What is the immediate management for wheezing during a blood transfusion?

Immediate Management of Wheezing During Blood Transfusion

Stop the transfusion immediately and administer IV epinephrine 50 mcg (0.5 mL of 1:10,000 solution) for adults, as wheezing during transfusion suggests anaphylaxis or severe allergic reaction requiring urgent intervention. 1

Initial Critical Actions

Stop the transfusion and maintain IV access with normal saline to keep the vein open—do not remove the IV line as it will be needed for medication administration and fluid resuscitation. 2

Call for help immediately and note the time of reaction onset. 1

Assess airway, breathing, and circulation (ABC approach) using a team-based approach to accomplish multiple tasks simultaneously. 1

Immediate Pharmacologic Management

Administer epinephrine intravenously as the first-line treatment for wheezing with any signs of systemic reaction:

• Adult dose: 50 mcg IV (0.5 mL of 1:10,000 solution) initially 1
• Repeat doses every 5-15 minutes if bronchospasm persists or worsens 1
• Consider starting an epinephrine infusion if multiple boluses are required, given its short half-life 1

Provide 100% oxygen and ensure adequate ventilation—intubate if necessary for severe respiratory compromise. 1

Administer aggressive fluid resuscitation with normal saline or lactated Ringer's solution at high rates (1-2 liters initially, 5-10 mL/kg in first 5 minutes) through a large-bore IV cannula. 1, 2

Differential Diagnosis Considerations

Wheezing during transfusion can indicate several serious reactions that require immediate recognition:

Anaphylaxis presents with bronchospasm, hypotension, tachycardia, and potential cardiovascular collapse—this is the most life-threatening scenario requiring immediate epinephrine. 1, 2

Transfusion-related acute lung injury (TRALI) manifests with dyspnea, hypoxemia, and pulmonary edema within 1-6 hours of transfusion and is now one of the top three causes of transfusion-related deaths. 1

Transfusion-associated circulatory overload (TACO) is the most common cause of transfusion-related mortality and presents with acute respiratory compromise, pulmonary edema, tachycardia, and hypertension—particularly in elderly patients (>70 years), those with heart or renal failure, or during rapid transfusion. 1

Severe allergic reaction may present with bronchospasm along with urticaria and pruritus, but without cardiovascular collapse. 1, 2

Secondary Management

For persistent bronchospasm after initial epinephrine:

• Administer IV salbutamol infusion as a bronchodilator 1
• Consider IV aminophylline or magnesium sulfate for refractory bronchospasm 1
• Metered-dose inhaler may be used if appropriate breathing-system connector is available 1

Administer adjunctive medications:

• Chlorphenamine 10 mg IV (adult dose) for allergic component 1
• Hydrocortisone 200 mg IV (adult dose) to prevent delayed reactions 1

Position the patient appropriately:

• Elevate legs if hypotension is present 1
• Sit patient upright if respiratory distress predominates (suggesting TACO) 2

Critical Monitoring

Monitor vital signs every 5-15 minutes including heart rate, blood pressure, temperature, respiratory rate, and oxygen saturation until stabilized. 2, 3

Assess peak airway pressure in intubated patients to monitor for worsening bronchospasm or pulmonary edema. 1

Monitor urine output and color to detect potential hemolytic reactions, which may present with hemoglobinuria alongside respiratory symptoms. 1, 2

Laboratory and Documentation

Notify the transfusion laboratory immediately and send the blood component bag with administration set for analysis. 2, 3

Collect mast cell tryptase levels at three time points to confirm anaphylaxis:

• Initial sample as soon as feasible (do not delay resuscitation)
• Second sample at 1-2 hours after symptom onset
• Third sample at 24 hours or in convalescence for baseline comparison 1

Obtain post-reaction blood samples including repeat crossmatch, complete blood count, coagulation studies, and blood cultures if septic reaction is suspected. 2, 3

Common Pitfalls to Avoid

Do not use steroids and antihistamines indiscriminately without first administering epinephrine for severe reactions—epinephrine is the definitive treatment for anaphylaxis and should never be delayed. 1

Do not attribute wheezing to other causes during anesthesia without considering transfusion reaction—general anesthesia may mask typical symptoms of both hemolytic and nonhemolytic reactions. 1

Do not restart the transfusion even if symptoms improve—the reaction may worsen with continued exposure. 2, 4

Do not give diuretics empirically for all cases of wheezing—while appropriate for TACO, diuretics are contraindicated in anaphylaxis or hypovolemic states. 1, 2

Post-Stabilization Care

Transfer to appropriate critical care area for continued monitoring and management. 1

Continue observation for at least 24 hours for severe reactions, as delayed complications may occur. 2

Consider washed blood products or premedication for future transfusions if allergic reaction is confirmed. 2, 3