What are the immediate steps to take in the event of a blood transfusion reaction?

Immediate Management of Blood Transfusion Reactions

Stop the Transfusion Immediately

When any signs or symptoms of a transfusion reaction appear, stop the transfusion immediately and maintain IV access with normal saline at a keep-vein-open rate. 1, 2, 3 This is the single most critical action that affects patient outcomes, as even small amounts of incompatible blood can cause devastating consequences including death. 4, 5, 6

Initial Assessment and Stabilization (First 5 Minutes)

Verify Patient and Product Identity

• Check patient identification bands against blood component compatibility labels for any clerical errors, as most hemolytic transfusion reactions result from ABO-incompatible blood administration due to misidentification. 1, 5

Assess ABCs and Vital Signs

• Evaluate Airway, Breathing, Circulation, and level of consciousness using a team-based approach. 1, 3
• Monitor heart rate, blood pressure, temperature, respiratory rate, and oxygen saturation immediately and repeat every 5-15 minutes until stabilized. 1, 2, 3
• Assess urine output and color to detect potential hemolytic reactions. 2, 3

Position Patient Based on Presentation

• Hypotension: Place in Trendelenburg position. 1
• Respiratory distress: Sit patient upright. 1
• Unconscious: Place in recovery position. 1

Notify Key Personnel

• Call for medical assistance immediately and note the time of reaction onset. 1, 3
• Notify the transfusion laboratory/blood bank immediately, as this can affect laboratory analysis and future transfusion decisions. 1, 2, 3

Reaction-Specific Management

Anaphylaxis (Wheezing, Hypotension, Respiratory Distress)

Administer epinephrine 0.01 mg/kg (maximum 0.5 mg) intramuscularly into the lateral thigh immediately. 1, 3 For adults, give 50 mcg IV (0.5 mL of 1:10,000 solution) initially if IV access is established. 3

• Repeat epinephrine every 5-15 minutes if bronchospasm persists or worsens. 1, 3
• Provide 100% oxygen and ensure adequate ventilation. 3
• Administer aggressive fluid resuscitation: 1-2 liters of normal saline at 5-10 mL/kg in first 5 minutes. 1, 3
• Give adjunctive medications: diphenhydramine 25-50 mg IV plus ranitidine 50 mg IV (H1 and H2 antagonists). 1
• Consider methylprednisolone 1-2 mg/kg IV every 6 hours. 1
• For persistent bronchospasm after initial epinephrine, administer IV salbutamol infusion or consider aminophylline or magnesium sulfate for refractory cases. 3

Critical Pitfall: Do not use steroids and antihistamines as first-line treatment without administering epinephrine for severe reactions—epinephrine is the only life-saving intervention. 3

Allergic Reactions (Urticaria, Pruritus, Rash Without Hypotension)

• Administer antihistamines (diphenhydramine 25-50 mg IV). 1
• If reaction progresses to include wheezing or hypotension, immediately escalate to anaphylaxis protocol. 1, 3

Fever (With or Without Other Symptoms)

Do not assume isolated fever is benign—fever within 6 hours after platelet transfusion may indicate bacterial contamination, a leading cause of transfusion-related mortality. 2

Risk Stratification:

• Fever + hypotension/tachycardia: Treat as hemolytic reaction or septic transfusion. 2
• Fever + respiratory symptoms within 1-6 hours: Consider TRALI (top three cause of transfusion-related deaths). 2
• Fever + oliguria/dark urine: Suspect hemolytic reaction with renal involvement. 2

Management:

• Collect blood cultures immediately before antibiotics if bacterial contamination suspected. 2
• Initiate broad-spectrum antibiotics immediately after blood cultures for suspected bacterial contamination. 2
• For suspected hemolytic reaction, provide aggressive fluid resuscitation to maintain urine output >100 mL/hour. 2
• Administer acetaminophen 650-1000 mg orally or IV for symptomatic fever control only after ruling out serious causes. 2

Critical Pitfall: General anesthesia and critical illness can mask early signs of serious reactions—do not continue transfusion despite "just fever." 2

Transfusion-Associated Circulatory Overload (TACO)

TACO is the most common cause of transfusion-related mortality and presents with acute respiratory compromise, pulmonary edema, tachycardia, and hypertension. 3

• Position patient upright. 1
• Consider administering diuretics (but contraindicated in anaphylaxis or hypovolemic states). 1, 3
• Provide respiratory support as needed. 1

Critical Pitfall: Do not give diuretics empirically for all cases of respiratory distress—they are contraindicated in anaphylaxis or hypovolemic states. 3

Transfusion-Related Acute Lung Injury (TRALI)

TRALI manifests with dyspnea, hypoxemia, and pulmonary edema within 1-6 hours of transfusion. 3

• Provide supportive respiratory care with oxygen and mechanical ventilation if needed. 3
• Avoid diuretics, as TRALI is not volume overload. 3

Laboratory Evaluation

Immediate Sample Collection

• Send the blood component bag with administration set back to the transfusion laboratory for analysis. 1, 2, 3
• Collect post-reaction blood samples for:
  • Repeat crossmatch and direct antiglobulin test (Coombs test). 1, 2
  • Complete blood count. 1, 2, 3
  • Coagulation studies. 1, 3
  • Visual inspection of plasma for hemolysis. 2
  • Blood cultures if bacterial contamination suspected. 1, 2, 3
• Obtain urine analysis for hemoglobinuria. 2
• Collect mast cell tryptase levels at three time points (immediately, 1-2 hours, and 24 hours) to confirm anaphylaxis. 3

Documentation and Monitoring

• Document pre-infusion assessments, description and grading of the reaction, time of onset, and all management steps taken. 1
• Continue monitoring vital signs every 5-15 minutes until resolution of symptoms. 1, 3
• For severe reactions, observe the patient for at least 24 hours, as delayed complications may occur. 1, 3
• Transfer to an appropriate critical care area for continued monitoring and management. 3

Prevention of Future Reactions

Critical Pitfall: Do not restart the transfusion even if symptoms improve—the reaction may worsen with continued exposure, and laboratory clearance is required. 2, 3

• Consider washed blood products for future transfusions if allergic reaction occurred. 1, 3
• Consider slower transfusion rates for patients at risk for TACO. 1
• Report all reactions to the hemovigilance system, as any symptom occurring within 24 hours of transfusion should be considered a transfusion reaction. 6