POLSKI

PRZEGLĄD CHIRURGICZNY 10.1515/pjs-2015-0039

2015, 87, 4, 166–173

Analysis of complications after blood components’

transfusions

Dariusz Timler1, Jadwiga Klepaczka2, Anna Kasielska-Trojan3,

Katarzyna Bogusiak4
Department of Emergency Medicine and Disaster Medicine Medical University in Łódź1
Kierownik: prof. dr hab. T. Gaszyński
Department of Diagnostics, Copernicus Memorial Hospital in Łódź2
Kierownik: mgr. E. Sobolewska
Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University in Łódź3
Kierownik: prof. dr hab. B. Antoszewski
Department of Cranio-Maxillofacial and Oncological Surgery, Medical University in Łódź4
p.o. Kierownika: dr A. Neskoromna-Jędrzejczak

Complications after blood components still constitute an important clinical problem and serve as
limitation of liberal-transfusion strategy.
The aim of the study was to present the 5-year incidence of early blood transfusions complications
and to assess their relation to the type of the transfused blood components.
Material and methods. 58,505 transfusions of blood components performed in the years 2006-2010
were retrospectively analyzed. Data concerning the amount of the transfused blood components and
the numbers of adverse transfusion reactions reported to the Regional Blood Donation and Treatment
Center (RBDTC) was collected.
Results. 95 adverse transfusion reactions were reportedto RBDTC 0.16% of alldonations (95/58 505) – 58
after PRBC transfusions, 28 after platelet concentrate transfusions and 9 after FFP transfusion. Febrile
nonhemolytic and allergic reactions constitute respectively 36.8% and 30.5% of all complications.
Conclusion. Nonhemolyticand allergic reactions are the most common complications of blood compo-
nents transfusion and they are more common after platelet concentrate transfusions in comparison to
PRBC and FFP donations.
Key words: blood components, transfusions, complications

In the last decades new screening proce- (HTLV)-1 and -2, West Nile virus, Treponema
dures and tests were implemented to improve pallidum (syphilis), Trypanosoma cruzi (Chagas
the safety of blood transfusions. However be- disease), and cytomegalovirus (CMV). Other
cause of the most recent risks and threats, a infectious threats include Babesia, Plasmodi-
zero-risk blood supply is still nearly impossible ums (malaria), prions (variant Creutzfeldt-
(1). Transfusion complications can be catego- Jakob disease), hepatitis A virus and human
rized into infectious and noninfectious: im- herpes virus 8. Although various methods of
munologic and non-immunologic. The risk of pathogen inactivation are under investigation
infections cannot be eliminated completely, their efficacy and effect on the quality of blood
because of window periods during which patho- products need to be determined (3).
gens are not detectable and because of the risk Bacterial infections (TTBI) also create an
of new pathogens emerging (2). Currently, infec- important issue in blood transfusions.The in-
tious agents for which donated blood can be cidence of TTBI is higher than the incidence
tested include hepatitis B (HBV) and C (HBC), of transfusion transmitted viral infection (4,
HIV-1 and -2, human T-cell lymphotropic virus 5, 6). Many studies showed that the most com-

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 Analysis of complications after blood components’ transfusions 167

mon bacterial contaminants in case of red Material and methods

blood cell concentrates (RBCC) are: Yersinia
enterocolitica (51% of all bacterial infections), We analyzed 58,505 transfusions of blood
Pseudomonas fluorescens (26.5%), Pseudomo- components performer in the years 2006-2010
nas putida (4.1%) and Treponema palidum in the Copernicus Memorial Hospital in Łódź,
(4.1%) (7, 8). Different bacteria are responsible which has about 1,000 beds on different wards,
for platelet concentrates (PC) contamination: including 9 surgical wards and a Regional
Corynebacterium sp. (36.5%) Staphylococcus Cancer Centre with a Department of Hematol-
epidermidis (25%), Salmonellscholeraesuis ogy. This retrospective research has IRB ap-
(13.5%), Serratia marcescens (9.6%), Staphy- proval No RNN/485/13/KB. Data concerning
lococcus aureus, Bacillus cereus and Strepto- the amount of the transfused blood components
coccus viridans group (7). and the number of adverse transfusion reac-
It was estimated that in the United States tions reported to the Regional Blood Donation
bacterial contamination of transfusion prod- and Treatment Center in Łódź (RBDTC) was
ucts is the second most common cause of death collected. The analysis of transfusion complica-
from transfusion (mortality rates from 1/20,000 tions was performed for: surgical wards (to-
to 1/85,000 donor exposures) (8). However, due gether and separately for the Department of
to the recent strategies in blood donation and Surgical Oncology), internal medicine wards
newest technologies in pathogens inactivation (together and separately for the Department
the rate of transfusion transmitted bacterial of Hematology), oncology wards, Intensive
infection has decreased. Care Unit and Emergency Department.
According to some studies, risks of infection A criterion of hemoglobin concentration of
per blood unit range from 1:100,000 to 1:400,000 less than 6 g/dL in combination with symptoms
for HBV, 1:1,600,000 to 1:3,100,000 for HCV, of severe hemorrhagic diathesis was adopted
1:1,400,000 to 1: 4,700,000 for HIV, 1:500,000 as the indications for transfusion of packed red
to 1: 3,000,000 for HTLV, and 1:4,000,000 for blood cells (PRBC) in patients with chronic
malaria (9). Bacterial contamination is esti- diseases in the study. In the event of a sudden
mated for approximately 1:60,000 units of loss of 1500-2000 mL of blood, a PRBC trans-
RBCC and is more common in apheresis plate- fusion was indicated in patients with signs of
lets (1:8000) (10). According to the UK’s Seri- cardiac decompensation without prior anemia.
ous Hazards of Transfusion (SHOT) 2010 re- The loss of 40% (> 2000 mL) of circulating blood
port, no confirmed case of transfusion-trans- volume was treated as an absolute indication
mitted infection was detected. However, non- for rapid transfusion of PRBC preparations.
infectious risks and complications of blood For platelet preparations, the indications for
transfusion have taken the lead (11). administration was platelet count of less than
Noninfectious risks of transfusion are far 20,000/µL in patients with acute leukemia and
more common and usually more severe. They those after transplantation of hematopoietic
can be grouped under immunologic (hemolytic stem cells, with concomitant bleeding or below
and non-hemolytic transfusion reactions, al- 10,000/µL in stable patients. Transfusion of
lergic and anaphylactic reactions, multiple fresh frozen plasma (FFP) was performed in
organ failure, immunomodulation, HLA al- patients with coagulation disorders and those
loimmunization, autoimmunization RBC, with symptoms of bleeding disorders. The final
transfusion-associated graft versus host decision on a particular blood component
disease,transfusion-associated acute lung in- transfusion was taken on the basis of the pa-
jury) and non-immunologic (febrile non-hemo- tient’s general state, clinical symptoms and
lytic transfusion reactions RBC storage the patient’s adaptation to the decreased val-
lesions,circulatory overload, iron overload, ues of blood counts.
metabolic disturbances) complications. All the transfused PRBC were without buffy
The aim of the study was to presentthe 5- coat and all platelet concentrates were fil-
year incidence of early blood transfusions tered– according to RBDTC issues only buffy-
complications and to assess their relation to coat deprived PRBC preparations and platelet
the type of the transfused blood components in concentrates subjected to previous filtration
the Copernicus Memorial Hospital in Łódź. are donated. In the Department of Hematol-
ogy, in immunosuppressed and immunocom-

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168 D. Timler et al.

promised recipients, most cell concentrates than platelet concentrates. There was a statis-
were irradiated in order to minimize the risk tically significant correlation between the fre-
of TA-GvHD. quency of early transfusion complications and
Of the 58,505 transfused blood components, the type of blood component used in the five-
68.96% (40 348/58 505) were PRBC and 13.22% year observation period. Significantly higher
(7 734/58 505) were platelet concentrate incidence of adverse transfusion reactions was
preparations. Platelet preparations were ob- observed after platelet preparations than for
tained with two methods – by apheresis or from PRBC (p <0.001) and FFP transfusions (p
buffy coat with ORBISAK apparatus. The re- <0.001), as shown in tab. 1.
maining 17.82% (10 423/58 505) were plasma From early adverse transfusion reactions
transfusions. we observed: febrile non-hemolytic reactions,
Inthe event of an adverse transfusion reac- allergic reactions, anti-HLA antibodies produc-
tion, a procedure in accordance with thehospi- tion, symptoms such as pulmonary edema,
tal standards designed on the basis of the shortness of breath, heart failure, transfusion
Minister of Health Regulation was under- of AB0-incompatible blood components and in
taken – documentation and patient blood one patient we observed symptoms, suggesting
sampleas well as the transfused blood sample bacterial complication. After PRBC transfu-
were provided to the Regional Centre. Among sions, the most common complications (22
the adverse transfusion reactions, only early cases) were febrile non-hemolytic reactions.
reactions that can be detected during hospi- More rarely the cause of adverse PRBC reaction
talization, were noted. were anti-HLA antibodies produced by the pa-
tient (12 cases) and allergic reactions (12 cases).
Platelet concentration transfusions caused al-
Statistical Analysis lergic reactions more often (12 cases) than the
febrile non-hemolytic reactions (11 cases). Only
To seek the relationship between the data, in 4 cases the transfusion reaction involved the
chi2 test of independence was used. The thresh- production of anti-HLA antibodies in the re-
old for statistical significance was the value of cipient. Allergic reactions were the most com-
p ≤0.05. mon cause of reactions after FFP transfusions
and occurred in 5 patients. There was one case
of transfusion of an AB0-incompatible blood
Results component. FFP group 0 was transfused to a
group B recipient. There were no symptoms
Annually,approximately 9000 units of associated with the effect of the transfused
PRBC, 2,000 platelet donations and 3,000 FFP anti-B antibodies to the recipient red blood cells.
donations were transfused in the hospital. On Statistical analysis of the incidence of complica-
average, 20 adverse transfusion reactions were tions in relation to the type of blood components
reported each year. Five-year analysis of data showed that platelet concentration transfusions
on early transfusion complications showed that were associated with a significantly higher risk
in the years 2006-2010, 95 adverse transfusion of developing a febrile non-hemolytic reaction
reactions were reported to RBDTC – 58 after and allergic reaction, as compared with PRBC
PRBC transfusions, 28 after platelet concen- (p<0.01 and p<0.001) and FFP transfusions
trate transfusions and 9 after FFP transfusion. (p<0.001 and p<0.05). Platelet concentration
In relation to the total number of the trans- transfusions significantly more often caused
fused blood components, adverse reactions HLA antibodies production, as compared to
were reported after 0.16% of all donations FFP administration (p<0.05) (tab. 2).
(95/58 505). Most complications occurred after Department of Hematology transfused the
platelet concentration transfusions and con- largest amounts of blood components. Within
cerned approximately 0.36% of cases. Although the analyzed 5 years, transfusions on this ward
complications after PRBC transfusions oc- accounted for approximately 34% (19 900/58
curred only in 0.14% of cases, they constituted 505) of all blood components transfused in the
the largest group of reactions reported to RB- Copernicus Memorial Hospital. Transfusions
DTC due to the overall number of transfusions in the Department of Hematology accounted
– PRBC were transfused 5 times more often for almost 30% (11 997/40 348) of PRBC trans-

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 Analysis of complications after blood components’ transfusions 169

fusions, 88.8% (6 869/7 734) of plate-

chi2 significance

chi2 significance chi2 significance chi2 significance

Table 1. Number of transfused blood components and early transfusion complicationsreported to Regional Blood Donation and Treatment Center in the years 2006-2010

let concentrate transfusions and

p<0,001

p<0,001

p<0,001
p>0,05

p>0,05
p>0,05
p>0,05

p<0,05
p<0,05
p>0,05
p>0,05
p>0,05
approximately 9.92% (1 034/10 423)
PC – FFP

PC – FFP
of all FFP transfusion. The number
of adverse reactions in the Depart-
13,228

16,593

11,825
2,602

1,817
0,985
2,230

5,452
5,392
0,710
0,742
ment of Hematology in this period

Comparison of blood components

-
accounted to 54, which constituted
Statistical analysis

approximately 57% (54/95) of all

chi2 significance
p>0,05
p>0,05
p>0,05
p>0,05
p>0,05
p>0,05
confirmed adverse transfusion reac-

p>0,05
p>0,05
p>0,05
p>0,05
p<0,05
p>0,05
PRBC – FFP
PRBC – FFP

tions in the Hospital. Only 11.2% of

platelet concentrations were trans-
fused to recipients outside the He-
1,795
1,694
0,892
0,744
0,055
2,070

3,692
0,823
3,105
1,096
3,874
0,260
matology Department. However, the
Table 2. Analysis of adverse transfusion reactions frequency in relation to blood component

number of adverse reactions after

chi2 significance

transfusion of platelet concentrates

0,23 15,461 p<0,001
p<0,001

17,322 p<0,001

p<0,001
p>0,05

p>0,05
p>0,05

p<0,01

p>0,05
p>0,05
p>0,05
p>0,05
PRBC – PC

PRBC – PC

on wards other than the Department

of Hematology accounted for only
approximately 10% of all complica-
0,21 0,525

0,15 8,478
0,17 0,144
0,09 2,949

5,26 20,463
1,05 7,280

0,940
1,05 0,001

0,190 tions after transfusion of this blood

-

component. Among other wards of

the Copernicus Memorial Hospital,
1,05
%

particularly high numbers of trans-

total

FFP

fusions were carried out in 2 surgical

20
23
19
20
13
95

n
22 23,16 11 11,58 1
12 12,63 12 12,63 5
0
1
1
0
n

departments (Department of Endo-

Number of transfusion complications

Blood components
Note: n – number, PRBC – Packed Red Blood Cells, PC – Platelet Concentrate, FFP – Fresh Frozen Plasma

Note: n – number, PRBC – Packed Red Blood Cells, PC – Platelet Concentrate, FFP – Fresh Frozen Plasma

crine Surgery, Department of Vas-

4,21
2,11
0,05
0,17
0,09
0,06

0
0

cular, General and Oncologic Sur-

%

PC
FFP

gery) and in the Department of In-

n

12 12,63 4
11 11,58 2
0
0

tensive Care Medicine and Anesthe-

n

1
4
2
2
9
-

siology. Total number of transfusions

1,05
%

performed in patients on surgical

PRBC
0,30
0,84
0,39
0,23
0,22
%

wards in the years 2006 – 2010 was

PC

0
1

22 990 (15 293 PRBC units, 2 229

29

platelet concentrates and 5 468 FFP

n
5
9
7
3
4

donations), which represented ap-

0,20
0,18
0,10
0,18
0,08

proximately 40% of all transfusions.

%
PRBC

More than 52% of FFP units trans-

fused in the hospital were adminis-
15
13

15

60
n

tered to recipients from these wards.

Pulmonary edema, shortness of breath, heart failure
Transfusion of AB0-incompatible blood components

Nevertheless, adverse reactions oc-

Adverse transfusion reactions
10304
12417
11933
13908
58505
9943
total

curred in only 20 cases on these

wards, which represented approxi-
Number of donations

mately 21% of all reported adverse

10423
1976
2339
2136
3092
FFP
880

transfusion reactions. In the Depart-

ment of Intensive Care Medicine and
Anty-HLA antibodies production

Anesthesiology there was no adverse

Febrilenon hemolytic reactions
1694
1072
1802
1333
1833
7734
PC

Suspected bacterial infection

reaction observed after FFP dona-

tions (fig. 1).
Statistical analysis disclosed that
PRBC

40348
7369
7256
8276
8464
8983

in departments of Internal Medicine

Allergic reactions

(the Department of Hematology was

included in this group) and in Depart-
ment of Hematology separately,
Year

complications were observed signifi-

Total
2006
2007
2008
2009
2010

cantly more often than in surgical

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170 D. Timler et al.

Anesthesiology, adverse transfusion reactions

after FFP donations were observed with similar
frequency (p<0.05). No statistical difference
was observed among departments in frequency
of complications after platelet concentrate
(p>0.05) (tab. 3).

Discussion

In recent years a great progress was made

in blood components preparation technologies,
however, complications after their transfusion
still constitute an important clinical problem
and serve as limitation of liberal-transfusion
strategy. The data from the UK’s Serious Haz-
ards of Transfusion (SHOT) (2010) showed that
505 serious complications and events resulting
in 4.5 deaths and 35 major morbidities were
reported per 1 million units of blood component
issued (11). The report presents a relatively low
incidence of complications, however the fre-
quency of unfavorable outcomes associated with
allogeneic blood transfusions observed in many
studies examining specific groups of patients is
much higher (12-23). In the analyzed group of
patients the incidence of early adverse transfu-
sion reactions was 0.16%, however it is difficult
to interpret this rate and compare it with the
values presented in the literature as it depends
on the hospital profile, transfusion strategy and
reporting programs. Different programs of
documenting complications result in the fact
that some of them [e.g. transfusion-related
acute lung injury (TRALI)] are vastly under-
diagnosed and under-reported (24, 25). How-
ever as concluded by Shander et al. these sta-
tistics provide an overall picture of the preva-
and oncological departments (p<0.001 and lence of complications and risks of blood
p<0.05). The frequency of adverse transfusion transfusions and their consequences (26).
reactions in departments of Internal Medicine It was estimated that a single noninfectious
and the Department of Hematology was similar complication [eg, transfusion-related acute
(p>0.05). There was a significantly higher inci- lung injury (TRALI)] occurs in 1 case per every
dence of adverse reactions in patients treated 5000 units of blood component transfused (25).
in the Department of Oncological Surgery than Febrile non-hemolytic transfusion reaction is
in other surgical departments altogether known to be the most common cause of trans-
(p<0.05). Complications after PRBC donations fusion-associated fever and occurs in 0.1% to
occurred significantly more often in depart- 1% of RBC transfusions (27). The same obser-
ments of Internal Medicine (with Department vation was made on the basis of our material
of Hematology included to this group) and in analysis, as the most common complications
the Department of Hematology separately in were febrile non-hemolytic reactions and al-
comparison to surgical departments (p<0.01 lergic reactions, which constituted 35.79% and
and p<0.01). In all departments, except for the 30.53% of all noted reactions. Moreover, there
Department of Intensive Care Medicine and was a significantly higher incidence of these

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 Analysis of complications after blood components’ transfusions 171

Table 3. Comparison of adverse transfusion reactions in relation to type of blood component and department
on which the transfusion had place

Statistical analysis
Departments PRBC PC FFP Total
chi2 significance chi2 significance chi2 significance chi2 significance
Internal Medicine vs Surgery 8,582 p<0,01 1,597 p>0,05 2,422 p>0,05 16,615 p<0,001
Internal Medicine vs Oncologic 0,002 p>0,05 0,154 p>0,05 0,327 p>0,05 0,003 p>0,05
Surgery
Internal Medicine vs Emergency 0,219 p>0,05 0,071 p>0,05 0,723 p>0,05 1,140 p>0,05
Department
Internal Medicine vs Oncology 2,999 p>0,05 0,063 p>0,05 0,000 p>0,05 3,953 p<0,05
Internal Medicine vs Intensive Care 0,001 p>0,05 0,990 p>0,05 4,645 p<0,05 2,515 p>0,05
Medicine
Hematology vs Surgery 7,199 p<0,01 1,518 p>0,05 3,807 p>0,05 17,534 p<0,001
Hematology vs Oncologic Surgery 0,001 p>0,05 0,157 p>0,05 0,032 p>0,05 0,031 p>0,05
Hematology vs Emergency 0,193 p>0,05 0,073 p>0,05 1,003 p>0,05 1,258 p>0,05
Department
Hematology vs Oncology 2,656 p>0,05 0,074 p>0,05 0,083 p>0,05 4,409 p<0,05
Hematology vs Intensive Care 0,002 p>0,05 0,944 p>0,05 6,441 p<0,05 2,880 p>0,05
Medicine
Surgery vs Emergency Department 0,168 p>0,05 0,176 p>0,05 0,252 p>0,05 0,003 p>0,05
Surgery vs Oncology 0,027 p>0,05 0,990 p>0,05 0,960 p>0,05 0,269 p>0,05
Surgery vs Intensive Care Medicine 3,502 p>0,05 0,040 p>0,05 1,624 p>0,05 0,751 p>0,05
Oncologic Surgery vs Emergency 0,157 p>0,05 0,000 p>0,05 1,180 p>0,05 0,901 p>0,05
Department
Oncologic Surgery vs Oncology 1,223 p>0,05 0,119 p>0,05 0,166 p>0,05 1,666 p>0,05
Oncologic Surgery vs Intensive Care 0,001 p>0,05 0,408 p>0,05 7,575 p<0,01 1,038 p>0,05
Medicine
Emergency Department vs Oncology 0,094 p>0,05 0,055 p>0,05 0,719 p>0,05 0,059 p>0,05
Emergency Department vs Intensive 0,188 p>0,05 0,190 p>0,05 0,000 p>0,05 0,149 p>0,05
Care Medicine
Oncology vs Intensive Care Medicine 1,831 p>0,05 0,858 p>0,05 4,622 p<0,05 0,081 p>0,05
Internal Medicine without 0,069 p>0,05 0,540 p>0,05 0,706 p>0,05 0,591 p>0,05
Hematology vs Hematology
Surgery without Oncologic Surgery vs 2,676 p>0,05 0,233 p>0,05 6,456 p<0,05 5,806 p<0,05
Oncologic Surgery
Internal Medicine without 7,410 p<0,01 1,601 p>0,05 0,760 p>0,05 7,093 p<0,01
Hematology vs Surgery without
Oncologic Surgery
Note: n – number, PRBC – Packed Red Blood Cells, PC – Platelet Concentrate, FFP – Fresh Frozen Plasma

adverse transfusion reactions after platelet group 0 was transfused to a group B recipient.
concentrate transfusions in comparison to We did not observed any symptoms associated
PRBC and FFP donations. with the effect of the transfused anti-B anti-
Delayed hemolytic reactions occurrence is bodies to the recipient red blood cells. The only
estimated for approximately 1 out of 1000 to detectable reaction was positive direct anti-
1 out of 9000 RBC units transfused while acute globulin test, persisting for several days after
hemolytic reactions due to AB0-incompatible the transfusion.
blood resulting from transfusion errors is ob- Although non-infectious complications of
served in approximately 1:30,000 transfusions. blood transfusion are considerably more com-
According to the SHOT 2010 report, 345 criti- mon and according to the SHOT 2010 report
cal transfusion errors occurred per 1 million no transfusion-transmitted infection was de-
units of blood component issued (11). In our tected, such risk needs to be mentioned. The
material there was one case of transfusion of incidence of bacterial contamination is much
an AB0-incompatible blood component. FFP higher in case of platelets donations while

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172 D. Timler et al.

minimal for RBC units (10). Such complica- (TRALI) and nearly zero per million units for
tions may result from the fact that the stan- the rest (11).
dard procedure for blood preparation cannot To sum up, it can be seen from the study
eliminate the risk completely, because of that non-hemolytic and allergic reactions are
pathogens window periods and some new the most common complications of blood com-
pathogens emerging. In our analysis, we sus- ponents transfusion and they are more com-
pected transfusion-transmitted bacterial infec- mon after platelet concentrate transfusions in
tion in one patient after PRBC donation. comparison to PRBC and FFP donations. Al-
Complications such as: transfusion-associ- though strict procedures are applied during
ated acute lung injury (TRALI), post-transfu- blood donations preparations and transfusions,
sion purpura, acute hemolytic reactions, ana- errors in transfusion and infection complica-
phylactic shock, septic shock did not occur in tions still serve a problem in clinical practice.
our patients. This observation is consistent We also found that the Department of Hema-
with the data presented in the literature as tology is leading in the number oft ransfusions
such complications are rare: 20 per 1 million performed, with the highest rate of early ad-
units (hemolytic reactions), 5 per million units verse transfusion reactions.

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