What are the clinical manifestations of transfusion reactions?

Clinical Manifestations of Transfusion Reactions

Transfusion reactions present with a wide range of symptoms including fever, chills, pruritus, hypotension, dyspnea, chest discomfort, rash, urticaria, angioedema, wheezing, and tachycardia, with severe reactions potentially progressing to anaphylaxis requiring urgent intervention. 1

Types of Transfusion Reactions and Their Clinical Manifestations

Immediate Reactions (Within 24 Hours)

Febrile Non-Hemolytic Transfusion Reactions

• Fever (temperature elevation of ≥1°C)
• Chills and rigors
• Headache
• Malaise
• Most commonly associated with red blood cell transfusions 1

Allergic Reactions

• Pruritus
• Urticaria
• Rash
• Angioedema
• Wheezing
• More commonly associated with plasma and platelet transfusions 1

Anaphylactic Reactions

• Sudden onset of respiratory distress
• Bronchospasm
• Severe hypotension
• Urticaria
• Angioedema
• Potential for rapid progression to cardiovascular collapse 1

Transfusion-Related Acute Lung Injury (TRALI)

• Acute respiratory distress
• Bilateral pulmonary edema
• Hypoxemia
• Fever
• Hypotension
• Onset typically within 6 hours of transfusion 2

Transfusion-Associated Circulatory Overload (TACO)

• Dyspnea
• Orthopnea
• Hypertension
• Tachycardia
• Pulmonary edema
• Jugular venous distention 1

Bacterial Contamination/Septic Transfusion Reactions

• Rapid onset of high fever
• Severe chills
• Hypotension
• Nausea or vomiting (26%)
• Shock
• Symptoms may appear during transfusion (47%) or up to several days after 3

Monitoring and Early Detection

Vital sign monitoring is essential for early detection of transfusion reactions. According to AAGBI guidelines, clinical observations should include:

• Heart rate
• Blood pressure
• Temperature
• Respiratory rate

These should be monitored at minimum pre-transfusion, at the end of transfusion, and 15 minutes after transfusion 1.

Grading of Transfusion Reactions

The Common Terminology Criteria for Adverse Events (CTCAE) grades reactions from 1-5:

1. Grade 1: Mild transient reactions not requiring intervention
2. Grade 2: Reactions requiring therapy or infusion interruption but responding promptly to symptomatic treatment
3. Grade 3: Prolonged reactions not rapidly responsive to symptomatic medication; may require hospitalization
4. Grade 4: Life-threatening reactions requiring urgent intervention
5. Grade 5: Death 1

Management Approach

When a transfusion reaction is suspected:

1. Immediately stop the transfusion 1
2. Contact the laboratory to report the reaction and for further investigation
3. Assess severity of symptoms and provide appropriate interventions:
   • For mild allergic reactions: antihistamines
   • For febrile reactions: antipyretics like paracetamol
   • For severe reactions: follow local anaphylaxis protocols including adrenaline administration if life-threatening 1

Important Considerations

• Many transfusion reactions are underdiagnosed and underreported 2
• Symptoms of different reaction types often overlap, making precise diagnosis challenging
• The most rapid-onset reactions are typically the most severe 1
• Any symptoms occurring within 24 hours of transfusion should be considered a potential transfusion reaction 4

Prevention

The best way to prevent transfusion reactions is to:

• Avoid unnecessary blood transfusions
• Maintain a transfusion-restrictive strategy
• Ensure proper blood product verification before administration
• Follow established transfusion protocols 4

Early recognition of transfusion reactions is critical as prompt intervention can significantly reduce morbidity and mortality associated with these events.