How to manage pruritis (itching) in patients undergoing blood transfusion?

Management of Pruritus During Blood Transfusion

For patients experiencing pruritus during blood transfusion, antihistamines should be administered only for true allergic reactions with urticaria, not used prophylactically or for all types of transfusion reactions. 1

Identifying the Type of Transfusion Reaction

Proper management of pruritus during blood transfusion requires first identifying the type of reaction:

Allergic Reaction

• Presentation: Primarily urticaria, skin manifestations, pruritus
• Management:
  • Stop the transfusion temporarily
  • Administer a second-generation antihistamine (preferred):
    • Loratadine 10 mg orally OR
    • Cetirizine 10 mg IV/orally 1
  • Avoid first-generation antihistamines like diphenhydramine as they can potentially worsen hemodynamic status 1

Febrile Non-Hemolytic Reaction

• Presentation: Fever, chills, possibly pruritus
• Management:
  • Stop the transfusion temporarily
  • Administer intravenous paracetamol/acetaminophen 1
  • Avoid steroids unless severe symptoms persist 1

Management Algorithm for Pruritus During Transfusion

1. When pruritus occurs during transfusion:

   • Stop the transfusion immediately
   • Keep IV line open with normal saline
   • Check vital signs (temperature, pulse, blood pressure, respiratory rate)
   • Assess for other symptoms (urticaria, dyspnea, hypotension)

2. Determine reaction type:

   • If urticaria/skin manifestations predominate → Allergic reaction
   • If fever/chills predominate → Febrile reaction
   • If respiratory distress/hypotension → Consider TACO or TRALI (transfusion-associated circulatory overload or transfusion-related acute lung injury)

3. For isolated pruritus with urticaria (allergic reaction):

   • Administer second-generation antihistamine 1
   • Monitor for 15 minutes
   • If symptoms resolve, consider rechallenge at 50% of the initial infusion rate 1
   • If symptoms recur, stop transfusion completely

4. For pruritus with fever (febrile reaction):

   • Administer intravenous paracetamol/acetaminophen 1
   • Monitor for 15 minutes
   • If symptoms resolve, consider rechallenge at slower rate

Important Considerations

Avoid Prophylactic Premedication

• Current evidence does not support routine premedication with antihistamines or acetaminophen before transfusions 2, 3
• Premedication may mask early signs of more serious reactions
• A meta-analysis showed no significant reduction in transfusion reactions with prophylactic antihistamines 2

Washed Red Blood Cells

• Consider washed RBCs only for patients with history of severe or recurrent allergic reactions despite appropriate management 4
• Recent evidence suggests washing may be unnecessary for many patients previously thought to require it 4
• Washing reduces shelf life and effective dose of blood products

Special Populations

• For patients with recurrent mild pruritus during transfusion:
  • Document reactions carefully
  • Consider slower transfusion rates
  • Use second-generation antihistamines for symptomatic relief 1

Post-Transfusion Monitoring

• Patients should be informed about possible delayed reactions (hours to days)
• Common delayed symptoms include pruritus, flu-like symptoms, arthralgias
• Symptoms lasting more than a few days require medical evaluation 1

Pitfalls to Avoid

1. Do not use steroids and antihistamines indiscriminately - this can suppress immunity in immunocompromised patients 1

2. Avoid first-generation antihistamines (e.g., diphenhydramine) as they can potentially worsen hemodynamic status in transfusion reactions 1

3. Do not restart transfusion at the same rate after a reaction - reduce to 50% of initial rate if rechallenge is attempted 1

4. Do not miss signs of more serious reactions - pruritus with respiratory symptoms or hypotension may indicate TACO or TRALI, which require immediate intervention 1

5. Do not continue monitoring only temperature - respiratory rate is a critical early indicator of serious transfusion reactions 1