What is the management of a blood transfusion reaction?

Management of Blood Transfusion Reactions

The immediate management of a blood transfusion reaction requires stopping the transfusion immediately, maintaining intravenous access with normal saline, and contacting the transfusion laboratory for investigation of the blood unit. 1

Initial Steps

• Stop the transfusion immediately when signs of a reaction are observed (tachycardia, rash, breathlessness, hypotension, or fever) 1
• Maintain intravenous (IV) access with normal saline for medication administration and fluid resuscitation 1
• Call for medical assistance as soon as possible 2
• Assess the 'ABCs' (Airway, Breathing, and Circulation) and the patient's level of consciousness 2
• Position the patient appropriately: Trendelenburg for hypotension, sitting up for respiratory distress, or recovery position if unconscious 2
• Administer oxygen if needed 2
• Monitor vital signs closely, including heart rate, blood pressure, temperature, and respiratory rate 1, 3
• Contact the transfusion laboratory immediately and send the blood unit with administration set for investigation 1

Management Based on Reaction Type

Anaphylaxis/Severe Allergic Reaction

• Administer epinephrine 0.2-0.5 mg (1 mg/mL) IM, repeating every 5-15 minutes as needed 2
• Provide fluid resuscitation with normal saline 1-2 L IV at a rate of 5-10 mL/kg in the first 5 minutes 2
• Administer H1/H2 antagonists: diphenhydramine 50 mg IV plus ranitidine 50 mg IV 2
• For bradycardia, administer atropine 600 μg IV 2
• For persistent hypotension:
  • Dopamine 400 mg in 500 mL, at a rate 2-20 μg/kg/min or
  • Vasopressin 25 U in 250 mL of 5% dextrose water or normal saline (0.1 U/mL), dose of 0.01–0.04 U/min 2
• For patients on beta-blockers, administer glucagon 1-5 mg IV infusion over 5 minutes 2
• Give corticosteroids at a dose equivalent to 1-2 mg/kg of IV methylprednisolone every 6 hours 2

Mild to Moderate Reactions (Febrile Non-Hemolytic or Mild Allergic)

• For Grade 1 reactions: Slow the rate of infusion 2
• For Grade 2 reactions: Slow the rate or temporarily stop the infusion 2
• Administer H1/H2 antagonists: diphenhydramine 50 mg IV plus ranitidine 50 mg IV 2
• Give corticosteroids at a dose equivalent to 1-2 mg/kg of IV methylprednisolone every 6 hours 2
• After symptom resolution, restart infusion at 50% of the previous rate and titrate to tolerance 2

Severe Reactions (Grade 3/4)

• Stop the infusion completely 2
• Administer H1/H2 antagonists: diphenhydramine 50 mg IV plus ranitidine 50 mg IV 2
• Give corticosteroids at a dose equivalent to 1-2 mg/kg of IV methylprednisolone every 6 hours 2
• Rechallenge is discouraged in severe reactions 2

Monitoring and Follow-up

• Monitor vital signs until resolution of symptoms 2
• For severe reactions, provide close observation for 24 hours 2
• Assess urine output and color to monitor for hemolytic reactions 1
• Monitor peak airway pressure to detect potential transfusion-related acute lung injury (TRALI) 1

Special Considerations

• General anesthesia may mask symptoms of both hemolytic and nonhemolytic transfusion reactions 1
• Diagnosis of a transfusion reaction during ongoing hemorrhage may be difficult 1
• If concerns arise, double-check documentation for administration errors 1, 3
• For patients requiring both blood transfusion and vasopressors, ensure adequate monitoring with vital signs checked at least every 15 minutes 4
• Consider separate IV access sites when administering blood products simultaneously with vasopressors 4

Prevention of Future Reactions

• Consider washed blood products for future transfusions if allergic reactions occurred 1
• Use slower transfusion rates if transfusion-associated circulatory overload (TACO) is suspected 1
• Implement weight-based dosing of blood products to prevent volume overload 1
• Ensure positive patient identification before transfusion using at least four core identifiers 4, 1
• Visually check blood components for any leakage, discoloration, or presence of clots before administration 4

Common Pitfalls to Avoid

• Do not delay reporting suspected transfusion reactions 5, 6
• Avoid rapid transfusion in patients on vasopressors due to increased risk of TACO 4
• Do not restart transfusion if hemolytic reaction is suspected 3
• Remember that signs of hemolytic reactions may be erroneously attributed to other causes in anesthetized patients 1