What is the management of a ward patient who desaturates during a blood transfusion?

Management of Desaturation During Blood Transfusion

Stop the transfusion immediately, maintain IV access with normal saline, assess airway-breathing-circulation, administer high-flow oxygen, and contact the transfusion laboratory urgently while monitoring vital signs every 15 minutes. 1, 2

Immediate Actions (First 5 Minutes)

Stop the blood transfusion immediately when desaturation is observed, as this is the most critical first step for any suspected transfusion reaction. 1, 2

• Keep the IV line open with normal saline to maintain vascular access for medication administration and fluid resuscitation. 2
• Call for immediate medical assistance and alert the transfusion laboratory. 1, 2
• Administer high-flow oxygen (FiO₂ 100%) via non-rebreather mask or appropriate delivery device. 3, 2
• Position the patient sitting upright if respiratory distress is present to optimize ventilation. 2

Rapid Clinical Assessment

Monitor vital signs immediately and continuously, including:

• Respiratory rate (most sensitive early indicator of serious transfusion reactions). 1
• Heart rate, blood pressure, and temperature. 1
• Oxygen saturation on pulse oximetry. 1
• Assess for signs of respiratory distress: tachypnea, dyspnea, use of accessory muscles. 1, 2

Check for signs of specific transfusion reactions:

• TACO (Transfusion-Associated Circulatory Overload): hypertension, tachycardia, jugular venous distension, pulmonary edema, frothy sputum. 1
• TRALI (Transfusion-Related Acute Lung Injury): acute hypoxemia, bilateral pulmonary infiltrates, normal cardiac pressures. 4
• Anaphylaxis: hypotension, bronchospasm, urticaria, angioedema. 2
• Hemolytic reaction: fever, hypotension, dark urine, flank pain. 2

Laboratory and Diagnostic Workup

Send the blood unit with administration set back to the transfusion laboratory immediately for investigation. 1, 2

Obtain urgent investigations:

• Arterial blood gas to assess oxygenation and acid-base status. 1
• Repeat full blood count and coagulation screen. 1
• Urine output and color assessment to monitor for hemolysis. 2
• Chest X-ray if TACO or TRALI suspected. 1, 4

Specific Management Based on Clinical Picture

If TACO Suspected (Most Common Cause of Transfusion-Related Mortality)

TACO is now the leading cause of transfusion-related death and occurs most commonly in older patients (>70 years), those with heart failure, renal failure, or low body weight. 1

• Administer IV furosemide (loop diuretic) immediately. 1
• Sit patient upright and provide high-flow oxygen. 1, 2
• Monitor fluid balance strictly. 1
• Consider non-invasive ventilation or mechanical ventilation if respiratory failure develops. 1, 4

If TRALI Suspected

TRALI typically presents with acute hypoxemia and bilateral pulmonary infiltrates within 6 hours of transfusion. 4

• Provide respiratory support with mechanical ventilation if needed (most cases require 2-4 days of ventilation). 4
• Give cardiovascular support as needed. 4
• Most cases show clinical improvement within the first few hours and resolve completely within 96 hours. 4

If Anaphylaxis Suspected

• Administer epinephrine 0.2-0.5 mg IM immediately, repeating every 5-15 minutes as needed. 2
• Give fluid resuscitation with normal saline 1-2 L IV at 5-10 mL/kg in first 5 minutes. 2
• Administer H1/H2 antagonists: diphenhydramine 50 mg IV plus ranitidine 50 mg IV. 2
• Give corticosteroids equivalent to 1-2 mg/kg IV methylprednisolone every 6 hours. 2

If Mild Febrile or Allergic Reaction

Current recommendations advise against indiscriminate use of steroids and antihistamines; instead, tailor treatment to specific symptoms. 1

• For febrile reactions: administer IV paracetamol only. 1
• For allergic reactions: administer antihistamine only. 1
• Slow or temporarily stop the infusion for Grade 1-2 reactions. 2

Ongoing Monitoring and Documentation

• Monitor vital signs every 15 minutes until symptoms resolve. 2
• For severe reactions, provide close observation for 24 hours in a monitored setting. 2
• Document the reaction thoroughly, including timing, symptoms, vital signs, and interventions. 1
• Complete transfusion reaction reporting as per local protocols. 1

Prevention of Future Reactions

• Consider washed blood products for future transfusions if allergic reactions occurred. 2
• Use slower transfusion rates in high-risk patients (elderly, heart failure, renal failure, low body weight). 1
• Implement weight-based dosing of blood products to prevent volume overload. 1, 2
• Consider prophylactic diuretics in high-risk patients before future transfusions. 1

Critical Pitfalls to Avoid

Do not continue the transfusion while investigating the cause of desaturation, as this can worsen potentially life-threatening reactions. 1, 2

• Do not assume desaturation is unrelated to transfusion—always treat as a transfusion reaction until proven otherwise. 1
• Do not delay oxygen administration while assessing the patient. 3, 2
• Do not use rapid transfusion rates in elderly or cardiac patients without careful monitoring. 1
• Remember that general anesthesia may mask symptoms of transfusion reactions in perioperative patients. 2