General Principles

• For all transfusion reactions, stop the transfusion.
• Replace infusion set and keep intravenous line open with normal saline.
• Draw a fresh purple top sample of transfusing blood, complete the transfusion reaction form, notify the blood bank and return remaining blood products.

Specific Types of Transfusion Reactions

• Acute hemolytic transfusion reaction:
  • Naturally occurring anti-A/anti-B antibodies or alloantibodies to other red cell antigens may cause hemolysis of donor RBCs. 
  • Fever, chills, flank pain, dyspnea and hypotension may occur early in the transfusion.
  • Stop transfusion immediately. As little as 30ml can be fatal.
  • Provide hemodynamic and renal support.
  • Maintain steady diuresis with IV fluids and furosemide; consider alkalinization of urine with bicarbonate to prevent renal failure.
• Delayed hemolytic transfusion reaction:
  • A newly formed alloantibody or an anamnestic rise in titer of a previously undetectable antibody results in hemolysis of transfused RBCs.
  • Patients may be asymptomatic or present with anemia, fever, jaundice, malaise and even hemoglobinuria and renal failure 3-14 days after transfusion.
• Allergic transfusion reaction:
  • Symptoms range from mild uncomplicated urticaria to fatal anaphylaxis.
  • Mild reactions are limited to localized rash, pruritus and flushing. Stop the transfusion. Administer antihistamines and/or hydrocortisone 1mg/kg IV. Restart transfusion if symptoms have resolved. 
  • If symptoms re-appear, DO NOT restart the transfusion. Use alternate donor.
  • Severe reactions may manifest with bronchospasm, laryngeal swelling, hypotension and shock. Stop the transfusion immediately. Resuscitate with epinephrine, bronchodilators, fluids and steroids as needed.
  • Premedication with antihistamines and steroids is adequate for future transfusions in most patients. Evaluate for IgA deficiency, if deficient, use washed pRBCs and platelets/plasma products from IgA deficient donors.
• Febrile non-hemolytic transfusion reaction:
  • Characterized by fever either during or up to 4 hours after completing transfusion. Patients may also have chills, rigors, headache and nausea.
  • Stop the transfusion and complete the transfusion reaction work up. Obtain blood cultures if sustained fever and hemodynamic instability raise concern for bacterial contamination of blood product.
  • Treatment is generally supportive (i.e. antipyretics).
• Bacterial contamination:
  • Platelets are more likely to be contaminated than other blood products (unable to be frozen for storage).
  • Reactions range from mild to septic shock depending on the organism.
  • Stop the transfusion, resuscitate, and start broad-spectrum antibiotics. Inform the blood bank immediately. Send the remaining product for gram stain and culture. Send patient samples for bacterial culture.
• Transfusion related acute lung injury (TRALI):
  • Usually from donor HLA antibodies attacking recipient granulocytes leading to complement activation, and clinically, non-cardiogenic pulmonary edema. 
  • Presents as respiratory distress and severe hypoxemia 1-6 hours following transfusion. May also present with fever and/or hypotension. Chest x-ray typically with pulmonary edema (but no evidence of heart failure).
  • Stop the transfusion and provide rapid and intensive respiratory support. Generally no indication for diuresis. Inform blood bank of suspected TRALI reaction. Remove donor from donor pool.
  • Approximately 80% of patients improve in 48-96 hours. 
• Transfusional Volume Overload (TACO):
  • Pulmonary edema from congestive failure commonly in patients with decreased cardiac function, the elderly.
  • Presents with respiratory distress, tachycardia, and hypoxemia within six hours of transfusion.
  • Preventable by decreasing transfusion rate.
  • Treatment includes stopping or slowing transfusion, diuresis, and consider noninvasive positive pressure ventilation.

Nambiar A, Leitman S. Transfusion therapy. In: Hematology-Oncology Therapy. Edited by Boyiadzis, MM, Lebowitz,PF, Frame JN and Fojo,T.  New York. McGraw-Hill, 2007: 607-63