What are the immediate steps to take in the event of a packed red blood cell (PRBC) transfusion reaction?

Immediate Management of Packed Red Blood Cell Transfusion Reaction

Stop the transfusion immediately and keep the IV line open with normal saline—this is the single most critical action that directly impacts patient survival. 1, 2

First 60 Seconds: Critical Actions

Stop the transfusion immediately at the first sign of any adverse reaction, as continuing transfusion worsens outcomes and can be fatal. 1, 2

Maintain IV access with normal saline through the existing line to preserve venous access for emergency medications and prevent circulatory collapse. 3, 4

Notify the blood bank immediately and return the blood product with all tubing and administration sets, as this allows investigation of potential bacterial contamination or clerical errors that could affect other patients. 5, 1

Assess airway, breathing, and circulation with immediate focus on:

• Signs of anaphylaxis (stridor, wheezing, hypotension, urticaria) 2
• Respiratory distress suggesting transfusion-related acute lung injury (TRALI) or circulatory overload (TACO) 6, 2
• Hemodynamic instability indicating acute hemolytic reaction 1, 2

Immediate Clinical Assessment

Administer high-flow oxygen to maintain SpO2 >94%, as hypoxemia commonly accompanies serious transfusion reactions including TRALI and acute hemolytic reactions. 3, 4

Obtain vital signs every 5-15 minutes including temperature, blood pressure, heart rate, respiratory rate, and oxygen saturation to detect progression of the reaction. 2

Perform focused physical examination looking specifically for:

• Fever (suggests febrile non-hemolytic reaction or bacterial contamination) 6, 2
• Urticaria or flushing (indicates allergic reaction) 6, 2
• Dyspnea with bilateral crackles (suggests TACO) or hypoxemia without volume overload (suggests TRALI) 2
• Flank pain, dark urine, or bleeding from multiple sites (indicates acute hemolytic reaction with DIC) 1, 2

Laboratory Investigation

Draw immediate blood samples from the opposite arm (not the transfusion site) including:

• Complete blood count to assess for hemolysis 2
• Direct antiglobulin test (Coombs) to detect antibody-coated red cells 1, 2
• Coagulation studies (PT, aPTT, fibrinogen) if DIC suspected 3, 4
• Renal function and electrolytes to assess for acute kidney injury 2
• Blood cultures if bacterial contamination suspected (fever >39°C or septic shock) 2

Examine the first post-transfusion urine for hemoglobinuria (pink or red urine indicating intravascular hemolysis), as this is a critical early sign of acute hemolytic transfusion reaction. 1, 2

Send the blood bag and tubing to the blood bank for repeat crossmatch, direct antiglobulin test, bacterial culture, and visual inspection for hemolysis. 5, 1

Specific Treatment Based on Reaction Type

For Allergic Reactions (urticaria, pruritus without hemodynamic compromise):

• Administer antihistamines (diphenhydramine 25-50 mg IV) and monitor for 30 minutes. 6, 2
• Transfusion may be resumed cautiously if symptoms resolve completely and no other concerning features develop. 6

For Anaphylaxis (hypotension, bronchospasm, angioedema):

• Administer epinephrine immediately (0.3-0.5 mg IM, repeat every 5-15 minutes as needed) as this is life-saving. 2
• Give aggressive IV fluid resuscitation with crystalloids. 2
• Administer corticosteroids (hydrocortisone 100-200 mg IV) and H1/H2 blockers. 2

For Febrile Non-Hemolytic Reaction (fever >1°C rise, chills):

• Administer antipyretics (acetaminophen 650-1000 mg) and provide supportive care. 6, 2
• Rule out more serious reactions (hemolytic reaction, bacterial contamination) before attributing symptoms to benign febrile reaction. 2

For Suspected Acute Hemolytic Reaction (fever, hypotension, flank pain, hemoglobinuria):

• Maintain aggressive IV hydration with normal saline at 150-200 mL/hour to maintain urine output >100 mL/hour and prevent acute tubular necrosis. 2
• Monitor for DIC with serial coagulation studies every 4-6 hours. 3, 7
• Consider diuretics (furosemide) if fluid overload develops, but only after adequate volume resuscitation. 2

For TRALI (acute hypoxemia, bilateral infiltrates, within 6 hours of transfusion):

• Provide aggressive respiratory support with high-flow oxygen or mechanical ventilation as needed. 2
• Avoid diuretics as TRALI is non-cardiogenic pulmonary edema and diuresis worsens outcomes. 2
• Consult ICU immediately for potential intubation and ventilatory support. 2

For TACO (dyspnea, hypertension, elevated JVP, pulmonary edema):

• Administer diuretics (furosemide 20-40 mg IV) to reduce volume overload. 2
• Elevate head of bed and provide supplemental oxygen. 2
• Slow or stop further transfusions until volume status optimized. 2

Documentation and Reporting

Document the reaction thoroughly in the medical record including: time of reaction onset, volume transfused before stopping, vital signs, symptoms, and all interventions performed. 5

Complete transfusion reaction report for the hospital transfusion committee and hemovigilance system, as this is a statutory requirement with records maintained for 30 years. 5

Critical Pitfalls to Avoid

Never continue the transfusion "to see if symptoms worsen"—any symptom within 24 hours of transfusion should be considered a reaction requiring immediate cessation. 2

Never assume mild symptoms are benign without ruling out serious reactions, as early signs of acute hemolytic reaction or bacterial contamination can initially appear minor. 1, 2

Never delay epinephrine in anaphylaxis while attempting antihistamines first, as this increases mortality. 2

Never give diuretics for TRALI, as this is non-cardiogenic pulmonary edema and diuresis does not improve outcomes and may worsen hypotension. 2

Never transfuse additional units until the blood bank has investigated the reaction and confirmed compatibility, as this could worsen an ongoing hemolytic reaction. 1, 2