Medications During Blood Transfusion

Routine Blood Transfusion: No Prophylactic Medications

For routine blood transfusions, do not administer prophylactic medications such as steroids or antihistamines indiscriminately. 1

The most recent 2025 Association of Anaesthetists guidelines explicitly advise against routine premedication for standard transfusions, representing a significant shift from older practices. 1 This recommendation is based on evidence that:

Repeated steroid doses may further suppress immunity in already immunocompromised patients 1
Prophylactic medications have not been shown to prevent serious transfusion reactions 1
Indiscriminate use masks early warning signs of genuine reactions 1

Essential Monitoring Instead of Medications

Rather than medications, implement strict vital sign monitoring: 1

Before transfusion (within 60 minutes): baseline respiratory rate, pulse, blood pressure, temperature 1
15 minutes after starting each unit: repeat all vital signs 1
Within 60 minutes of completion: final vital sign check 1
Respiratory rate is critical as dyspnea and tachypnea are early symptoms of serious reactions 1

Patients with Prior Febrile Non-Hemolytic Reactions

For febrile reactions, administer only intravenous paracetamol (acetaminophen). 1

The 2025 guidelines recommend a personalized approach tailored to the specific reaction type: 1

Red blood cell units are typically associated with febrile-type reactions 1
Do not use steroids or antihistamines for febrile reactions 1
IV paracetamol addresses fever without immunosuppression 1

Patients with Prior Allergic Reactions

For allergic reactions, administer only an antihistamine. 1

Key considerations: 1

Plasma and platelet products more commonly cause allergic reactions than red blood cells 1
Use antihistamines alone without adding steroids 1
If severe reaction or anaphylaxis is suspected, immediately follow local anaphylaxis protocols (epinephrine, IV fluids, airway management) 1

Massive Transfusion Protocol: Specific Medications Required

Tranexamic Acid (Primary Antifibrinolytic)

Administer tranexamic acid 1 gram IV bolus over 10 minutes, followed by 1 gram infusion over 8 hours. 1

This represents the standard of care for massive hemorrhage: 1

Inhibits plasminogen activation and prevents fibrinolysis 1
CRASH-2 trial established this dosing regimen 1
Few adverse events except seizures at high doses 1
Contraindicated in subarachnoid hemorrhage due to risk of cerebral edema and infarction 1
Use cautiously in renal impairment as drug is renally excreted 1

Calcium Replacement

Monitor and correct hypocalcemia during massive transfusion. 1

Citrate in stored blood products binds calcium, causing: 1

Impaired coagulation (calcium is essential for clotting cascade) 1
Cardiac dysfunction 1
Regular monitoring and IV calcium replacement required 1

Magnesium Replacement

Monitor and correct hypomagnesemia during massive transfusion. 1

Hypomagnesemia commonly occurs with massive transfusion and requires correction. 1

Vitamin K and Prothrombin Complex Concentrate (For Warfarin Reversal)

If patient is on warfarin, administer IV vitamin K 5-10 mg plus prothrombin complex concentrate (PCC) dosed by INR: 1

INR 2-3.9: PCC 25 units/kg 1
INR 4-5.9: PCC 35 units/kg 1
INR >6: PCC 50 units/kg 1

Protamine (For Heparin Reversal)

For unfractionated heparin reversal, administer protamine 1 mg per 100 units of heparin, typically 25-50 mg IV. 1

Critical warnings: 1

Excess protamine induces coagulopathy 1
Low molecular weight heparin only partially reversed by protamine 1
Direct thrombin inhibitors (dabigatran, rivaroxaban, fondaparinux) cannot be reversed 1

High-Risk Patients: TACO Prevention

Prophylactic Diuretics

For patients at high risk of transfusion-associated circulatory overload (TACO), consider prophylactic diuretic prescribing. 1, 2

TACO is now the most common cause of transfusion-related mortality. 1, 2 High-risk patients include: 1, 2

Age >70 years 1, 2
Heart failure 1, 2
Renal failure 1, 2
Hypoalbuminemia 1, 2
Low body weight 1, 2
Non-bleeding patients 1, 2

Additional TACO prevention strategies (not medications): 1, 2

Body weight dosing of red blood cells 1
Slow transfusion rate 1
Close fluid balance monitoring 1

Common Pitfalls to Avoid

Never warm blood using improvised methods (warm water, microwave, radiator) - use only approved blood warming equipment with visible thermometer and audible warning 1
Do not routinely premedicate - this represents outdated practice that may harm patients 1
Do not use aprotinin except in highly specialized cardiac/liver transplant surgery on named-patient basis due to risks of renal failure, MI, and anaphylaxis 1
Do not use recombinant Factor VIIa (rFVIIa) outside approved indications due to arterial thrombotic complications 1
Distinguish febrile from allergic reactions - they require different treatments (paracetamol vs antihistamine) 1

What medications should be administered during a routine blood transfusion, and what additional drugs are indicated for patients with prior febrile non‑hemolytic reactions, allergic reactions, or during massive transfusion?

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