From the Guidelines
Transfusion reactions require prompt recognition and specific treatments based on their type, with the most recent guidelines from 2025 emphasizing a personalized approach to managing febrile and allergic reactions 1.
Types of Transfusion Reactions
- Acute hemolytic transfusion reactions: caused by ABO incompatibility, require immediate transfusion cessation, IV access maintenance, fluid resuscitation with normal saline, and monitoring for DIC and renal failure.
- Febrile non-hemolytic reactions: present with fever and chills, managed by stopping the transfusion, administering antipyretics like acetaminophen (650mg), and potentially using premedication for future transfusions.
- Allergic reactions: range from mild urticaria to anaphylaxis, mild cases can be treated with diphenhydramine (25-50mg IV/PO), while severe reactions require epinephrine (0.3-0.5mg IM), corticosteroids, and airway management.
- Transfusion-related acute lung injury (TRALI): presents with acute respiratory distress, requires oxygen support, ventilation if needed, and supportive care.
- Transfusion-associated circulatory overload (TACO): treated by stopping the transfusion, positioning the patient upright, administering oxygen, diuretics like furosemide (20-40mg IV), and potentially morphine for pulmonary edema.
- Bacterial contamination: requires immediate transfusion cessation, blood cultures, and broad-spectrum antibiotics.
- Delayed hemolytic reactions: typically occur days later, usually require monitoring rather than intervention.
Treatment and Prevention Strategies
- For febrile reactions, only intravenous paracetamol may be required, while for allergic reactions, only an antihistamine should be administered 1.
- Prevention strategies include careful cross-matching, using leukoreduced blood products for patients with previous febrile reactions, and slow transfusion rates for at-risk patients.
- Intra-hospital transfer of patients may occur during transfusion, and large numbers of units of RBCs should not be transferred with the patient, with the receiving clinicians ensuring blood is returned to appropriate storage and collected for transfusion when required to avoid unnecessary wastage 1.
- Clinical teams should communicate effectively with the transfusion laboratory when the decision to transfer a patient with blood is confirmed, with the transfusion laboratory coordinating the transfer and traceability of blood.
From the Research
Types of Transfusion Reactions
- Immediate transfusion reactions 2
- Delayed transfusion reactions 2
- Acute transfusion reactions 2, 3, 4, 5
- Non-haemolytic transfusion reactions, including:
- Anaphylaxis 6
- Alloimmunizations 5
- Febrile non-hemolytic transfusion reactions 5
- Septic transfusion reactions 5
Treatment and Management of Transfusion Reactions
- Timely identification and immediate cessation of transfusion 2, 4, 5
- Vigilance to distinguish delayed responses or reactions that present nonspecific signs and symptoms 2, 3
- Stop the transfusion immediately and report the reaction to the blood bank when a reaction is suspected 4
- New evidence-based algorithms of transfusion, newer blood screening methods and donor policies and deferrals, new laboratory testing, electronic verification systems, and improved hemovigilance to avoid unnecessary transfusions and decrease the incidence of serious transfusion reactions 4
- Washed platelets to prevent allergic transfusion reactions 6
- Fluid resuscitation as part of the initial management of blood transfusion reactions 5
- Early consultation of the hematologic and ICU departments 5
- Maintaining a transfusion-restrictive strategy to prevent transfusion reactions 5