Acute Hemolytic Transfusion Reaction
This patient is experiencing an acute hemolytic transfusion reaction (AHTR), which represents a life-threatening medical emergency requiring immediate cessation of the transfusion. The clinical triad of pain at the IV site, chest tightness, and fever occurring within minutes of blood transfusion is pathognomonic for AHTR 1.
Why This is AHTR and Not the Other Options
The timing and symptom constellation definitively distinguish AHTR from other transfusion reactions:
Febrile non-hemolytic reaction presents with isolated fever and chills (incidence 1.1-2.15%) but critically lacks the characteristic pain at the IV site and does not cause acute respiratory distress or hemodynamic instability 1
Allergic reaction typically manifests with urticaria, pruritus, and skin flushing rather than IV site pain, and respiratory symptoms result from bronchospasm or laryngeal edema, not the acute dyspnea from systemic inflammation seen in AHTR 1
Bacterial contamination can present similarly but typically occurs within 6 hours after platelet transfusion specifically, and the immediate onset (within minutes) with the classic triad makes AHTR more likely 2, 3
Immediate Management Algorithm
Stop the transfusion immediately—this is the single most critical intervention that can prevent progression to severe morbidity or mortality 1, 4:
Maintain IV access with normal saline for medication administration and fluid resuscitation 1
Administer high-flow oxygen (high FiO₂) to address potential hypoxemia 4
Monitor vital signs every 5-15 minutes, including heart rate, blood pressure, temperature, respiratory rate, and oxygen saturation 1, 4
Maintain mean arterial pressure >65-70 mmHg with IV fluid resuscitation (normal saline bolus 1000-2000 mL) 1, 4
Critical Laboratory Workup
Send urgent laboratory studies immediately 1, 4:
- Complete blood count
- Direct antiglobulin test (Coombs test)
- Repeat crossmatch
- PT, aPTT, Clauss fibrinogen
- Visual inspection of plasma for hemolysis
- Urine analysis for hemoglobinuria
Return the blood component bag with administration set to the transfusion laboratory for investigation 1
Pathophysiology and Clinical Consequences
The clinical manifestations result from complete complement activation, formation of anaphylatoxins (C3a, C5a), and release of cytokines causing systemic inflammatory response syndrome 5, 6. This cascade leads to:
- Hypotension and shock
- Disseminated intravascular coagulation
- Diffuse bleeding
- Disruption of microcirculation leading to renal failure 5, 6
The risk of AHTR is approximately 1:70,000 per unit, with an estimated mortality risk of 1:1,250,000 RBC units transfused 1, 5.
Critical Pitfalls to Avoid
Do not wait to confirm the reaction type before stopping the transfusion 4. The first 10 minutes of infusion are critical—immediate reactions typically occur within the first minute 4.
Do not assume this is a benign febrile reaction simply because fever is present. The combination of IV site pain, respiratory distress, and fever within minutes mandates treating this as AHTR until proven otherwise 1.
Double-check all documentation for administration errors, particularly patient identification and blood component compatibility, as clerical errors remain the leading cause of ABO-incompatible transfusions 4, 7.