What is the protocol for managing chills and hypotension during a blood transfusion?

Management Protocol for Chills and Hypotension During Blood Transfusion

When a patient experiences chills and hypotension during blood transfusion, immediately stop the transfusion, maintain IV access, and initiate supportive measures based on symptom severity while investigating the underlying cause. 1, 2

Immediate Actions

1. Stop the transfusion immediately 1, 2
2. Maintain IV access 1
3. Assess ABCs (Airway, Breathing, Circulation) and level of consciousness 1
4. Position the patient appropriately 1:
   • Trendelenburg position for hypotension
   • Sitting up for respiratory distress
   • Recovery position if unconscious

Assessment and Monitoring

• Vital signs: Check respiratory rate, temperature, pulse/heart rate, blood pressure, oxygen saturation 2
• Evaluate symptom onset: Note that approximately 50% of hypotensive transfusion reactions occur within 15 minutes of starting transfusion 3
• Differentiate between reaction types:
  • Febrile reactions (more common with RBC units)
  • Allergic reactions (more common with plasma and platelets)
  • Hypotensive reactions
  • Anaphylaxis 1, 2

Management Based on Severity

Mild to Moderate Reactions (Grade 1-2)

• Slow or stop the infusion rate
• Provide symptomatic treatment:
  • For febrile reactions: IV paracetamol 1, 2
  • For allergic reactions: antihistamine only 1, 2
• Monitor vital signs every 15 minutes until stabilized 2

Severe Reactions (Grade 3-4)

1. For hypotension with anaphylactic features:

   • Administer epinephrine (adrenaline) 0.01 mg/kg (1mg/mL dilution, max 0.5 mL) intramuscularly into lateral thigh 1
   • Can repeat every 5-15 minutes if needed 1
   • Consider IV epinephrine if no prompt response 1

2. Fluid resuscitation:

   • Rapid infusion of 1-2 liters normal saline at 5-10 mL/kg in first 5 minutes 1
   • Give crystalloids or colloids in boluses of 20 mL/kg, followed by slow infusion 1

3. Antihistamines:

   • Combined H1 and H2 antagonists are superior to either alone 1
   • Diphenhydramine (1-2 mg/kg or 25-50 mg) IV slowly plus ranitidine (50 mg diluted in 5% dextrose) IV over 5 minutes 1

4. For persistent hypotension:

   • Norepinephrine: Add 4 mg to 1,000 mL of 5% dextrose solution (4 mcg/mL). Start at 2-3 mL/minute (8-12 mcg/minute) and titrate to maintain systolic BP 80-100 mmHg 4
   • Alternative: Dopamine (400 mg in 500 mL of 5% dextrose) at 2-20 μg/kg/min 1
   • For patients on β-blockers: Consider glucagon 1-5 mg IV over 5 minutes, followed by infusion (5-15 mg/min) 1

Special Considerations

• Risk factors for hypotensive reactions:

  • Patients on angiotensin-converting enzyme inhibitors 5
  • Rapid transfusion, especially with infusion systems 6
  • Bedside filtered platelets 3

• Risk factors for transfusion-associated circulatory overload (TACO):

  • Older patients (>70 years)
  • Heart failure, renal failure, hypoalbuminemia
  • Low body weight
  • Rapid transfusion 1, 2

Documentation and Follow-up

• Document all vital sign measurements and interventions 2
• Consider collecting blood samples for tryptase levels (15 min to 3 hours after reaction onset) 1
• Report the reaction to the transfusion laboratory
• Monitor the patient for at least 12 hours after transfusion for delayed reactions 2

Prevention Strategies for Future Transfusions

• Assess the need for each transfusion carefully 2
• Consider body weight dosing for RBCs in high-risk patients 1, 2
• Administer transfusions slowly (particularly in patients with prior reactions) 1, 2
• Consider prophylactic diuretics in patients at high risk for TACO 1, 2
• For patients with prior reactions, consider premedication based on the specific type of previous reaction 1

Remember that most hypotensive transfusion reactions resolve within an hour after stopping the transfusion 3, but prompt recognition and appropriate management are essential to prevent serious complications.