What is the protocol for a blood transfusion reaction in a patient requiring blood due to a gastrointestinal (GI) bleed?

From the Guidelines

For a blood transfusion reaction in a patient with GI bleeding, immediately stop the transfusion, maintain IV access with normal saline, and notify the physician and blood bank, as recommended by the most recent guidelines from the Association of Anaesthetists 1. When managing a blood transfusion reaction, it is crucial to assess the patient's symptoms and signs to distinguish between febrile and allergic reactions, and to tailor the treatment approach accordingly.

• For febrile reactions, only intravenous paracetamol may be required, whereas for allergic reactions, only an antihistamine should be administered 1.
• If a severe reaction and/or anaphylaxis is suspected, local anaphylaxis protocols should be followed, which may include the administration of oxygen, IV fluids for volume resuscitation, and epinephrine 0.3-0.5mg IM for anaphylaxis. For the GI bleed, continue resuscitation with packed red blood cells (PRBCs) after the reaction is managed, targeting hemoglobin >7 g/dL (>8 g/dL for cardiac patients), and consider the use of type-specific or O-negative blood in emergencies, as well as platelet transfusion if count <50,000/μL and FFP if INR >1.5, as suggested by the guidelines 1. Key considerations in the management of blood transfusion reactions include:
• Monitoring vital signs every 15 minutes until stable
• Collecting post-reaction blood samples and returning the blood product with administration set to the blood bank for investigation
• Maintaining effective communication with the transfusion laboratory to ensure the cold chain is maintained and evidenced during transport, especially in cases of intra-hospital or inter-hospital transfer 1. The priority is to stabilize the patient while identifying the cause of the transfusion reaction to prevent recurrence during subsequent necessary transfusions for the ongoing GI bleed, and to minimize the risk of morbidity, mortality, and compromised quality of life.

From the Research

Protocol for Blood Transfusion Reaction

• When a transfusion reaction is suspected, it is critical to stop the transfusion immediately and report the reaction to the blood bank, as this can affect the patient's outcome 2.
• The differential diagnosis of any untoward clinical event should always consider adverse sequelae of transfusion, even when transfusion occurred weeks earlier 3.
• Any symptom occurring within 24 h of a blood transfusion should be considered a transfusion reaction and referred to the hemovigilance reporting system 4.
• The initial management of blood transfusion reactions requires early identification, immediate interruption of the transfusion, early consultation of the hematologic and ICU departments, and fluid resuscitation 4.

Blood Transfusion for GI Bleed

• Blood transfusions have been the cornerstone of life support since the introduction of the ABO classification in the 20th century, and the physiologic goal is to restore adequate tissue oxygenation when the demand exceeds the offer 4.
• The best way to prevent transfusion reactions is to avoid unnecessary blood transfusions and maintain a transfusion-restrictive strategy 4.
• Blood transfusion is one of the most common procedures in patients in hospital, so it is imperative that clinicians are knowledgeable about appropriate blood product administration, as well as the signs, symptoms, and management of transfusion reactions 5.

Prevention and Management of Transfusion Reactions

• 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.
• Febrile nonhemolytic and allergic reactions are the most common transfusion reactions, but usually do not cause significant morbidity 6.
• Acetaminophen and diphenhydramine are effective therapies for fever and allergy, respectively, but their use as premedication before blood component transfusions has failed to prevent transfusion reactions and requires reexamination 6.