What is the management for a patient experiencing hives and swollen eyelids during a Fresh Frozen Plasma (FFP) transfusion?

Management of Allergic Reactions During FFP Transfusion

Immediately stop the FFP transfusion and administer an antihistamine for allergic reactions such as hives and swollen eyelids. 1

Understanding Allergic Reactions to FFP

Allergic reactions are common with plasma transfusions compared to other blood products. Fresh Frozen Plasma (FFP) more commonly causes allergic reactions than red blood cells, which are typically associated with febrile-type reactions 1.

The incidence of allergic reactions to FFP includes:

• Overall risk of allergic reactions per unit of plasma is approximately 1.37% 2
• Up to 65.8% of patients receiving large volumes of plasma (such as in TTP treatment) may experience allergic reactions 2
• Urticaria (hives) comprises about 96% of allergic reactions to plasma 2

Management Algorithm for Allergic Reactions During FFP Transfusion

1. Immediate actions:

   • Stop the transfusion immediately
   • Maintain IV access
   • Assess vital signs and airway status
   • Notify the blood bank of the reaction

2. Treatment based on severity:

   • For mild-moderate allergic reactions (hives, swollen eyelids):

     • Administer antihistamine (diphenhydramine) 1
     • Do NOT administer steroids indiscriminately 1
     • Monitor for resolution of symptoms

   • For severe reactions/anaphylaxis:

     • Follow local anaphylaxis protocols 1
     • Administer epinephrine
     • Consider IV fluids for hypotension
     • Consider airway management if significant angioedema

3. Post-reaction management:

   • Document the reaction in patient's chart
   • Report to hemovigilance system/transfusion committee
   • Consider premedication for future transfusions if clinically necessary

Important Clinical Considerations

Prevention for Future Transfusions

• For patients with prior allergic reactions, consider antihistamine premedication before subsequent FFP transfusions 1
• Avoid routine premedication with steroids as they may further suppress immunity in immunocompromised patients 1
• Premedication with antihistamines may be warranted for patients with a history of allergic reactions to the same blood product type 3

Pitfalls to Avoid

1. Do not restart the same unit if an allergic reaction occurs
2. Do not administer steroids indiscriminately - use a personalized approach based on symptoms 1
3. Do not ignore mild symptoms as they may progress to more severe reactions
4. Do not assume all reactions are allergic - differentiate between febrile and allergic reactions for appropriate management 1
5. Do not premedicate for different blood product types if the patient only had a reaction to FFP specifically 3

Risks Associated with FFP

FFP transfusion carries several risks beyond allergic reactions:

• Transfusion-related acute lung injury (TRALI) 1, 4
• Transfusion-associated circulatory overload (TACO) 1, 4
• Transmission of infectious diseases 1, 4
• Febrile non-hemolytic transfusion reactions 4
• Red blood cell alloimmunization 4

Evidence Quality Assessment

The recommendations are primarily based on guidelines from the Association of Anaesthetists (2025) 1, which provides the most recent and comprehensive guidance on managing transfusion reactions. These guidelines emphasize a personalized approach to managing transfusion reactions rather than indiscriminate use of medications.

While some studies have questioned the efficacy of premedication for preventing transfusion reactions 5, 6, the current standard of practice still includes antihistamine administration for established allergic reactions.