The most common complications of transfusion are febrile non-hemolytic reactions chills-rigor reactions of the most serious complications that are associated with high mortality, including transfusion-associated circulatory overload transfusion-related acute lung injury Acute hemolytic reaction due to AB0 incompatibility symptoms that indicate a transfusion reaction, should are detected as early as possible and reported to the blood bank immediately. Most commonly, chills, rigors, fever, dyspnea, dizziness, urticaria, itching and flank pain occur as symptoms. Upon the occurrence of these symptoms (other than localized urticaria, itching), the transfusion should be stopped immediately and intravenous access is kept open with normal saline. The rest of the blood product and blood samples of the patients (with and without anticoagulant) should be sent for further review to the blood bank. Minweis: The unit of blood in question should not be transfused and waives the transfusion further originally planned transfusions. More transfusions should be delayed until the reason for the reaction is clear, unless the transfusion is absolutely necessary. In this case, the blood of the group should be 0 Rh negative uses. Hemolysis of red blood cells of the donor or the recipient (usually of donor erythrocytes) during or after transfusion can (through a AB0 / Rh incompatibility, antibodies in the plasma or hemolyzed or fragile RBCs for. Example by overheating of the stored blood or contact with hypotonic iv solution) is caused. Hemolysis occurs most frequently and is most difficult when incompatible donor RBCs are hemolyzed by antibody in the plasma of the recipient. Hemolytic reactions can acutely (within 24 h) and delayed development (within 1-14 days). Acute hemolytic transfusion reactions (AHTR) in the US die each year about 20 people at a AHTR. The AHTR usually caused by antibodies against the donor red cell antigens in the plasma of the recipient. The AB0-incompatibility is the most common reason for AHTR, but also antibodies against other blood group antigens as the AB0 can trigger a AHTR. The false labeling of certain of the blood bank blood sample receiver during the acceptance or the lack of balance between the recipient and blood product immediately prior to transfusion are the most common reasons. Hemolysis occurs intravascularly and leads to hemoglobinuria with acute renal failure varying degrees and may cause disseminated intravascular coagulation (DIC). The severity of AHTR depends on the degree of incompatibility, the amount of administered blood, the speed of administration and the functional state of kidney, liver and heart. The acute phase usually occurs within 1 hour after transfusion beginning. However, it can also later during the transfusion or use immediately. The onset is usually abrupt. The patient may experience discomfort here and restlessness or anxiety. It may dyspnea, fever, chills, a flush symptoms and severe pain, especially in the lumbar region, occur. It can also develop a shock symptoms with rapid, weak pulse, cold, moist skin, low blood pressure, nausea and vomiting. After the acute hemolysis jaundice may occur. If a AHTR as part of general anesthesia developed, the only symptoms may be a hypotension, uncontrolled bleeding at incision sites or mucous membranes by DIC occurring or dark urine (hemoglobinuria). Suspicion of AHTR one of the first steps should be to compare the data on the transfusion bag with those of the patient. The diagnosis is confirmed by a positive direct antiglobulin test, a measurement of the Hb-value in the urine, serum LDH, bilirubin and haptoglobin. The haptoglobin are greatly reduced. Intravascular hemolysis resulting in free hemoglobin in plasma and urine. As a result, hyperbilirubinemia may occur. After the acute phase, the extent of acute renal failure determines the prognosis. The resumption of diuresis and falling urea values ??indicate usually point to a recovery. A permanent renal failure is unusual. Prolonged oliguria or shock symptoms is considered a bad prognostic sign. If a AHTR suspected, the transfusion should be stopped and the supportive care measures are initiated. The goal of initial treatment is to achieve and maintain an adequate blood pressure and an adequate renal perfusion with i.v. administered 0.9% saline solution and furosemide. Intravenous saline is administered to maintain a urine production of 100 ml / h over 24 hours of time. The initial dose of furosemide is 40-80 mg (1-2 mg / kg in children). Subsequent doses are adjusted so that a urine production of> 100 ml / h is ensured during the first day. In the drug treatment of hypotension must be done carefully. Pressor drugs that reduce renal blood flow (epinephrine, norepinephrine, high-dose dopamine) are contraindicated. but if they are necessary, dopamine is usually at a dosage of 2-5 g / kg / min administered. It should be quickly consulted a nephrologist, especially if no diuresis can be observed within the first 2-3 hours after initiation of therapy, which may indicate an acute tubular necrosis. The additional administration of fluids and diuretic therapy may be contraindicated here, early dialysis, however helpful. Delayed transfusion reaction Occasionally, patients who have been sensitized in the past against an erythrocyte antigen, only very low levels of antibodies on, so that the test results are negative before transfusion. After a transfusion containing erythrocytes with the corresponding antigens, may be primary or only a history tangible caused a delayed hemolytic transfusion reaction (usually within 1-4 weeks). This usually does not manifest itself as dramatic as the AHTR. Patients may be asymptomatic or have mild fever. Severe symptoms are rare. Usually only a destruction of the transfused RBCs (with the antigen) occurs, resulting in a falling hematocrit, a slight increase in LDH and bilirubin and a positive direct antiglobulin test. Since the delayed hemolytic transfusion reaction usually turns slightly and self-limiting, it often goes undetected. The only clinical indication may be an unexplained drop in hemoglobin value against the values ??before transfusion 1-2 weeks after transfusion. Severe reactions are treated in a similar manner to acute reactions. Febrile non-hemolytic transfusion reaction febrile reactions can occur without hemolysis. One of the reasons is the presence of antibodies directed against the HLA characteristics of leukocytes of an otherwise suitable blood donor. This is especially common in several occasions transfused patients or after several pregnancies. Cytokines which are released during storage of leukocytes, in particular in platelet concentrates, are another possible cause. Clinically, the fever response is by a temperature increase of ? 1 ° C, chills, and sometimes also characterized header or back pain. Often symptoms occur simultaneously on an allergic reaction. Because fever and chills may be the harbinger of severe hemolytic transfusion reaction, fever reactions as well AHTR and all other transfusion reactions should be closely investigated. Most febrile reactions can be treated with acetaminophen and diphenhydramine if required. Patients with such reactions should be treated accordingly prophylactically before any further transfusions (z. B. with acetaminophen). If at a receiver more than a fever reaction has occurred, special filters should be used for leukocyte reduction for future transfusions. Most hospitals already use leukozytenreduzierte blood components. Allergic reactions Allergic reactions to an unknown component in donor blood are common, usually due to an allergen in the plasma of the donor and rarely due to an allergic antibodies donor. These reactions are usually mild and manifest themselves in the form of urticaria, edema and occasionally dizziness and headache during or immediately after the transfusion. Often fever occurs simultaneously. Less frequently it comes to symptoms such as dyspnea, bronchoconstriction or incontinence, which point to a generally smooth muscle spasm. Anaphylactic shock occurs especially in recipients with an IgA deficiency, however, is very rare. In patients with allergy or allergic transfusion reactions in the history an antihistamine may be administered prophylactically shortly before or at the start of transfusion (eg. As diphenhydramine 50 mg p.o. or i.v.). Note: medications should never be mixed with the transfused blood. Upon the occurrence of an allergic reaction, the transfusion is stopped. Most an antihistamine ranges (z. B. diphenhydramine 50 mg i.v.) in order to treat a slight urticaria and itching, and the transfusion can be continued. However, a moderate allergic reaction (generalized urticaria or lighter bronchospasm) requires the administration of hydrocortisone (100-200 mg i.v.). If a severe anaphylactic response, should also adrenaline 0.5 ml of a 1: 1000 solution s.c. and physiological saline i.v. (Anaphylaxis: therapy) can be administered. Simultaneously, a clarification of transfusion reaction by the blood bank is necessary. There should be no further transfusions prior to the conclusion of these investigations. In patients with severe IgA deficiency washed platelets and plasma from a donor with IgA deficiency are for transfusion washed red blood cell concentrates needed. Although the volume overload volume overload is too rarely recognized and reported, it is currently the second leading cause of transfusion-related deaths (20%), which were reported to the FDA. The osmotic pressure of blood products makes over a period of hours for a fluid shift into the intravascular space. This may result (eg. As with heart or renal failure) to a volume overload in susceptible patients. Erythrocyte concentrates should be transfused slowly. Careful monitoring of the patient is crucial. If signs of heart failure occur (such as dyspnea and moist rales), the transfusion must be stopped and cardiac emergency measures initiated. Typically, the treatment in the administering of diuretics such. As furosemide 20-40 mg iv Occasionally, patients need a greater amount of plasma infusions to treat a Warfarinüberdosierung. The simultaneous use of low-dose furosemide may be useful here; However, the prothrombin complex concentrate (PBSB) is the first choice for such patients. Patients with high risk of volume overload (for. Example, in congestive heart failure or severe renal failure) can be prophylactically treated with a diuretic (z. B. furosemide 20-40 mg i.v.). Pulmonary transfusion reactions caused by a transfusion pulmonary reaction occurs only very rarely. It is caused by anti-HLA and / or anti-Granulozytenantikörper in the plasma of the donor. These result in agglutination and degranulation of Empfängergranulozyten in the lungs. It occurred acute respiratory symptoms, and a chest X-ray shows characteristic changes of a nichtkardial induced pulmonary edema. This complication is the most common cause of transfusion-related deaths (45% of deaths that have been reported to the FDA). The incidence is 1: 5000 to 1: 10,000, but most cases are mildly. Mild to moderate transfusion-related pulmonary reaction may often not be detected. General supportive measures usually lead to recovery without sequelae. The use of diuretics should be avoided. Donor blood of men reduces the risk of such a reaction. The cases should be reported to the transfusion medicine service of the hospital or blood bank. Altered oxygen affinity A storage of blood over the period> 7 days leads to a reduction of red cell 2,3-Diphosphoglycerats (DPG), 2,3-DPG is no longer detectable in> 10 days. This deficiency leads to increased affinity for O2 and O2 a slower release into the tissues. There are few indications that a 2,3-DPG deficiency is clinically significant, except for exchange transfusion in neonates and patients with sickle cell disease in which acute chest syndrome, stroke or severe heart failure is present. After transfusion of packed red blood cells, the 2,3-DPG regenerated within 12-24 h. Graft-versus-host disease (GVHD) The transfusional GVHD (Other complications) usually occurs then when an immunocompromised recipient receives transfusions of immunocompetent lymphocytes. These donor lymphocytes attacking the tissue of the recipient. GVHD can occur occasionally in immunocompetent patients when blood of a (usually nearby related) donor is transfused, the homozygous for an HLA haplotype, but the patient is heterozygous. The clinical symptoms include fever, rash (from rashes that spread Peripherals Windwärts, a erythroderma developed blisters), vomiting, watery and bloody diarrhea, lymphadenopathy and pancytopenia due to bone marrow aplasia. Often jaundice and elevated liver enzyme levels are found. GVHD occurs 4-30 days after a transfusion. If a clinical suspicion, the diagnosis is confirmed by a skin and bone marrow biopsy. GVHD has a mortality rate of> 90%, as no specific treatment exists. As prevention against a GVHD blood products can be irradiated (destruction of the DNA of the donor lymphocytes). This should take place if the recipient is immunocompromised (eg., Patients with hereditary immune deficiency syndromes, hematological malignancies, hematopoietic stem cell transplantation, newborns) if the donor is a relative of the first degree, or when HLA-matched blood components (no stem) transfused become. Treatment with corticosteroids or other immunosuppressive drugs, including those that are used in the transplantation of solid organs, is not an indication for irradiation of blood products. Complications of massive transfusion as massive transfusion is defined as the transfusion of a blood volume greater than or equal to the total body blood volume within 24 h (z. B. 10 units for an adult of 70 kg). In a standard fluid replacement with red blood cell concentrates (colloid) and crystalloids (Ringer’s lactate or normal saline) in such a volume, the plasma coagulation factors and platelets are diluted, which has a coagulation disorder (dilutional coagulopathy) result. This clotting disorder exacerbates the DIC caused by severe trauma (i. E. As a result of a significant activation of the coagulation cascade) and results in leading to death triad of acidosis, hypothermia and bleeding. Recently, protocols for mass transfusions were developed in which fresh frozen plasma and platelets are early added to a fluid replacement; so coagulopathy should be prevented, rather than trying to “stop”. This mortality could be reduced, with the perfect amount of red blood cells, plasma and platelets has yet to be developed. Current recommendations are that a unit plasma and platelet concentrate per two units will give erythrocytes. Hypothermia as a result of rapid transfusion of large Menger cold blood can lead to heart arrhythmias and even cardiac arrest. It can be avoided by a transfusion equipment is used with a heat exchanger, which allows a cautious warming of the blood. Other methods for heating of the blood (eg. As microwaves) are contraindicated because of the potential damage to red blood cells and hemolysis. Toxicity by supplying citrate and potassium are not significant even at mass transfusions usually. However, there is a hypothermia, increased hazards that may exist by these substances. In patients with hepatic insufficiency problems in the metabolism of citrate may occur. A resulting hypocalcemia rarely requires treatment. If necessary, 10 ml of a 10% Kalziumglukonatlösung can (diluted to 100 ml with a 5% dextrose solution, D5W) can be administered over 10 minutes. In patients with renal insufficiency may lead to hyperkalemia, when blood is used which has been stored for more than 1 week. For shorter stored blood potassium enrichment is mostly irrelevant. The mechanical hemolysis during transfusion can increase the level of potassium levels. Hypokalemia can about 24 hours after a transfusion of packed red blood cells older (> 3 weeks) occur because these erythrocytes absorb potassium. Infectious complications Bacterial contamination of packed red blood cells occurs very rarely, perhaps due to the inadequate aseptic technique during collection or temporary asymptomatic bacteremia of the donor. bacterial growth is usually inhibited by cooling the packed red blood cells. Exceptions are cryophilic organisms such. As Yersinia sp., The dangerous amounts can produce endotoxin. All packed red blood cells are checked for bacterial growth before their release, which is manifested by a change in color. Since platelet concentrates are stored at room temperature, the risk of bacterial growth and endotoxin is increased when a contamination. In order to minimize the growth of bacteria, platelet concentrates should not be stored longer than 5 days. The risk of bacterial contamination of platelets is 1: 2500th Therefore, platelets are routinely tested for bacterial contamination. In rare cases, transmission of syphilis by fresh blood or platelets occurs. A storage of the blood for ? 96 hours at 4-10 ° C kills the spirochetes. Although statutory regulations stipulate the serological test for syphilis of donor blood is to remember that infected donors are seronegative during the early phase of the disease. Recipients of infected units may develop the characteristic lesions of the secondary stage of syphilis. Hepatitis may occur after transfusion of blood products of any kind. However, the risk has been reduced by the virus inactivation by heat treatment of serum albumin and plasma proteins as well as through the use of recombinant clotting factor concentrates. Tests for hepatitis are compulsory for all blood donors (see table: testing for infectious diseases). The risk for infection with hepatitis B is 1: 500,000 for hepatitis C in 1: 2.6 million Hepatitis A (infectious hepatitis) plays as a cause of transfusion-associated hepatitis usually does not matter since the temporary viremic phase of hepatitis a is accompanied by clinical signs of disease, leading to the exclusion of blood donation. In the US, those who are treating HIV infection with HIV-1 in the foreground, although infection with HIV-2 occur. A test for antibodies against both virus strains is prescribed. Moreover, a nucleic acid test for HIV-1 antigen and HIV-1 p24 antigen assay is performed. In addition, blood donors are asked about certain behaviors that can lead to a high risk of HIV infection for assignment. HIV-0 could not be found in blood donors so far. The risk of HIV infection through a blood transfusion is 1: 2.6 million Infection with cytomegalovirus (CMV) can be done by leukocytes, which are located in the transfused blood. CMV is not transmitted through fresh frozen plasma. Since it does not cause disease in immunocompetent recipients, no routine antibody test donor blood is performed. However, CMV can cause serious and fatal infections in immunocompromised patients. Therefore, these CMV-negative blood products should – either in the form of blood products CMV antibody-negative donors or leucocyte-depleted blood products – received. The human T-cell lymphotropic virus 1 (HTLV-1) that can trigger in adults a T-cell lymphoma or leukemia, HTLV-1-associated myelopathy or tropical spastic paraparesis, causing several receivers to seroconversion after transfusion. All donors are tested for HTLV-1 and HTLV-2 antibodies. The risk of a false-negative result is 1: 641,000. There are so far no reports of transfusion-associated Creutzfeldt-Jakob disease. Nevertheless, the current practice includes people from the donation that received human growth factors or dura mater transplants or in whose family Creutzfeldt-Jakob disease has occurred. The new variant of Creutzfeldt-Jakob disease (vCJD or mad cow disease) has not been transmitted by blood transfusion. Nevertheless, donors who have spent a longer time in the UK or elsewhere in Europe, are excluded in the US permanently from donating blood (see table: Temporary or permanent exclusion criteria for blood donation). A malaria infection can be easily transmitted via infected erythrocytes. Many donors do not realize that they have malaria because the disease can proceed latent and is non-transferable after 10-15 years. Through the storage of blood infectivity is not reduced. Potential donors must occur after malaria and a stay in a region where malaria to be interviewed. Travelers who resided in endemic areas will be excluded for 1 year. Dispensers in which the diagnosis of malaria infection was found or emigrants, refugees or citizens from countries where malaria is endemic are excluded for the period of 3 years from the donation. Babesiosis, Chagas disease and West Nile virus have so far rarely transmitted by transfusion.