What is the treatment protocol for an acute transfusion reaction?

Protocol for Management of Acute Transfusion Reactions

The immediate management of an acute transfusion reaction requires stopping the transfusion immediately, maintaining IV access, and initiating a systematic approach based on the severity and type of reaction. 1

Initial Response to Suspected Transfusion Reaction

1. Stop the transfusion immediately
2. Maintain IV access with normal saline (keep vein open)
3. Assess ABCs (Airway, Breathing, Circulation) and level of consciousness
4. Check vital signs (heart rate, blood pressure, temperature, respiratory rate)
5. Position the patient appropriately:
   • Hypotension: Trendelenburg position
   • Respiratory distress: Sitting up
   • Unconscious: Recovery position
6. Administer oxygen if needed
7. Call for medical assistance

Reaction Assessment and Classification

Anaphylaxis/Severe Reaction Management

If patient meets criteria for anaphylaxis:

1. Administer epinephrine immediately: 0.01 mg/kg (1 mg/mL dilution, maximum 0.5 mL) intramuscularly into lateral thigh 1
2. For refractory hypotension:
   • Fluid resuscitation with normal saline
   • Vasopressors if needed:
     • Dopamine: 400 mg in 500 mL 5% dextrose water at 2-20 μg/kg/min
     • Vasopressin: 25 units in 250 mL 5% dextrose water (0.1 U/mL) at 0.01-0.04 U/min
3. For patients on beta-blockers with refractory effects: Consider glucagon 1-5 mg IV over 5 minutes
4. Corticosteroids: Methylprednisolone 1-2 mg/kg IV every 6 hours 1

Mild to Moderate Reactions

Febrile Non-Hemolytic Reaction

1. Antipyretics: Intravenous paracetamol 1
2. Avoid indiscriminate use of steroids 1

Allergic Reaction

1. Antihistamines:
   • Prefer second-generation antihistamines (loratadine 10 mg PO or cetirizine 10 mg IV/PO) 1
   • Avoid first-generation antihistamines like diphenhydramine as they may exacerbate hypotension 1
2. For urticaria: Consider hydrocortisone 200 mg IV 1

Nausea/Vomiting

• 5-HT3 antagonist (ondansetron 4-8 mg IV) 1

Cytokine Release Syndrome

1. Short-term cessation of infusion
2. Symptomatic treatment:
   • Histamine blockers
   • Corticosteroids
   • Antipyretics 1

Monitoring and Follow-up

1. Monitor vital signs until resolution of symptoms 1
2. For severe reactions: Close observation for 24 hours 1
3. Document the reaction thoroughly:
   • Pre-infusion assessments
   • Description and grading of reaction (using CTCAE or similar classification)
   • Management provided 1

Rechallenge Considerations

For Mild/Moderate Reactions with Complete Resolution

1. Discuss rechallenge with patient and provide reassurance
2. Restart infusion ~15 minutes after symptom resolution
3. Use slower infusion rate (50% of initial rate)
4. If well tolerated, increase slowly after 15 minutes
5. If symptoms recur, stop infusion 1

For Severe Reactions

• Rechallenge is discouraged 1

Special Considerations

1. Avoid indiscriminate use of steroids and antihistamines - tailor treatment to specific symptoms 1
2. For patients with SCD and transfusion reactions:
   • Consider immunosuppressive therapy (IVIg, steroids, rituximab) for patients with history of severe reactions 1
   • Consult hematology for specialized management

Common Pitfalls to Avoid

1. Delayed recognition - Watch for early warning signs like patient feeling "odd" or uncomfortable 1
2. Using first-generation antihistamines (diphenhydramine) which may worsen hypotension 1
3. Indiscriminate use of steroids which may further suppress immunity in immunocompromised patients 1
4. Failure to maintain proper documentation of the reaction for future reference 1
5. Missing biphasic reactions - continue monitoring even after initial symptom resolution 1

This protocol provides a systematic approach to managing acute transfusion reactions with emphasis on immediate intervention, proper assessment, and appropriate treatment based on reaction severity and type.