Immediate Management of Acute Transfusion Reaction
Discontinue the transfusion immediately (Option B) – this is the single most critical intervention that can prevent progression to severe morbidity or mortality in this patient presenting with classic signs of an acute hemolytic transfusion reaction. 1, 2
Why Stop the Transfusion First
The patient's presentation of chest tightness, fever, nausea, and vomiting occurring minutes after starting transfusion represents a classic acute hemolytic transfusion reaction. 3, 4 The American Society of Anesthesiologists explicitly states that stopping the transfusion immediately at the first sign of any suspected transfusion reaction is the single most critical intervention. 1, 5
- The symptoms described (chest tightness, fever, nausea, vomiting) are mediated by complement cleavage products (C3a, C5a) activated by red cell antigen-antibody reactions, which can rapidly progress to shock, disseminated intravascular coagulation, and renal failure if transfusion continues. 3, 4
- Every additional milliliter of incompatible blood increases the severity of the reaction and worsens outcomes. 4, 6
Sequential Management After Stopping Transfusion
After immediately discontinuing the transfusion, maintain IV access with normal saline for medication administration and fluid resuscitation. 1, 2
Immediate Actions (First 5 Minutes)
- Contact the transfusion laboratory/blood bank immediately to report the reaction and initiate investigation. 1, 2
- Monitor vital signs every 5-15 minutes, including heart rate, blood pressure, temperature, respiratory rate, and oxygen saturation. 1, 5
- Send the blood unit with administration set back to the laboratory for investigation. 1, 2
- Double-check patient identification and blood component compatibility labels for clerical errors. 2, 5
Laboratory Workup
- Collect post-reaction blood samples for repeat crossmatch, direct antiglobulin test (Coombs test), complete blood count, PT, aPTT, fibrinogen, and visual inspection of plasma for hemolysis. 2, 5
- Monitor urine output and color for hemoglobinuria, which indicates intravascular hemolysis. 1, 5
Supportive Care Based on Severity
- Administer high-flow oxygen to address potential hypoxemia. 5
- Aggressive fluid resuscitation to maintain urine output >100 mL/hour for suspected hemolytic reaction to prevent renal failure. 2, 5
- Maintain adequate blood pressure (MAP >65-70 mmHg) with IV fluids, preparing for potential vasopressor support. 5
Why Other Options Are Incorrect
Diphenhydramine (Option A) is only appropriate for mild allergic reactions with urticaria, not for acute hemolytic reactions with systemic symptoms. 1 Administering antihistamines before stopping the transfusion would allow continued exposure to incompatible blood, worsening the hemolytic reaction. 4
Epinephrine (Option C) is reserved for anaphylaxis with life-threatening features like severe bronchospasm or cardiovascular collapse. 1 While this patient has chest tightness, the presentation is more consistent with acute hemolytic reaction than anaphylaxis, and stopping the transfusion takes priority regardless. 1, 2
Ondansetron (Option D) addresses only the symptom of nausea without treating the underlying life-threatening hemolytic reaction. 2 Symptomatic treatment should never precede stopping the transfusion. 1
Critical Pitfalls to Avoid
- Never continue the transfusion despite "just fever" or mild symptoms – general anesthesia and critical illness can mask early signs of serious reactions. 2
- Do not restart the transfusion before laboratory clearance, even if symptoms improve, as the reaction may worsen with continued exposure. 2
- Recognize that this patient's severe anemia (Hgb 5.2 g/dL) does not justify continuing an incompatible transfusion – the hemolytic reaction will worsen anemia and cause additional complications including DIC and renal failure. 4, 6