Resident Readiness General Surgery by Debra Klamen, Brian George, Alden Harken, Debra Darosa Page A
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Pathogens:
A. Bacteria—most bacteria survive happily in blood.
B. Viruses—CMV, Epstein-Barr, hepatitis A, B, and C, HIV-1 and HIV-2, and human T-cell lymphotropic virus (HTLV)-1 and HTLV-2.
C. Parasites—Chagas and malaria.
D. Others: Creutzfeldt-Jakob disease has been associated with lots of things, including blood transfusions.
2. Non–red blood cell culprits:
A. Leukocytes
B. Platelets
C. Immunoglobulins
D. Cytokines
3. Transfusion reactions can be categorized as acute or delayed. Some, like hemolytic transfusion reactions, can be both. This patient had a delayed reaction with likely hemolysis.
Acute Transfusion Reactions
The Centers for Disease Control and Prevention (CDC) have characteristically catalogued these reactions into a sociobiological spectrum:
Level I: No big deal
Presentation: Maculopapular rash, flushing, pruritus, and urticaria.
Response: Give antihistamine and proceed.
Level II: Start to worry
Presentation: Bronchospasm, laryngeal tightness, hoarseness, and stridor.
Response: If possible, abort the transfusion and give β- and α-adrenergic agonists.
Level III: Drama
Presentation: Hypotension, disseminated intravascular coagulation (DIC), and hemoglobinuria.
Response: Stop the transfusion immediately! Give calcium gluconate or calcium chloride (it doesn’t matter which), warm the patient, and give an α- or β-adrenergic agonist.
Delayed Transfusion Reactions
Like people, formed blood elements (leukocytes and platelets) can be happy, irritated, or overtly hostile. Much like a hibernating polar bear, most marginating neutrophils are tough to arouse. But, when you irritate them, they are capable of stirring up a lot of trouble—especially at home. Not surprisingly, self-satisfied quiescent white cells become aggrieved when they are drawn unceremoniously into a plastic, calcium-depleted bag. They get testy. And the longer they hang out in this foreign environment, the less neighborly they get. Your typical blood bank director will therefore not keep blood longer than a 42-day stay.
A transfused activated neutrophil expresses a sticky Velcro of adhesion molecules that facilitates lodging in the pulmonary endovasculature, where they blow big holes and promote interstitial fluid loss. This is the pathogenesis of transfusion-related acute lung injury (TRALI). These same neutrophils can also result in graft-versus-host disease, another type of delayed transfusion reaction that can be seen several weeks after a transfusion. A third type of delayed transfusion reaction is termed “posttransfusion purpura,” which is simply a delayed thrombocytopenia (usually 1 or 2 weeks later). There is no reason to inflict this kind of damage on any patient, so all blood transfusions should be leukodepleted with a filter.
Hemolytic Transfusion Reactions
When an unfortunate patient already has (acute) or develops (delayed) antibodies to ABO-incompatible or other allotypic red cell antigens, rapid red blood cell destruction will ensue. The clinical manifestations of this hemolysis include chills, fever, hypotension, hemoglobinuria, and DIC, which can be most easily recognized by oozing at the IV site.
DON’T BE INTIMIDATED TO GIVE BLOOD
Blood bank directors thrive on detailed complexity. Surgeons like things simple. When your patient requires additional oxygen-carrying capacity, give blood. If you perseverate yourself into paralysis by conjuring all of the catastrophic and cataclysmic components of the contagious colostrum we, with inspirational innocence, term a “blood transfusion,” your patient will succumb to deficient oxygen delivery—while you watch!
TIPS TO REMEMBER
The sole reason to transfuse blood is to increase oxygen-carrying capacity.
All blood transfusions are at least a little mismatched.
Treat minor transfusion reactions with an antihistamine.
Treat major transfusion reactions with α- and β-adrenergic agonists.
With a suspected transfusion reaction, send blood specimens from both the patient
A. Bacteria—most bacteria survive happily in blood.
B. Viruses—CMV, Epstein-Barr, hepatitis A, B, and C, HIV-1 and HIV-2, and human T-cell lymphotropic virus (HTLV)-1 and HTLV-2.
C. Parasites—Chagas and malaria.
D. Others: Creutzfeldt-Jakob disease has been associated with lots of things, including blood transfusions.
2. Non–red blood cell culprits:
A. Leukocytes
B. Platelets
C. Immunoglobulins
D. Cytokines
3. Transfusion reactions can be categorized as acute or delayed. Some, like hemolytic transfusion reactions, can be both. This patient had a delayed reaction with likely hemolysis.
Acute Transfusion Reactions
The Centers for Disease Control and Prevention (CDC) have characteristically catalogued these reactions into a sociobiological spectrum:
Level I: No big deal
Presentation: Maculopapular rash, flushing, pruritus, and urticaria.
Response: Give antihistamine and proceed.
Level II: Start to worry
Presentation: Bronchospasm, laryngeal tightness, hoarseness, and stridor.
Response: If possible, abort the transfusion and give β- and α-adrenergic agonists.
Level III: Drama
Presentation: Hypotension, disseminated intravascular coagulation (DIC), and hemoglobinuria.
Response: Stop the transfusion immediately! Give calcium gluconate or calcium chloride (it doesn’t matter which), warm the patient, and give an α- or β-adrenergic agonist.
Delayed Transfusion Reactions
Like people, formed blood elements (leukocytes and platelets) can be happy, irritated, or overtly hostile. Much like a hibernating polar bear, most marginating neutrophils are tough to arouse. But, when you irritate them, they are capable of stirring up a lot of trouble—especially at home. Not surprisingly, self-satisfied quiescent white cells become aggrieved when they are drawn unceremoniously into a plastic, calcium-depleted bag. They get testy. And the longer they hang out in this foreign environment, the less neighborly they get. Your typical blood bank director will therefore not keep blood longer than a 42-day stay.
A transfused activated neutrophil expresses a sticky Velcro of adhesion molecules that facilitates lodging in the pulmonary endovasculature, where they blow big holes and promote interstitial fluid loss. This is the pathogenesis of transfusion-related acute lung injury (TRALI). These same neutrophils can also result in graft-versus-host disease, another type of delayed transfusion reaction that can be seen several weeks after a transfusion. A third type of delayed transfusion reaction is termed “posttransfusion purpura,” which is simply a delayed thrombocytopenia (usually 1 or 2 weeks later). There is no reason to inflict this kind of damage on any patient, so all blood transfusions should be leukodepleted with a filter.
Hemolytic Transfusion Reactions
When an unfortunate patient already has (acute) or develops (delayed) antibodies to ABO-incompatible or other allotypic red cell antigens, rapid red blood cell destruction will ensue. The clinical manifestations of this hemolysis include chills, fever, hypotension, hemoglobinuria, and DIC, which can be most easily recognized by oozing at the IV site.
DON’T BE INTIMIDATED TO GIVE BLOOD
Blood bank directors thrive on detailed complexity. Surgeons like things simple. When your patient requires additional oxygen-carrying capacity, give blood. If you perseverate yourself into paralysis by conjuring all of the catastrophic and cataclysmic components of the contagious colostrum we, with inspirational innocence, term a “blood transfusion,” your patient will succumb to deficient oxygen delivery—while you watch!
TIPS TO REMEMBER
The sole reason to transfuse blood is to increase oxygen-carrying capacity.
All blood transfusions are at least a little mismatched.
Treat minor transfusion reactions with an antihistamine.
Treat major transfusion reactions with α- and β-adrenergic agonists.
With a suspected transfusion reaction, send blood specimens from both the patient
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