輸血反應

Buzzwords → Dx

Workup of Reaction

• STOP transfusion at first symptom (fever, chills, hypotension, dyspnea, flank pain, urticaria).
• Maintain IV access with normal saline (different bag).
• Verify ID on bag + patient (clerical mismatch is leading cause of AHTR).
• Send blood bank workup: post-transfusion EDTA + clotted samples + remaining blood bag.
• Targeted labs: CBC, LDH, haptoglobin, indirect bili, DAT, urinalysis (hemoglobinuria), coagulation panel (DIC).
• Chest X-ray if respiratory symptoms (TRALI vs TACO).
• Cultures if febrile (donor unit + patient).

Management Algorithm

flowchart TD
  A[Reaction symptom during transfusion] --> B[STOP transfusion<br>verify ID<br>send blood bank workup]
  B --> C{Symptom pattern}
  C -- fever + flank pain + hemoglobinuria + DIC --> D[AHTR<br>IVF + supportive<br>maintain UO + Cr<br>treat DIC]
  C -- new ARDS within 6 h --> E[TRALI<br>respiratory support<br>NO diuretics<br>supportive — usually resolves 48-96 h]
  C -- pulmonary edema + JVD + ↑CVP --> F[TACO<br>diuretics + O₂<br>upright positioning]
  C -- isolated fever --> G[FNHTR<br>acetaminophen<br>rule out hemolysis + sepsis]
  C -- urticaria mild --> H[Allergic / urticarial<br>diphenhydramine<br>can resume slowly]
  C -- anaphylaxis --> I[Anaphylactic<br>epinephrine + steroids<br>future: washed RBCs / IgA-deficient products]
  C -- high fever + hypotension early --> J[Bacterial contamination<br>broad-spectrum antibiotics<br>blood cultures]
  C -- delayed Hb drop + jaundice + + DAT --> K[DHTR<br>identify alloantibody<br>antigen-negative units for future]
  C -- 8-10 day pancytopenia + rash + LFT/diarrhea --> L[TA-GVHD<br>~100% fatal<br>steroids ± IS, supportive — prevention is irradiation]

Pearls / Pitfalls

• AHTR is overwhelmingly clerical error (wrong patient / wrong unit) — verify ID twice. Hemolysis is intravascular with hemoglobinuria, DIC, AKI.
• TRALI is NOT volume overload — normal CVP/PCWP, but ARDS-like presentation. Diuretics worsen it. Treat with respiratory support only. Donors with anti-HLA antibodies (multiparous females) are common source — most blood banks now use male-only plasma to reduce TRALI.
• TACO = volume overload — diuretics + upright + slow future transfusions. Most common in CHF, CKD, elderly, peds.
• Anaphylactic reaction in IgA-deficient patient with anti-IgA antibodies — needs washed RBCs or IgA-deficient products for future transfusions.
• TA-GVHD is preventable with irradiation of cellular blood products. Required in: severe immunocompromise, HCT recipients, hemato-oncology pts on T-cell-depleting therapy (purine analogues, ATG, alemtuzumab, CAR-T pre/post), Hodgkin lymphoma, intrauterine / neonatal transfusions, directed donations from blood relatives.
• CMV-safe products (leukoreduced or CMV-negative) for: pregnant women, neonates, severely immunocompromised, intrauterine transfusion, transplant recipients.
• Bacterial contamination more common in platelets (room-temperature stored) than RBCs (refrigerated).
• Massive transfusion complications: hypothermia, hyperkalemia, hypocalcemia (citrate), dilutional coagulopathy → MTP 1:1:1 + Ca replacement + warming.
• Iron overload with chronic transfusion — start chelation when ferritin >1000 ng/mL or cumulative >20 RBC units.
• Acute pain / chest tightness during transfusion of platelets in some pts → mild allergic; differential FNHTR.
• Reporting: AHTR, TRALI, severe reactions reportable to FDA (USA) / national hemovigilance systems.

Cross-references

• Blood Groups + crossmatch
• Products + irradiation indications
• Alloimmunization → DHTR
• Iron chelation for chronic transfusion
• Lab Values — hemolysis labs, DAT
• DIC complicating AHTR

相關題目

• Q-163 — TRALI vs TACO distinction
• Q-164 — Acute hemolytic transfusion reaction (AHTR)
• Q-165 — TA-GVHD prevention

Sources