How to manage Packed Red Blood Cells (PRBC) transfusion reactions?

Management of PRBC Transfusion Reactions

Stop the transfusion immediately at the first sign of any reaction, maintain IV access with normal saline, call for help, and assess airway-breathing-circulation while determining if this is anaphylaxis requiring immediate epinephrine or a less severe reaction. 1

Immediate Recognition and Initial Actions

When any transfusion reaction is suspected, execute these steps within the first minute:

• Stop the blood transfusion immediately but maintain the IV line with normal saline to preserve venous access for medication administration and fluid resuscitation 1
• Call for medical assistance immediately and note the exact time of reaction onset 1, 2
• Assess the patient's airway, breathing, and circulation (ABC approach) and level of consciousness 3, 1
• Position the patient appropriately: Trendelenburg position for hypotension, sitting upright for respiratory distress, or recovery position if unconscious 3, 1
• Administer supplemental oxygen if needed 3, 1
• Monitor vital signs every 5-15 minutes including heart rate, blood pressure, temperature, respiratory rate, and oxygen saturation 1, 2
• Contact the transfusion laboratory immediately and send the blood unit with administration set for investigation 1

Determine Reaction Severity: Anaphylaxis vs. Less Severe Reactions

Signs of Anaphylaxis (Requires Immediate Epinephrine)

If the patient exhibits any of the following, treat as anaphylaxis:

• Bronchospasm or wheezing 2
• Hypotension (systolic BP drop >30 mmHg from baseline) 3
• Cardiovascular collapse or severe tachycardia 2
• Angioedema or laryngeal edema 3
• Severe urticaria with systemic symptoms 2

Management of Anaphylaxis

Epinephrine is the first-line treatment and must be given immediately:

• Administer epinephrine 0.2-0.5 mg (1 mg/mL) intramuscularly into the lateral thigh muscle 3, 1
• For patients already with IV access, give epinephrine 50 mcg IV (0.5 mL of 1:10,000 solution) 2
• Repeat epinephrine every 5-15 minutes if symptoms persist or worsen 3, 1, 2
• Provide aggressive fluid resuscitation with normal saline 1-2 L IV at 5-10 mL/kg in the first 5 minutes, followed by crystalloid or colloid boluses of 20 mL/kg 3, 1
• Administer H1/H2 antagonists: diphenhydramine 50 mg IV plus ranitidine 50 mg IV 3, 1
• Give corticosteroids at 1-2 mg/kg IV methylprednisolone every 6 hours 3, 1

For refractory hypotension despite epinephrine and fluids:

• Start dopamine 400 mg in 500 mL at 2-20 mcg/kg/min titrated to blood pressure response 3
• Consider vasopressin 25 units in 250 mL (0.1 U/mL) at 0.01-0.04 U/min 3
• If patient is on beta-blockers, administer glucagon 1-5 mg IV over 5 minutes 3
• If bradycardia develops, give atropine 600 mcg IV 3

For persistent bronchospasm after initial epinephrine:

• Administer IV salbutamol infusion as a bronchodilator 2
• Consider IV aminophylline or magnesium sulfate for refractory bronchospasm 2

Management of Non-Anaphylactic Reactions

Grade 1 Reactions (Mild symptoms without hemodynamic instability)

• Slow the rate of infusion but do not necessarily stop 3, 1
• Monitor vital signs closely 1
• Consider symptomatic treatment only if needed 3

Grade 2 Reactions (Moderate symptoms: fever, urticaria, mild dyspnea)

• Slow the rate or temporarily stop the infusion 3, 1
• Administer H1/H2 antagonists: diphenhydramine 50 mg IV plus ranitidine 50 mg IV 3, 1
• Give corticosteroids at 1-2 mg/kg IV methylprednisolone every 6 hours 3, 1
• For febrile reactions specifically, give IV paracetamol only (avoid indiscriminate steroid use) 3
• For allergic reactions specifically, give antihistamine only 3
• Restart infusion at 50% rate and titrate to tolerance once symptoms resolve 3

Grade 3/4 Reactions (Severe symptoms without anaphylaxis)

• Stop the infusion permanently 3
• Administer H1/H2 antagonists: diphenhydramine 50 mg IV plus ranitidine 50 mg IV 3, 1
• Give corticosteroids at 1-2 mg/kg IV methylprednisolone every 6 hours 3, 1
• Rechallenge is discouraged in severe reactions 3

Specific Reaction Types and Their Management

Transfusion-Associated Circulatory Overload (TACO)

TACO is now the most common cause of transfusion-related mortality 3:

• Presents with acute respiratory compromise, pulmonary edema, tachycardia, and hypertension (distinguishes from anaphylaxis) within 12 hours of transfusion 3, 2
• Do not give diuretics empirically without confirming TACO, as they are contraindicated in anaphylaxis or hypovolemic states 2
• If TACO is confirmed, administer diuretics and provide respiratory support 3
• Slow or stop transfusion and elevate head of bed 3

Febrile Non-Hemolytic Transfusion Reaction

• Most common adverse reaction, decreased by prestorage leukoreduction 3
• Treat with IV paracetamol only 3
• Avoid indiscriminate use of steroids and antihistamines 3
• Monitor for progression to more severe reaction 3

Acute Hemolytic Transfusion Reaction

• Assess urine output and color to monitor for hemolysis 1, 2
• Maintain urine output >100 mL/hour with aggressive fluid resuscitation 4
• Send post-reaction blood samples including repeat crossmatch, complete blood count, coagulation studies, and blood cultures 2
• Perform direct antiglobulin test (DAT) to detect antibody-coated red cells 5

Transfusion-Related Acute Lung Injury (TRALI)

• Presents with dyspnea, hypoxemia, and pulmonary edema within 1-6 hours of transfusion 2
• Monitor peak airway pressure in intubated patients 1, 2
• Provide supportive respiratory care with mechanical ventilation if needed 2

Laboratory Investigation

Immediately send to transfusion laboratory:

• The blood unit with administration set for bacterial culture and compatibility testing 1, 2
• Post-reaction blood samples for repeat crossmatch, complete blood count, direct antiglobulin test, and coagulation studies 2, 5
• Collect mast cell tryptase levels at three time points to confirm anaphylaxis 2
• First urine sample after reaction to check for hemoglobinuria 1, 2

Monitoring and Observation

• Monitor vital signs until complete resolution of symptoms 3, 1
• For severe reactions, provide 24-hour observation as delayed complications or biphasic reactions may occur 3, 1, 2
• Continue monitoring urine output and color for hemolytic reactions 1, 2
• In anesthetized patients, be aware that general anesthesia may mask symptoms of both hemolytic and nonhemolytic reactions 1

Prevention of Future Reactions

• Consider washed blood products for future transfusions if allergic reactions occurred 1, 2
• Use leukocyte-reduced blood products to minimize febrile reactions in patients requiring repeated transfusions 3
• Premedication with acetaminophen or antihistamine is seldom required for patients not planning long-term transfusion 3
• If repeated transfusions are required, use premedication to minimize adverse reactions 3
• For patients with history of severe reactions requiring ongoing transfusion, consider prophylactic immunosuppression such as rituximab 5
• Use slower transfusion rates in high-risk patients (age >70, heart failure, renal failure, low body weight) to prevent TACO 3
• Implement weight-based dosing of blood products 1

Critical Pitfalls to Avoid

• Never restart the transfusion even if symptoms improve, as the reaction may worsen with continued exposure 2
• Do not delay epinephrine in anaphylaxis by giving antihistamines or steroids first 3, 1, 2
• Do not use steroids and antihistamines indiscriminately without first determining reaction type 3, 2
• Do not attribute symptoms to other causes during anesthesia without considering transfusion reaction 1, 2
• Do not give diuretics empirically for all cases of respiratory distress without confirming TACO 2
• Do not transfuse rapidly in patients on vasopressors due to increased TACO risk 1
• Do not ignore subtle early symptoms such as patient expressing feeling "odd" or needing to urinate/defecate—these should prompt immediate vital sign assessment 3

Delayed Transfusion Reactions (3-14 Days Post-Transfusion)

• Present with flu-like symptoms, fever, arthralgias, myalgias, and unexplained anemia 5
• Stop any ongoing transfusion immediately and notify blood bank urgently 5
• Perform direct antiglobulin test (DAT) to detect antibody-coated red cells 5
• Avoid further transfusion unless absolutely life-threatening anemia exists, as additional transfusions may worsen hemolysis 5
• For severe delayed hemolytic reactions or hyperhemolysis syndrome, consider immunosuppressive therapy with IVIg, corticosteroids, or rituximab 5, 6
• Provide symptomatic treatment with NSAIDs or acetaminophen for mild to moderate reactions 5