From the Guidelines
Management of a blood transfusion reaction requires immediate action, with the first step being to stop the transfusion immediately and maintain IV access with normal saline through a new administration set. This is crucial in preventing further complications and ensuring the patient's safety, as emphasized in the guidelines for the use of blood components and their alternatives 1. The management of transfusion reactions should prioritize the patient's morbidity, mortality, and quality of life, and the most recent and highest quality study should be considered when making a definitive recommendation.
Key Steps in Managing Transfusion Reactions
- Stop the transfusion immediately and maintain IV access with normal saline through a new administration set
- Notify the physician and blood bank, and send the blood bag and tubing for investigation
- Obtain vital signs including temperature, blood pressure, heart rate, respiratory rate, and oxygen saturation
- Collect post-transfusion blood and urine samples for testing
- Treatment depends on the type of reaction, with options including:
- Diphenhydramine 25-50mg IV/PO for mild allergic reactions
- Epinephrine 0.3-0.5mg IM (1:1000 solution), hydrocortisone 100mg IV, and maintaining airway for anaphylactic reactions
- Acetaminophen 650mg PO/IV for febrile non-hemolytic reactions
- Aggressive IV fluids, maintaining urine output with furosemide 20-40mg IV if needed, and monitoring for DIC and renal failure for acute hemolytic reactions
- Oxygen support and possibly mechanical ventilation for TRALI (transfusion-related acute lung injury)
- Broad-spectrum antibiotics for bacterial contamination
Special Considerations
In patients with sickle cell disease (SCD), hyperhemolysis can occur with no identifiable antibody and a negative direct antiglobulin test, and recognition is critical to prevent further transfusions and potential multiorgan failure and death 1. In such cases, transfusion with extended matched red cells that also lack the offending antigen should be considered, and treatments such as IVIg, high-dose steroids, eculizumab, and/or rituximab may be used to manage hyperhemolysis. However, the optimal management remains unclear, and further research is needed to determine the best course of action.
From the Research
Management of Blood Transfusion Reactions
- Blood transfusions are generally safe but can carry considerable risks, and when a reaction is suspected, it is critical to stop the transfusion immediately and report the reaction to the blood bank 2.
- The management of blood transfusion reactions involves early identification, immediate interruption of the transfusion, early consultation of the hematologic and ICU departments, and fluid resuscitation 3.
- Clinical strategies may reduce the likelihood of reactions and improve patient outcomes, including avoiding unnecessary transfusions and maintaining a transfusion-restrictive strategy 4, 3.
Types of Transfusion Reactions
- Acute adverse reactions to transfusion occur within 24 hours and include acute hemolytic transfusion reaction, febrile nonhemolytic transfusion reaction, allergic and anaphylactic reactions, and transfusion-related acute lung injury, transfusion-related infection or sepsis, and transfusion-associated circulatory overload 4.
- Delayed transfusion adverse reactions develop 48 hours or more after transfusion and include erythrocyte and platelet alloimmunization, delayed hemolytic transfusion reactions, posttransfusion purpura, transfusion-related immunomodulation, transfusion-associated graft versus host disease, and, with long-term transfusion, iron overload 4.
- The most common type of transfusion reaction is allergic reaction, followed by febrile nonhemolytic reaction and anaphylactoid reaction 5.
Diagnosis and Treatment
- Symptoms of transfusion reactions are often overlapping and nonspecific, and any symptom occurring within 24 h of a blood transfusion should be considered a transfusion reaction and referred to the hemovigilance reporting system 2, 3.
- New evidence-based algorithms of transfusion, newer blood screening methods and donor policies and deferrals, new laboratory testing, electronic verification systems, and improved hemovigilance lead to the avoidance of unnecessary transfusions and decrease the incidence of serious transfusion reactions 2.
- Transfusion reactions may have a negative impact on organ function, and patients who had transfusion reactions were older and had more comorbidities, and acute kidney injury was more prevalent among those who had transfusion reactions 5.