What is the management for a blood transfusion reaction?

Management of Blood Transfusion Reactions

Stop the transfusion immediately when any signs of a reaction are observed—this is the single most critical action that can affect patient outcome. 1, 2

Immediate Actions (First 5 Minutes)

• Stop the transfusion immediately upon observing any signs such as tachycardia, rash, breathlessness, hypotension, fever, or desaturation 1, 2
• Maintain IV access with normal saline to enable medication administration and fluid resuscitation 1, 2
• Call for medical assistance immediately and alert the transfusion laboratory 1, 3
• Assess ABCs (Airway, Breathing, Circulation) and level of consciousness 1
• Position the patient appropriately: Trendelenburg for hypotension, sitting upright for respiratory distress, or recovery position if unconscious 1, 3
• Administer high-flow oxygen (FiO₂ 100%) via non-rebreather mask 1, 3
• Send the blood unit with administration set to the transfusion laboratory for investigation 1

Vital Signs Monitoring

• Monitor continuously: heart rate, blood pressure, temperature, and respiratory rate (the most sensitive early indicator of serious reactions) 1, 2
• Assess urine output and color to detect hemolytic reactions 1, 2
• Monitor peak airway pressure to detect transfusion-related acute lung injury (TRALI) 1, 2
• Check vital signs at least every 15 minutes until symptom resolution 1

Reaction-Specific Management

Anaphylaxis/Severe Allergic Reaction

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

Transfusion-Associated Circulatory Overload (TACO)

• Administer IV furosemide immediately 3
• Sit patient upright and provide high-flow oxygen 3
• Monitor for signs of fluid overload including dyspnea, tachypnea, and use of accessory muscles 3

Mild to Moderate Reactions (Febrile Non-Hemolytic or Mild Allergic)

• For Grade 1 reactions: slow the infusion rate 1
• For Grade 2 reactions: slow or temporarily stop the infusion 1
• Administer antihistamines for urticaria or mild allergic symptoms 2

Hemolytic Reactions

• Monitor for hypotension, tachycardia, hemoglobinuria, and microvascular bleeding 2
• Maintain aggressive fluid resuscitation to preserve renal function 2

TRALI

• Provide critical care supportive measures focusing on respiratory support 2
• No specific therapy exists beyond stopping transfusion and instituting critical care measures 2
• Most patients recover within 96 hours, though TRALI remains among the top three causes of transfusion-related deaths 2

Special Considerations

Anesthetized Patients

• General anesthesia masks symptoms of both hemolytic and nonhemolytic reactions 2
• Signs of hemolytic reactions may be erroneously attributed to other causes in anesthetized patients 2
• Diagnosis during ongoing hemorrhage is particularly difficult 2

Patients on Vasopressors

• Avoid rapid transfusion due to increased TACO risk 1
• Ensure vital signs are checked at least every 15 minutes 1
• Consider separate IV access sites when administering blood products simultaneously with vasopressors 1

Prevention of Future Reactions

• Consider washed blood products for future transfusions if allergic reactions occurred 1, 3
• Use slower transfusion rates in high-risk patients (elderly, heart failure, renal failure, low body weight) 3
• Implement weight-based dosing of blood products to prevent volume overload 1, 3
• Ensure positive patient identification before transfusion using at least four core identifiers 1
• Visually check blood components for leakage, discoloration, or clots before administration 1

Critical Pitfalls to Avoid

• Never continue the transfusion while investigating the cause of symptoms—this can worsen potentially life-threatening reactions 3
• Never assume symptoms are unrelated to transfusion—always treat as a transfusion reaction until proven otherwise 3
• Do not overlook that respiratory rate is the most sensitive early indicator of serious reactions 2
• Remember that any symptom occurring within 24 hours of transfusion should be considered a transfusion reaction and reported to the hemovigilance system 4

Follow-Up

• Provide close observation for 24 hours for severe reactions 1
• Document the reaction and ensure traceability records are maintained for 30 years (statutory requirement) 5
• Report to the hospital transfusion committee for audit and protocol refinement 5