What to do if a patient has a blood transfusion reaction?

Management of Blood Transfusion Reactions

Stop the transfusion immediately at the first sign of any suspected reaction—this is the single most critical intervention that can prevent progression to severe morbidity or mortality. 1

Immediate Actions (First 5 Minutes)

Stop the transfusion and maintain IV access with normal saline to preserve venous access for medication administration and fluid resuscitation. 2, 1

• Monitor vital signs every 5-15 minutes: heart rate, blood pressure, temperature, respiratory rate, and oxygen saturation 2, 1
• Administer high-flow oxygen (high FiO2) immediately to address potential hypoxemia 1
• Double-check all documentation for administration errors, particularly patient identification and blood component compatibility labels—clerical errors are a leading cause of fatal reactions 1, 3
• Contact the transfusion laboratory/blood bank immediately to report the reaction and initiate investigation 2, 1

Clinical Assessment and Risk Stratification

Assess for specific symptom patterns that indicate reaction severity:

High-Risk Presentations Requiring Aggressive Management:

• Pain at IV site + difficulty breathing + fever within 10 minutes = acute hemolytic transfusion reaction (medical emergency) 4
• Fever + hypotension + tachycardia = possible hemolytic reaction or bacterial contamination (potentially fatal) 3
• Respiratory distress within 1-6 hours = possible TRALI (leading cause of transfusion-related mortality) 1, 3
• Fever within 6 hours after platelet transfusion = bacterial contamination until proven otherwise 3

Management Based on Presentation:

For hemolytic reaction (pain/fever/dyspnea):

• Maintain mean arterial pressure >65-70 mmHg with IV fluid resuscitation 1, 4
• Aggressive fluid resuscitation to maintain urine output >100 mL/hour to prevent renal failure 3
• Prepare vasopressors, intubation equipment, and resuscitation medications 1

For suspected bacterial contamination:

• Obtain blood cultures immediately before antibiotics 3
• Initiate broad-spectrum antibiotics after cultures 3

For respiratory distress (TRALI/TACO):

• TACO: administer diuretics, slow future transfusion rates 1
• TRALI: provide critical care supportive measures and oxygen therapy—avoid diuretics (ineffective for TRALI) 1

Laboratory Investigation

Send immediately:

• Blood component bag with administration set back to transfusion laboratory 1, 3
• Post-reaction blood samples: complete blood count, PT, aPTT, Clauss fibrinogen, direct antiglobulin test (DAT), repeat cross-match 1, 4
• Visual inspection of plasma for hemolysis 3, 4
• Urine analysis for hemoglobinuria 3, 4
• Blood cultures if bacterial contamination suspected 3

Symptomatic Treatment

For fever: Acetaminophen 650-1000 mg orally or IV 3

For life-threatening reactions: Administer antihistamine, steroid drugs, or intramuscular/intravenous adrenaline as indicated 2

Critical Pitfalls to Avoid

• Never continue the transfusion despite "just fever"—general anesthesia and critical illness can mask early signs of serious reactions 3
• Never assume fever is always benign febrile non-hemolytic reaction—bacterial contamination from platelets can present with isolated fever and is potentially fatal 3
• Never restart the transfusion before laboratory clearance, even if symptoms improve—the reaction may worsen with continued exposure 3
• Never give diuretics for TRALI—this is non-cardiogenic pulmonary edema and diuretics are ineffective 1

Documentation and Reporting

• Notify the patient's general practitioner—receiving blood components removes them from the donor pool 1
• Report to blood bank—TRALI and other serious reactions are underdiagnosed and underreported despite being leading causes of transfusion-related mortality 1
• Document the reaction according to local protocols for hemovigilance 5