1. Blood Transfusion Reaction in neonates & management
Dr. Azita Azarkeivan
Pediatric Hematology Oncology
Adult Thalassemia Clinic

2. 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
In New born and infants these complications may have some differences

3. Complications of Transfusion in newborn and infants
Small Blood volume
Passive transfer of maternal antibody
Immature Immune system
CMV , TA-GVHD

4. Transfusion Side effects
Acute Hemolytic Reaction
Delayed Hemolytic Reaction
Febrile Non hemolytic Reaction
Allergic Reaction
Iron Over Load
TX Related Acute Leukocyte Lung Injury
Transfusion Transmitted Infections
Volume Over Load, Electrolyte Imbalance

5. Complications of Transfusions
Two Categories
Acute (< 24 hr )
Immunologic
Non-immunologic
Delayed (> 24 hr)

6. Acute Immunologic (< 24 hr)
Transfusion Reactions

7. Acute (< 24 hr) Immunologic
Hemolytic
Febrile ; Fever , chills, non-hemolytic
Allergic ; Urticarial , non-hemolytic
Transfusion-related acute lung injury (TRALI)
Anaphylactic ( IgA related)

8. Acute (< 24 hr) Immunologic
Hemolytic
Mostly ABO incompatibility
A clerical error (wrong specimen, wrong patient)
Sever hemolysis ,
In new born the ABO gp antigens not developed well and also their antibodies are not in high level
But The maternal antibodies may pass from mother and these antibodies may produce hemolysis in new born
Prevention : Correct ABO grouping of patient and blood bag
Careful cross match with maternal serum

9. Acute (< 24 hr) Immunologic
Febrile
FNHTR , Rise in temperature by 2F or 1C
HLA alloab of pt against Donor’WBC
Recipient has WBC antibodies against donor WBCs contained within RBCs and Platelet products
No hemolysis, Often occurs after multiple blood transfusions.
In newborn and infants not very common
Prevention : Use of leukoreduced product
It should be to rolled out the other causes for fever for the patient
Anti pyretic should use if there is no other cause

10. Acute (< 24 hr) Immunologic
Allergic
Allergic reaction to Donor’s plasma proteins
Urticaria, itching, flushing, wheezing
No hemolysis, Often occurs after multiple blood transfusions.
In newborn and infants not very common
Prevention : Use of Antihistamin

11. Acute (< 24 hr) Immunologic
Transfusion-related acute lung injury (TRALI)
Transfusion related pulmonary edema
Donor plasma contains WBC antibodies that when transfused to the recipient cause agglutination of recipient’s WBC in the pulmonary capillary beds
Chest X ray looks like ARDS
Signs/Symptoms:
Circulatory overload (TACO),
Allergic/Anaphylactic
Bacterial ;Acute hemolytic reaction
Clinical presentation (“classic”, severe form)
Acute respiratory distress,Pulmonary edema
Hypoxemia,,Hypotension
Rx usually within 6 hr (majority of cases during tx or within 2 hr of tx

12. Acute (< 24 hr) Immunologic
Transfusion-related acute lung injury (TRALI)
Insidious, acute onset of pulmonary insufficiency
Profound hypoxemia ; PaO2/FiO2 < 300 mmHg
CXR ; fluffy infiltrates , pulmonary edema
Cardiac ; PA wedge pressure  18 mmHg
Treatment/Prevention
Discontinue transfusion
Supportive care
Epinephrine
Antihistamine/steroids
In IgA deficient pts.  IgA-deficient product, wash blood product

13. Acute Non Immunologic (< 24 hr)
Transfusion Reactions

14. Acute (< 24 hr) Non-Immunologic
Circulatory overload
Air embolus
Hypocalcemia
Hypothermia
Hyperkalemia

15. Acute (< 24 hr) Non-Immunologic
Circulatory overload
Acute pulmonary edema due to volume overload
One of the most common complications of transfusion
Common in newborn and infants
Cardiac and pulmonary compromise
Dyspnea, cyanosis, CHF during or soon after transfusion
Prevention ; slow rate of transfusion , Care full estimation of volume of transfusion ,
Treatment ; stop Tx , Use of diuretics

16. Acute (< 24 hr) Non-Immunologic
Air Embolism
Air infusion via line of product transfusion
Cough, dyspnea, chest pain, shock
Prevention ; Care full transfusion via the trained and well experienced Nurse
Treatment ; stop Tx , Pt. placed on left side with head down , Displace air bubble from pulmonary valve

17. Acute (< 24 hr) Non-Immunologic
Metabolic Complications ; Hypocalcemia
If Large volumes of product transfused rapidly ; plasma citrate levels may rise ; binds iCa+2
Citrate rapidly metabolized ; manifestations transient
peripheral tingling , paresthesias,, tetanic seizure, hyperventilation, depressed cardiac function
Prevention ; Control the calcium level
Treatment ; Ca+2 replacement

18. Acute (< 24 hr) Non-Immunologic
Metabolic Complications ; Hyperkalemia
If old ( more than 2 weeks ) product transfused ; RBC Lysis may increase potassium level ;
Irradiation product may increase the rate of leak
Cardiac arrhythmia, electrolyte imbalance
Prevention ; Control the potassium level
Treatment ; potassium replacement

19. Acute (< 24 hr) Non-Immunologic
Metabolic Complications ; 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
May be common in newborn and infants
Prevention ; slow rate of transfusion , Blood warmer
Treatment ; warm the patient

20. Delayed Immunologic (> 24 hr)
Transfusion Reactions

21. Delayed (> 24 hr) Immunologic
Alloimmunization
RBC antigens
HLA Leukocyte Antigens
Graft-versus-host disease (GVHD)
Post-transfusion purpura
Immuno modulation

22. Delayed (> 24 hr) Immunologic Allo-immunization
Occurs weeks to months after transfusion
Incidence ; 1-1.6% to RBC antigens ; 10% to HLA
In new born and infants not very common
Signs/Symptoms:
PRBCs ; hemolysis
Plts. ; refractoriness
Treatment/Prevention :Leukoreduction ,Cross-matched and/or HLA-matched plts.

23. Delayed (> 24 hr) Immunologic Graft-versus-host disease (GVHD)
Fatal complication cause by clonal expansion of donor T lymphocytes in immunocompromized host
New borns and infants have immature immune system are susceptible to this event
Signs/Symptoms;Appears in days of transfusion
Skin ; whole body erythroderma, desquamation
GI ; diarrhea
Liver; high liver enayme
BM ; failure leading to pancytopenia
Treatment/Prevention; Gamma irradiation
T-cells inactivation by irradiation of2500 cGy to the product for 4.5 min

24. Delayed Non Immunologic (> 24 hr)
Transfusion Reactions

25. Delayed (> 24 hr) Non-Immunologic
Iron overload ( in repeated Tx )
Transfusion Transmitted Infections (TTI)

26. Delayed (> 24 hr) Non-Immunologic
Transfusion Transmitted Infections (TTI)
HBV 1 in 63,000
HCV 1 in 103,000
HTLV-I in 641,000
HTLV-II in 641,000
HIV in 587,000
HIV-2 < 1 in 1,000,000
Since 1999 the risks of infection have been greatly reduced by new laboratory tests (NAT or nucleic acid testing or PCR )

27. Transfusion Transmitted Infections (TTI) Cytomegalovirus (CMV) is important in newborn and infants specially in the CMV seronegative pregnant woman/fetus or premature infants (<1200g) of CMV seronegative mothers.(CMV “safe” blood) For Full term or premature infants of CMV seropositive mothers: ? pre-storage leukoreduced cellular components

28. Conclusion of Tx Rx in new born and infants
Small Blood volume
Passive transfer of maternal antibody
Immature Immune system
CMV , TA-GVHD
Risk of metabolic Complication Ca,K , Glucose , Hypothermia
Cross match with maternal Serum
Use of repeated donors
CMV neg products , Irradiated product

29. Thank You