Initial Management of Platelet Transfusion Reactions
In cases of suspected platelet transfusion reactions, the immediate management should be to stop the transfusion immediately, maintain intravenous access with normal saline, and report the reaction to the blood bank for further investigation. 1
Immediate Steps for Platelet Transfusion Reaction
Stop the transfusion immediately
- Disconnect the blood product but maintain IV access
- Switch to normal saline infusion through a new administration set
Assess vital signs and symptoms
- Monitor temperature, blood pressure, heart rate, respiratory rate, and oxygen saturation
- Evaluate for signs of:
- Fever, chills, rigors
- Urticaria, pruritus, flushing
- Dyspnea, wheezing, chest pain
- Hypotension, tachycardia
- Back pain, flank pain
Notify the blood bank
- Report the suspected reaction immediately
- Return the blood product with administration set to the blood bank
- Send post-reaction blood samples as directed by institutional protocol
Management Based on Reaction Type
Febrile Non-Hemolytic Transfusion Reactions (Most Common)
- Characterized by fever (≥1°C rise), chills, rigors
- Management:
- Antipyretics (acetaminophen)
- If severe, consider premedication for future transfusions
- Consider single-donor platelets for future transfusions, which have lower reaction rates (8.4%) compared to pooled concentrates (21.4%) 2
- Consider plasma-reduced platelets as bioreactive substances in plasma cause most febrile reactions 3
Allergic Reactions
- Characterized by urticaria, pruritus, erythema
- Management:
- Antihistamines (diphenhydramine)
- For recurrent reactions, consider washed platelets or premedication
Anaphylactic Reactions
- Characterized by hypotension, bronchospasm, angioedema, GI symptoms
- Management:
- Epinephrine (0.3-0.5 mg IM for adults)
- IV fluids for volume resuscitation
- Corticosteroids and antihistamines
- Consider HLA-matched platelets for future transfusions 4
Transfusion-Related Acute Lung Injury (TRALI)
- Characterized by acute respiratory distress, hypoxemia, bilateral pulmonary infiltrates
- Management:
- Oxygen therapy
- Ventilatory support if needed
- Supportive care
Prevention of Future Reactions
For Alloimmune Refractory Thrombocytopenia
- Use HLA-A and HLA-B antigen-matched platelets as first-line management 5
- For patients who don't respond to HLA-matched platelets or have rare HLA types, use platelet cross-matching techniques 5
- Avoid prophylactic non-matched platelet transfusions in alloimmunized patients who don't show adequate increments 5
For Recurrent Febrile Reactions
- Use leukoreduced platelets (standard in most countries)
- Consider single-donor apheresis platelets instead of pooled concentrates 2
- Consider removing plasma supernatant before transfusion 3
For ABO Incompatibility Concerns
- Use ABO-compatible platelets when possible to avoid hemolytic reactions 6
- When using ABO-incompatible platelets due to supply constraints, consider volume reduction to minimize incompatible plasma 6
Post-Reaction Monitoring
- Obtain post-transfusion platelet count 10-60 minutes after transfusion to assess adequacy 7
- Calculate corrected count increment (CCI) to standardize response:
- CCI = (absolute increment × body surface area [m²]) / (number of platelets transfused × 10¹¹)
- CCI ≥ 5,000 indicates satisfactory response 7
Common Pitfalls to Avoid
- Failing to stop the transfusion immediately when a reaction is suspected
- Not reporting the reaction to the blood bank
- Continuing to transfuse platelets without addressing the underlying cause of recurrent reactions
- Misdiagnosing refractoriness based on a single poor response (requires at least two ABO-compatible transfusions with poor increments) 5
- Not considering ABO compatibility when investigating poor platelet increments 5
By following this algorithmic approach to managing platelet transfusion reactions, clinicians can minimize morbidity and mortality while ensuring appropriate care for patients requiring platelet support.