What are the management steps for suspected transfusion-related complications, including acute hemolytic reactions, Transfusion-Related Acute Lung Injury (TRALI), allergic reactions, and Transfusion-Associated Circulatory Overload (TACO)?

Management of Transfusion-Related Complications

Stop the transfusion immediately at the first sign of any suspected transfusion reaction—this is the single most critical intervention that can prevent progression to severe morbidity or mortality. 1, 2, 3

Immediate Actions for Any Suspected Transfusion Reaction

• Halt the transfusion immediately but maintain IV access with normal saline for medication administration and fluid resuscitation 1, 3
• Contact the transfusion laboratory immediately to report the reaction and initiate investigation 1, 3
• Monitor vital signs every 5-15 minutes: heart rate, blood pressure, temperature, respiratory rate, and oxygen saturation 1, 3
• Double-check all documentation for administration errors, particularly patient identification and blood component compatibility 1

Acute Hemolytic Transfusion Reaction (AHTR)

Recognition

• Most commonly caused by human error and failure to apply rigorous cross-checks of patient and blood component blood groups 4
• Presents with fever, hypotension, tachycardia, back/flank pain, and dark urine (hemoglobinuria) 2, 3

Management

• Stop transfusion and maintain IV access with aggressive normal saline resuscitation 3
• Assess urine output and color to detect hemoglobinuria 3
• Send blood cultures, repeat crossmatch, complete blood count, coagulation studies, and direct antiglobulin test 3
• Notify the patient's general practitioner as this removes them from the donor pool 1

Transfusion-Related Acute Lung Injury (TRALI)

Recognition

• Presents with non-cardiogenic pulmonary edema appearing 1-2 hours after transfusion 2
• Key features: hypoxemia, fever, dyspnea, fluid in endotracheal tube, bilateral pulmonary infiltrates 2
• Fresh frozen plasma (FFP) and apheresis platelets carry the highest risk due to high plasma volumes containing leukocyte antibodies 2

Management

• Immediately cease transfusion 2
• Provide critical care supportive measures and oxygen therapy—this is the cornerstone of treatment 2, 3
• Do NOT give diuretics—they are ineffective and potentially harmful in TRALI 2
• Focus on respiratory support with mechanical ventilation if needed 2
• Report to the blood bank as TRALI is underdiagnosed and underreported despite being a leading cause of transfusion-related mortality 1

Transfusion-Associated Circulatory Overload (TACO)

Recognition

• Now the most common cause of transfusion-related mortality and major morbidity 2
• Occurs during or up to 12 hours after transfusion 2
• Key features: acute respiratory distress, pulmonary edema, cardiovascular changes (hypertension, tachycardia), jugular venous distension, evidence of fluid overload 2

High-Risk Patients

• Age >70 years 2
• Non-bleeding patients receiving transfusion 2
• Heart failure, renal failure, hypoalbuminemia 2

Management

• Stop transfusion immediately 2
• Administer diuretic therapy (unlike TRALI, diuretics ARE indicated for TACO) 2
• Provide oxygen and respiratory support as needed 2
• For future transfusions: use slower transfusion rates, body weight-based dosing, and monitor vital signs and fluid balance closely 2

Allergic and Anaphylactic Reactions

Recognition

• Range from mild urticaria and pruritus to life-threatening anaphylaxis with bronchospasm and hypotension 1, 5
• Typically occur within minutes to hours of transfusion 5

Management

• Stop transfusion immediately 1
• Mild allergic reactions: administer antihistamines 1
• Severe/anaphylactic reactions: give intramuscular or intravenous epinephrine immediately 1
• Consider corticosteroids for moderate-to-severe reactions 1
• For future transfusions: consider washed blood products or plasma-free components in patients with history of allergic reactions 3, 4
• Pre-medication with antihistamines may be considered for patients with prior reactions 4

Bacterial Contamination/Septic Transfusion Reaction

Recognition

• Presents similarly to TACO and TRALI with fever, hypotension, and respiratory distress 2, 3
• Must be considered in the differential diagnosis of any acute transfusion reaction 2, 3

Management

• Stop transfusion immediately 3
• Send blood cultures from patient and remaining blood component 3
• Administer broad-spectrum antibiotics immediately if bacterial contamination is suspected 3
• Provide aggressive fluid resuscitation and vasopressor support as needed 3

Critical Monitoring Parameters

• Pre-transfusion, 15 minutes after starting, and at completion are minimum monitoring timepoints 1
• Any signs of transfusion reaction (tachycardia, rash, breathlessness, hypotension, fever) require immediate cessation and laboratory notification 1
• In pregnant patients, continuous fetal monitoring is essential to assess fetal well-being 3

Prevention Strategies

• Minimize exposure to blood components—this is fundamental to avoiding all transfusion reactions 4
• Use electronic transfusion management systems rather than manual checking when available 1
• Ensure positive patient identification with four core identifiers (first name, last name, date of birth, patient ID number) on wristband 1
• Visually inspect blood components for leakage, discoloration, clots, or clumps before administration 1
• Transfuse single units in non-hemorrhaging patients and reassess before giving additional units 1
• Blood banks have implemented male-only plasma donors to reduce TRALI risk 2