How should an ABO‑incompatible transfusion reaction be managed?

Management of ABO-Incompatible Transfusion Reaction

Stop the transfusion immediately, maintain IV access with normal saline, and initiate aggressive supportive care while simultaneously removing incompatible antibodies and free hemoglobin through plasma exchange therapy. 1, 2

Immediate Actions (First 15 Minutes)

• Stop the transfusion immediately and keep the IV line open with normal saline to maintain vascular access and support blood pressure 1
• Verify patient identification with four core identifiers and confirm ABO incompatibility through immediate repeat typing and crossmatch 1
• Monitor vital signs continuously, particularly respiratory rate, as dyspnea and tachypnea are early indicators of acute hemolytic reaction 1
• Send stat laboratory studies: free hemoglobin levels, direct antiglobulin test (DAT), complete blood count, coagulation panel (PT/PTT/fibrinogen), renal function (creatinine, BUN), and urinalysis for hemoglobinuria 2

Definitive Treatment Protocol

Plasma Exchange Therapy (Primary Intervention)

• Initiate plasma exchange therapy immediately to remove anti-A or anti-B antibodies and free hemoglobin, which are the direct causes of acute hemolytic reaction, disseminated intravascular coagulation (DIC), and acute kidney injury 2
• Plasma exchange can reduce free hemoglobin levels from 13 mg/dL to 2 mg/dL within 2 hours, preventing progression to multi-organ failure 2
• Continue plasma exchange until free hemoglobin levels normalize and hemolysis markers stabilize 2

Renal Support

• Initiate continuous hemodiafiltration (CHDF) if hemodynamic instability develops or acute kidney injury progresses, as this stabilizes hemodynamics while clearing hemoglobin breakdown products 2
• Maintain aggressive IV hydration with normal saline to promote diuresis and prevent hemoglobin precipitation in renal tubules 2

Management of Complications

• For DIC: Administer fresh frozen plasma, cryoprecipitate, and platelets as needed based on coagulation parameters and clinical bleeding 2
• For hypotension: Use vasopressors if fluid resuscitation alone is insufficient to maintain mean arterial pressure above 65 mmHg 2
• Monitor for acute respiratory distress syndrome (ARDS) and provide respiratory support as needed 1

Resuming Transfusion After ABO-Incompatible Reaction

Life-Threatening Anemia Protocol

• In life-threatening anemia, transfuse the least incompatible blood available immediately, as the risk of death from severe anemia outweighs the risk of additional transfusion reaction 1
• ABO compatibility takes absolute priority—use only ABO-compatible blood for any subsequent transfusions 1, 3
• Administer immunosuppressive therapy simultaneously with transfusion: IVIg at 0.4-1 g/kg/day for 3-5 days, high-dose corticosteroids, and consider rituximab to prevent additional alloantibody formation 1

Monitoring Requirements

• Complete vital sign documentation before transfusion, at 15 minutes after starting each unit, and within 60 minutes of completion 1
• Maintain continuous monitoring throughout transfusion for any signs of recurrent hemolytic reaction 1

Prevention of Future Incidents

• Obtain extended red cell antigen profile (genotype preferred over phenotype) for this patient, as they will require extended antigen matching for all future transfusions 1
• The type and screen validity is only 72 hours after this transfusion event, requiring repeat testing if additional transfusions are needed beyond 3 days 4
• Never assume vital sign changes are due to the patient's underlying condition—always consider transfusion reaction when changes occur during or shortly after transfusion 1

Critical Pitfalls to Avoid

• Do not delay plasma exchange therapy while waiting for laboratory confirmation—clinical suspicion of ABO incompatibility warrants immediate intervention 2
• Do not use antihistamines or steroids alone without plasma exchange, as these do not address the underlying antibody-mediated hemolysis 1, 2
• The primary cause of ABO-incompatible transfusions is human error in patient identification, not laboratory crossmatch failure—strict adherence to identification protocols is paramount 5