From the Guidelines
Acute hemolytic transfusion reactions require immediate recognition and management, with the first step being to stop the transfusion immediately and notify the blood bank. If a hemolytic reaction is suspected during a blood transfusion, maintain IV access with normal saline, and send the blood bag and tubing to the blood bank for investigation, as recommended by the AAGBI guidelines 1. Collect blood samples for direct antiglobulin test (DAT), complete blood count, coagulation studies, and markers of hemolysis (bilirubin, LDH, haptoglobin).
Key Steps in Management
- Monitor vital signs frequently and assess urine output
- Management focuses on supportive care including IV fluids (normal saline at 150-200 mL/hour) to maintain renal perfusion and prevent acute kidney injury, as suggested by recent guidelines 1
- For hypotension, administer vasopressors like norepinephrine (starting at 0.05-0.1 mcg/kg/min) if needed
- Treat DIC if present with appropriate blood products
- Administer furosemide (20-40 mg IV) for fluid overload or to maintain urine output
- Monitor for complications including renal failure, DIC, and shock
Prevention and Treatment
The reaction typically occurs due to ABO incompatibility from clerical errors, so proper patient identification and blood product verification are essential preventive measures, as emphasized by the American Society of Hematology 2020 guidelines for sickle cell disease: transfusion support 1. Hemolytic reactions result from antibody-mediated destruction of transfused red blood cells, triggering complement activation, cytokine release, and potentially causing hypotension, renal failure, and DIC.
Immunomodulatory Therapy
In cases of life-threatening hemolysis, immunosuppressive therapy should be initiated promptly, with first-line agents including IVIg and high-dose steroids, and second-line agent being eculizumab, as recommended by the American Society of Hematology 2020 guidelines 1. Rituximab is primarily indicated for potential prevention of additional alloantibody formation in patients who may require further transfusion. A shared decision-making process is critical in managing these patients.
From the Research
Approach to Investigating Acute Hemolytic Transfusion Reactions
- When a transfusion reaction is suspected, it is critical to stop the transfusion immediately and report the reaction to the blood bank, as this can affect the patient's outcome 2
- A laboratory workup should be initiated to rule out an acute hemolytic transfusion reaction, including a direct antiglobulin (Coombs') test, and specimens obtained before and after transfusion should be assayed for hemoglobinemia and hemoglobinuria 3
- If the product transfused included red blood cells, then typing and crossmatching should be repeated on a posttransfusion blood specimen 3
Management of Acute Hemolytic Transfusion Reactions
- Discontinuing the transfusion and basic supportive methods, including adjunctive pharmacologic agents, are the primary management strategies 4
- In cases of severe reactions, adjunctive red blood cell exchange transfusion may be useful, particularly if there has been a large volume mismatched transfusion and a poor clinical response to basic supportive methods 4
- Withholding blood products from patients with prior allo-antibody formation until compatible products have been identified is recommended, as suspicion for hemolytic transfusion reactions should be high in these patients 5
Clinical Presentation of Haemolytic Transfusion Reactions
- Haemolytic transfusion reactions can be acute (occurring within 24 hours of transfusion) or delayed (when signs of red cell destruction do not occur until 4 to 10 days after transfusion) 6
- The severest signs and symptoms of acute reactions follow intravascular red cell lysis and progress to anaemia, fever, haemoglobinuria, and jaundice 6
- The subjective responses of pain, restlessness, nausea, skin flushing, dyspnoea, and shock are mediated by cleavage products of complement (C3a, C5a) activated by red cell antigen-antibody reaction 6