Blood Transfusion Reaction Ward Management
Immediate Critical Actions
Stop the transfusion immediately at the first sign of any suspected reaction—this single intervention is the most critical step that can prevent progression to severe morbidity or mortality. 1
First 5 Minutes
Maintain IV access with normal saline to preserve a route for medication administration and fluid resuscitation while the blood product is disconnected 1
Monitor vital signs every 5-15 minutes, including heart rate, blood pressure, temperature, respiratory rate, and oxygen saturation to detect deterioration early 1
Administer high-flow oxygen (high FiO₂) immediately to address potential hypoxemia, as respiratory compromise is a common feature of serious transfusion reactions including TRALI and TACO 1
Contact the transfusion laboratory immediately to report the reaction and initiate investigation—this is mandatory for all suspected reactions 1
Verification and Documentation
Double-check all documentation for administration errors, particularly patient identification and blood component compatibility, as clerical errors remain a leading cause of serious reactions 1
Visually inspect the blood bag for leakage, discoloration, clots, or clumps that might indicate bacterial contamination 1
Laboratory Investigation
Send baseline labs immediately to guide diagnosis and management 1:
- Complete blood count
- PT, aPTT, Clauss fibrinogen (to detect coagulopathy)
- Direct antiglobulin test (DAT) for hemolytic reactions
- Repeat cross-match
- Blood cultures if bacterial contamination suspected 1
Specific Management Based on Reaction Type
TACO (Transfusion-Associated Circulatory Overload)
TACO is now the most common cause of transfusion-related mortality, occurring during or up to 12 hours after transfusion 1
Clinical features: Acute respiratory distress, pulmonary edema, hypertension, elevated JVP, positive fluid balance 1
Treatment: Immediate diuretic therapy (furosemide) and upright positioning 1
High-risk patients: Age >70 years, heart failure, renal failure, hypoalbuminemia, non-bleeding patients 1
TRALI (Transfusion-Related Acute Lung Injury)
TRALI presents with non-cardiogenic pulmonary edema appearing 1-2 hours after transfusion 1
Clinical features: Hypoxemia, fever, dyspnea, bilateral infiltrates on chest X-ray, fluid in endotracheal tube if intubated 1
Critical distinction: Avoid diuretics in TRALI—they are ineffective and potentially harmful 1
Treatment: Critical care supportive measures, oxygen therapy, mechanical ventilation if needed 1
Most commonly implicated products: Fresh frozen plasma and platelet concentrates due to donor leukocyte antibodies 1
Hemodynamic Support
Maintain mean arterial pressure >65-70 mmHg with IV fluids initially 1
Prepare for escalation with vasopressors, intubation equipment, and resuscitation medications readily available at bedside 1
Reporting Requirements
Notify the blood bank for all reactions—TRALI and other serious reactions are significantly underdiagnosed and underreported despite being leading causes of transfusion-related mortality 1
Report to the patient's general practitioner as this removes them from the donor pool if they have antibodies 1
Document in hemovigilance system—any symptom occurring within 24 hours of transfusion should be considered a transfusion reaction and reported 2
Common Pitfalls to Avoid
Never continue the transfusion while "monitoring" symptoms—immediate cessation is non-negotiable 1, 3
Don't give diuretics for TRALI—this is non-cardiogenic pulmonary edema and diuretics are ineffective 1
Don't delay oxygen therapy while waiting for diagnosis—hypoxemia can rapidly worsen 1
Don't assume mild symptoms are benign—fever and chills can herald serious hemolytic reactions or bacterial contamination 2
Don't forget to maintain IV access—disconnecting the blood product doesn't mean removing venous access 1