Management and Treatment of Transfusion Reactions
Stop the transfusion immediately at the first sign of any reaction, maintain IV access with normal saline, assess ABCs, and call for medical assistance—this is the universal first step regardless of reaction type. 1
Initial Recognition and Immediate Actions
Prompt recognition is essential. Patients may feel odd, uncomfortable, or express a need to urinate or defecate before a reaction becomes apparent—take these symptoms seriously and immediately check blood pressure and pulse rate. 2
Universal First Steps (All Reaction Types)
- Stop the transfusion immediately when any signs appear (tachycardia, rash, breathlessness, hypotension, fever) 1
- Maintain IV access with normal saline for medication administration and fluid resuscitation 1
- Assess ABCs (Airway, Breathing, Circulation) and level of consciousness 2
- Position the patient appropriately: Trendelenburg for hypotension, sitting upright for respiratory distress, recovery position if unconscious 2, 1
- Administer oxygen if needed 2
- Call for medical assistance immediately 2
- Contact the transfusion laboratory urgently and send the blood unit with administration set for investigation 1
Management Based on Reaction Severity
Anaphylaxis (Life-Threatening)
If the patient meets criteria for anaphylaxis, epinephrine must be delivered immediately—this is non-negotiable. 2
Immediate Treatment:
- Epinephrine 0.2-0.5 mg (1 mg/mL) IM into the lateral thigh muscle, repeat every 5-15 minutes as needed 2, 3
- Aggressive fluid resuscitation: Normal saline 1-2 L IV at 5-10 mL/kg in first 5 minutes, then crystalloids or colloids in 20 mL/kg boluses followed by slow infusion 2
- H1/H2 antagonists: Diphenhydramine 50 mg IV plus ranitidine 50 mg IV 2
- Corticosteroids: 1-2 mg/kg IV methylprednisolone every 6 hours (prevents biphasic reactions but not critical for acute management) 2, 4
For Refractory Hypotension:
- If bradycardia: Atropine 600 μg IV 2
- Vasopressors if epinephrine and fluids fail:
- If patient on beta-blockers: Glucagon 1-5 mg IV infusion over 5 minutes 2
Mild to Moderate Reactions (Grade 1-2)
For Grade 1 reactions, slow the infusion rate; for Grade 2, slow or temporarily stop the infusion. 1
Treatment:
- H1/H2 antagonists: Diphenhydramine 50 mg IV plus ranitidine 50 mg IV 2
- Corticosteroids: 1-2 mg/kg IV methylprednisolone every 6 hours 2
- Restart infusion at 50% rate and titrate to tolerance after symptom resolution 2
Severe Non-Anaphylactic Reactions (Grade 3-4)
Stop the infusion completely—rechallenge is discouraged in severe reactions. 2
Treatment:
- H1/H2 antagonists: Diphenhydramine 50 mg IV plus ranitidine 50 mg IV 2
- Corticosteroids: 1-2 mg/kg IV methylprednisolone every 6 hours 2
- Do not restart the transfusion 2
Febrile Non-Hemolytic Reactions
These are the most common transfusion reactions (63.6% of acute reactions). 5
Management:
- Stop transfusion temporarily 1
- Administer antipyretics 2
- Consider H1/H2 antagonists and corticosteroids for symptom control 2
- May restart at slower rate if symptoms resolve and other causes excluded 2
Monitoring and Post-Reaction Care
Monitor vital signs continuously until complete resolution of symptoms. 2
Monitoring Requirements:
- Vital signs (heart rate, blood pressure, temperature, respiratory rate) checked at least every 15 minutes 1
- Urine output and color to monitor for hemolytic reactions 1
- Peak airway pressure to detect potential TRALI 1
- 24-hour observation is mandatory for severe reactions 2, 1
Laboratory Investigation:
- Direct antiglobulin test (DAT) to detect antibody-coated red cells in suspected hemolytic reactions 6
- Send blood unit and administration set to transfusion laboratory 1
Delayed Transfusion Reactions (3-14 Days Post-Transfusion)
Delayed reactions present with flu-like symptoms, arthralgias, myalgias, and fever—notify the blood bank immediately. 6
Management:
- Stop any ongoing transfusion and maintain IV access with normal saline 6
- Notify blood bank urgently and investigate for alloantibodies and hemolysis 6
- Avoid further transfusion unless life-threatening anemia exists, as additional transfusions may worsen hemolysis 6
- Symptomatic treatment: NSAIDs or acetaminophen for fever and pain 6
- For severe hyperhemolysis syndrome: Consider immunosuppressive therapy (IVIg, corticosteroids, or rituximab) 6
Prevention Strategies
The best prevention is avoiding unnecessary transfusions and maintaining a restrictive transfusion strategy. 7
Key Prevention Measures:
- Verify patient identity using at least four core identifiers before transfusion 1
- Visually inspect blood components for leakage, discoloration, or clots before administration 1
- Consider washed blood products for future transfusions if allergic reactions occurred 1
- Use slower transfusion rates if TACO is suspected 1
- Implement weight-based dosing to prevent volume overload 1
- Avoid transfusing blood stored ≥14 days when possible (3.85 times greater odds of reaction) 5
Critical Pitfalls to Avoid
General anesthesia may mask symptoms of transfusion reactions—maintain high index of suspicion in anesthetized patients. 1
Common Errors:
- Do not administer repeated epinephrine injections at the same site—vasoconstriction may cause tissue necrosis 3
- Do not use rapid transfusion in patients on vasopressors—increased risk of TACO 1
- Do not attribute hemolytic reaction symptoms to other causes in anesthetized or hemorrhaging patients 1
- Do not delay epinephrine in anaphylaxis—it must be given immediately, not after antihistamines 2
High-Risk Patients Requiring Close Monitoring:
- Previous transfusion history (3.3 times greater odds of reaction) 5
- History of abortion (4.2 times greater odds) 5
- Multi-unit transfusion ≥3 units (3.9 times greater odds) 5
- Patients on beta-blockers (may require glucagon for refractory hypotension) 2
Documentation Requirements
Accurate documentation is critical and should include pre-infusion status, all symptoms, timing, laboratory findings, and management interventions. 2, 6