What are the reactions to blood transfusion?

From the Guidelines

Blood transfusion reactions should be managed using a personalized approach, tailored to the patient's symptoms and signs, with current recommendations advising against the indiscriminate use of steroids and/or antihistamines. According to the most recent guidelines from the Association of Anaesthetists 1, the incidence of febrile, allergic, and hypotensive reactions is increasing, and a more personalized approach is recommended to distinguish between febrile and allergic reactions. For febrile reactions, only intravenous paracetamol may be required, while for allergic reactions, only an antihistamine should be administered.

Key Considerations

• Patients at highest risk of transfusion reactions include the elderly, those with cardiac or renal dysfunction, and patients with pre-existing fluid overload.
• Healthcare providers should administer blood products slowly (1-2 mL/kg/hour) for at-risk patients, use diuretics when appropriate, and split blood component units with adequate time between transfusions.
• Treatment of transfusion reactions involves stopping the transfusion immediately, elevating the patient's head, administering oxygen, and giving diuretics like furosemide 20-40 mg IV.

Prevention and Management

• The use of TACO checklists and infographics can help identify patients at risk of transfusion-associated circulatory overload (TACO) and guide management decisions.
• Intra-hospital transfer of patients may occur during transfusion, and large numbers of units of RBCs should not be transferred with the patient to avoid unnecessary wastage.
• Clinical teams should communicate effectively with the transfusion laboratory when the decision to transfer a patient with blood is confirmed, and the transfusion laboratory should coordinate the transfer and traceability of blood.

Evidence-Based Recommendations

• The Association of Anaesthetists guidelines 1 provide evidence-based recommendations for the management of blood transfusion reactions, including the use of a personalized approach and the avoidance of indiscriminate use of steroids and/or antihistamines.
• Other studies, such as those published in the Journal for ImmunoTherapy of Cancer 1 and the Annals of Internal Medicine 1, provide additional evidence on the management of transfusion reactions, but the most recent guidelines from the Association of Anaesthetists 1 should be prioritized.

From the Research

Types of Transfusion Reactions

• Acute hemolytic transfusion reaction
• Febrile nonhemolytic transfusion reaction
• Allergic and anaphylactic reactions
• Transfusion-related acute lung injury
• Transfusion-related infection or sepsis
• Transfusion-associated circulatory overload 2
• Delayed transfusion adverse reactions, including erythrocyte and platelet alloimmunization, delayed hemolytic transfusion reactions, posttransfusion purpura, transfusion-related immunomodulation, transfusion-associated graft versus host disease, and iron overload 2

Prevention and Management of Transfusion Reactions

• Avoiding unnecessary blood transfusions and maintaining a transfusion-restrictive strategy 3
• Early identification and immediate interruption of the transfusion 3
• Early consultation of the hematologic and ICU departments and fluid resuscitation 3
• Washing platelets to prevent allergic transfusion reactions, although this may result in substantial platelet loss 4
• Using evidence-based algorithms of transfusion, newer blood screening methods and donor policies and deferrals, new laboratory testing, electronic verification systems, and improved hemovigilance to decrease the incidence of serious transfusion reactions 5

Diagnosis of Transfusion Reactions

• Any symptom occurring within 24 h of a blood transfusion should be considered a transfusion reaction and referred to the hemovigilance reporting system 3
• Laboratory tests, such as those for alloimmunization and hemolysis, can aid in the diagnosis of transfusion reactions 4
• Clinical presentation, including symptoms such as fever, chills, and rash, can also aid in the diagnosis of transfusion reactions 3

Incidence of Transfusion Reactions

• The most frequent transfusion reactions in 2020 were alloimmunizations, febrile non-hemolytic transfusion reactions, and allergic transfusion reactions 3
• Transfusion-related acute lung injury, transfusion-associated circulatory overload, and septic transfusion reactions were less frequent 3
• The numbers of blood transfusions, transfusion reactions, and the reporting rate of transfusion reactions differ between countries in Europe 3