis nized problem but may be the most common serious compli C virus and tllV. In addition to these int'ections. bacterial cation of blood transtusion, afl'ecting 1"/,, to B"/,, of transtusion contamination may occur, especially in platelet components recipients. Risk factors include older age, pre existing cardio that are stored at room temperature. Bacterial testing is per vascular or kidney disease, and rapid administration rate. formed befbre issuing the unit, but the risk is still reported to Signs and symptoms include respiratory distress within be 1:1000 to 1:3000 units. Erythrocyte components may 6 hours oftransfusion, positive fluid balance, elevated central rarely be inf'ected with Yersinio, which thrive in a cold, iron venous pressure, elevated B type natriuretic peptide. and rich environment. compatible radiographic findings of pulmonary eden.ra. Therapy consists of diuretics and a slower rate of blood Allergic Reactions and Anaphylaxis administration. Pruritus and urtic:rria occur in 1% to 5'1, of recipients during or after transfusion. Because the reaction may be donor specific, Transfusion-Related Acute Lung Injury prophylaxis with antihistamines or glucocorticoids for future Transfusion related acute lung injury (TRALI) is defined as transfusions is unwarranted. noncardiogenic pulmonary edema that occurs u'ithin 6 hours Anaphylactic or anaphylactoid reactions are rare. oftransfusion. Patients present with dyspnea, fever, and hypo Manifestations include angioedema, stridor. abdominal symp tension without signs olvolun.re overload. Radiographic find toms, and hypotension. Patients may require epinephrine, ings usually resemble acute respiratory distress syndrome. bronchodilators, or fluid resuscitation. Protein deficiency (lgA Most cases of TRALI occur because of HLA or neutrophil or haptoglobin) should be ruled out. Documentation of severe specific antibodies in donors that bind to and activate recipi' IgA deficiency with anti IgA antibodies necessitates using ent leukocy'tes in the pulmonary vasculature. Screening washed cellular blood components or plasma components donors for these antibodies reduces the incidence. Management from IgA deficient donors for future transfusions. is supportive and includes supplemental oxygen or mechanical ventilation. The prognosis is better. and the recovery is quicker ftY PorilTs than in patients with typical acute respiratory distress syn o No evidence supports the routine use of antihistamine drome. TRALI is unlikely to recur in subsequent transfusions. or glucocorticoid prophylaxis in patients with a history of mild allergic transfusion reactions. Febrile Nonhemolytic Transfusion Reaction . Manifestations of anaphylactic or anaphylactoid trans- Febrile nonhemolytic transfusion reaction is common, occur fusion reactions include angioedema, stridor, abdomi- ring in about lul, of transfusion episodes, and is mediated by nal symptoms, and hypotension and should prompt an proinflammatory cytokines elaborated by donor leukocytes investigation for an underlying protein deficiency (lgA during storage. Symptoms encompass a temperature increlse or haptoglobin). of 1.0 "C (t.A 'F) to greater than 38.0 'C (100.4 'F) within 4 hours oftransfusion or chills and rigors even in the absence Transfusion-Associated G raft-versus-Host Disease ofa fever. The differential diagnosis offever occurring in trsso Transfusion associated graft versus host disease is a rare but ciation with transfusion includes hemolysis and septic trans fatal complication in which donor lymphocytes in a cellular fusion reaction. The direct antiglobulin test result is negative. blood product (erythrocytes or platelets) engraft in an immu Antipyretics are used fbr treatment, but routine prophylaxis nocompromised recipient and cause toxic efTects in the bone with antipyretics is not warranted. Leukoreduction reduces marrow skin, liver, and gastrointestinal tract. Patients at risk the incidence. include those receiving chemotherapy lbr autoimmune disor- XEY POIf,Is ders or malignancy, patients with aplastic anemia or other . Signs and symptoms of transfusion-associated circula fbrms of immunodeficiency, patients who have undergone stem cell or other transplantation, recipients ol blood compo- tory overload include respiratory distress within nents from first degree relatives, and premature infants. 6 hours oftransfusion, positive fluid balance, elevated Prevention involves irradiation of cellular blood components. central venous pressure, elevated B-type natriuretic Patients who have undergone stem cell transplantation typi- peptide, and compatible radiographic findings of pul cally require irradiated blood components indefinitely. monary edema. r Transfusion-related acute lung injury is defined as non- rEY POI]II cardiogenic pulmonary edema that occurs within o Patients who have undergone stem cell transplantation 6 hours of transfusion and is managed similarly to other typically require irradiated blood products to prevent causes of acute respiratory distress syndrome. transfusion associated graft-versus-host disease. 49