What are the types of reactions to blood transfusions?

Types of Blood Transfusion Reactions

Blood transfusion reactions can be broadly categorized into immune-mediated and non-immune-mediated reactions, with specific subtypes in each category that require different management approaches. 1

Immune-Mediated Reactions

Type I (IgE antibody-mediated)

• Allergic reactions ranging from mild urticaria to severe anaphylaxis 1
• Characterized by hives, generalized itching, flushing, and in severe cases, respiratory compromise and hypotension 1
• Accounts for approximately one-third of all transfusion reactions 2

Type II (Antibody-mediated cytotoxic)

• Hemolytic transfusion reactions (acute or delayed) 1
• Results from destruction of transfused red blood cells by recipient antibodies 1
• May present with fever, hypotension, flank pain, hemoglobinuria, and in severe cases, renal failure 3
• Preventable through proper antigen matching, particularly Rh (C, E or C/c, E/e) and K antigens 1

Type III (Immune complex-mediated)

• Includes serum sickness and vasculitis 1
• Characterized by fever, rash, arthralgia, and lymphadenopathy 1
• Typically occurs 1-2 weeks after transfusion 4

Type IV (Delayed T cell-mediated)

• Includes allergic contact dermatitis, maculopapular exanthema, erythema multiforme, and toxic epidermal necrolysis 1
• Typically presents days to weeks after transfusion 1

Non-Immune-Mediated Reactions

Febrile Non-Hemolytic Transfusion Reactions (FNHTR)

• Second most common reaction (25.7% of reactions) 2
• Characterized by fever (≥1°C rise) and chills without hemolysis 5
• Usually self-limiting but can mask more serious reactions 6

Transfusion-Related Acute Lung Injury (TRALI)

• Acute respiratory distress within 6 hours of transfusion 5
• Presents with hypoxemia, bilateral pulmonary infiltrates without evidence of circulatory overload 5
• Among the top three most common causes of transfusion-related deaths 5
• Most patients recover within 96 hours with supportive care 5

Transfusion-Associated Circulatory Overload (TACO)

• Volume overload leading to pulmonary edema 3, 5
• Risk factors include elderly patients, cardiac dysfunction, and rapid transfusion rates 5
• Presents with dyspnea, orthopnea, hypertension, and jugular venous distention 3

Septic Transfusion Reactions

• Due to bacterial contamination of blood products 5
• Presents with fever, hypotension, and shock 4
• Requires immediate antibiotic therapy and supportive care 5

Cytokine Release Syndrome (CRS)

• Pseudo-allergic reaction with direct mast cell degranulation 1
• Presents with tachycardia, hypotension, rash, and shortness of breath 1

Special Considerations in Sickle Cell Disease

• Patients with sickle cell disease are at higher risk for alloimmunization and delayed hemolytic transfusion reactions 1
• Prophylactic red cell antigen matching for Rh (C, E or C/c, E/e) and K antigens is strongly recommended over only ABO/RhD matching 1
• In rare cases of life-threatening anemia requiring immediate transfusion when compatible blood is unavailable, immunosuppressive therapy (IVIg, steroids, and/or rituximab) may be considered 1

Immediate Management of Suspected Transfusion Reactions

1. Stop the transfusion immediately when any signs or symptoms of a reaction appear 3, 5
2. Maintain IV access with normal saline 3
3. Check patient identification and blood component compatibility labels 3
4. Notify the transfusion laboratory immediately 3
5. Assess ABCs (Airway, Breathing, Circulation) and level of consciousness 3
6. Position the patient appropriately based on symptoms 3
7. Monitor vital signs closely 5
8. Collect post-reaction blood samples for laboratory evaluation 3

Common Pitfalls and Caveats

• General anesthesia may mask symptoms of both hemolytic and nonhemolytic transfusion reactions 5
• Diagnosis of a transfusion reaction during ongoing hemorrhage may be difficult 5
• Symptoms of different reaction types often overlap and can be nonspecific 7
• The reporting rate of transfusion reactions varies significantly between institutions and countries 4, 8
• Any symptom occurring within 24 hours of a blood transfusion should be considered a potential transfusion reaction 4