Management of Acute Transfusion Reactions

This was a teaching document for medical students and residents I made for NGHA Riyadh. I have updated it for leukodepleted components and platelet additive solution.

Immediate Steps for All Reactions:

  1. Stop Transfusion.
  2. Keep IV Open with 0.9% NaCl.
  3. Verify correct unit was given to correct patient.
  4. Notify attending physician and blood bank

After Transfusion is Terminated (except mild allergic, see below):

  1. Send report of reaction, freshly collected blood, and urine samples with blood unit and administration set to blood bank.
Reaction TypeSigns and SymptomsEtiologyClinical Action
Allergic (mild)Pruritus, urticaria (hives)Antibodies to plasma proteinsSteps 1-3 above; administer antihistamines (PO, IM, or IV); resume transfusion if improved; if no improvement in 30 minutes treat as below.
Allergic (moderate to severe)Hives, dyspnea, abdominal pain, hypotension, nausea, anaphylaxisAntibodies to plasma proteins, including IgA (patient has anti-IgA antibodies)Steps 1-5 above; administer antihistamines, epinephrine, vasopressors, and corticosteroids as needed; avoid future reactions by premedication and consider use of washed red cells if refractory.
Febrile (mild to moderate)Fever, chills, rigors, anxiety, mild dyspneaAntibodies to leukocyte antigens, (mostly HLA): cytokinesSteps 1-5 above; mild—administer antipyretics as needed; avoid future reactions by premedication and use of leukodepleted red cells and platelets
Acute lung injuryFever, chills, dyspnea, respiratory failureAntibodies form donor plasma to recipient WBCs; less commonly recipient antibodies to donor WBCsSupportive therapy for respiratory failure, oxygen, mechanical ventilation, leukodepleted blood components, consider use of solvent detergent plasma, minimize plasma transfusions (use platelets in additive solution and leukodepleted RBCs in additive solution).
Acute hemolyticAnxiety, chest pain, flank pain, dyspnea, chills, fever, shock, unexplained bleeding, hemoglobinemia/ hemoglobinuria, cardiac arrestHemolytic transfusion reaction; usually due to ABO incompatibilitySteps 1-5 above; treat shock with vasopressors, IV fluids, corticosteroids as needed; maintain airway; increase renal blood flow (IV fluids; furosemide); maintain a brisk diuresis; monitor renal status for acute renal failure. Monitor coagulation status for DIC; administer blood components as needed after etiology is clear.
Septic / toxicChills, fever, hypotensionBacteria in contaminated bloodSteps 1-5 above; treat shock with vasopressors, IV fluids, culture patient and blood bag,antibiotics.