Transfusion Reactions

6 min read

Presentation Questions

  • What’s being transfused, when did it start and how much has gone in?
  • Has the transfusion been stopped?
  • Observations compared with their pre-transfusion baseline, including temperature?
  • Symptoms?
    • Rash or itch
    • Dyspnoea, wheeze or stridor
    • Rigors, or chest, back or flank pain
    • Dark urine
  • Reason for the transfusion? (Are they still bleeding and likely to need more blood?)
  • Heart failure, renal impairment or positive fluid balance? ⇒ risk of TACO
  • Anaesthetised or unconscious? ⇒ the usual symptoms may not be reported

Instructions Over the Phone

  • Stop the transfusion, and keep the pack and giving set
  • Keep IV access with a new set and normal saline, and don’t flush the existing line
  • Full set of observations, and record the volume and colour of any urine
  • Call a clinical emergency if there are any ABC problems

Aetiologies

  • Fever: FNHTR, bacterial contamination, acute haemolytic reaction, or something unrelated to the transfusion
  • Rash or itch: minor allergic reaction, Anaphylaxis
  • Hypotension or dyspnoea, usually within 15 minutes of starting: bacterial contamination, acute haemolytic reaction, Anaphylaxis
  • Respiratory distress during or after the transfusion: TACO, TRALI
  • Anaesthetised: hypotension, uncontrolled bleeding or oozing, and haemoglobinuria may be the first signs of an acute haemolytic reaction

Assessment

  • Airway: stridor or swelling ⇒ Anaphylaxis
  • Breathing: RR, SpO2, wheeze, and whether crackles are basal or bilateral
  • Circulation: BP against baseline, HR, JVP, fluid balance, and any bleeding or oozing
  • Disability: restlessness or a sense of impending doom can occur in acute haemolytic reactions
  • Exposure: temperature, rash, pain at the infusion site, flank or back pain, and urine colour
  • Check correct pack went into correct patient

TACO or TRALI?

TACOTRALI
TimingUp to 12 hoursWithin 6 hours
BPTypically hypertensiveTypically hypotensive
JVPRaisedNot elevated
CracklesBasalBilateral
Fluid balancePositiveNo evidence of overload
FeverNot typicalCan occur
Pro-BNPRaised more oftenRaised less often
DiureticsGiveNot beneficial and may worsen it

Immediate Management

  • Stop the transfusion, then assess ABC and vital signs
  • Keep IV access, using a new line if needed and not flushing the existing one
  • Repeat the identity and clerical checks, and inspect the pack for clots, haemolysis, discolouration or cloudiness
  • Notify haematology and the transfusion service provider. The transfusion service provider will advise on returning the pack and on any further samples
  • Further transfusion needs advice from the transfusion service provider, a transfusion medicine specialist or a haematologist. If it’s needed before the lab has finished investigating the reaction (e.g. excluding a haemolytic reaction), a suitably experienced pathologist (lab director, haematologist or transfusion medicine specialist) has to authorise it

By Reaction

  • Mild febrile: >38°C and a rise of 1 to <1.5°C within 4 hours, with no other signs1. Give an antipyretic and restart slowly only if it settles, otherwise don’t restart
  • Moderate or severe febrile: ≥39°C, a rise of ≥1.5°C or other signs such as rigors, hypotension or pain. Don’t restart, and since FNHTR is a diagnosis of exclusion, work up for sepsis, incompatibility and DIC
  • Acute haemolytic: don’t restart, support BP and urine output, consider diuresis with IV fluids and diuretics2, and no more blood until haematology or the transfusion service provider clears it
  • Bacterial contamination: don’t restart, start broad-spectrum IV antibiotics (regimen from eTG) and support BP and urine output with fluids and inotropes
  • Isolated urticaria or pruritus: give an antihistamine and restart slowly if it settles and the product is still viable
  • Generalised urticaria or localised angioedema: don’t restart, give an antihistamine and a corticosteroid as required, and watch for progression
  • Anaphylaxis: don’t restart, and follow the local anaphylaxis protocol including adrenaline. If IgA deficient with IgA antibodies, consider washed red cells and IgA deficient components
  • TACO: during or up to 12 hours after transfusion3, mostly within 1-2 hours. Don’t restart, pause IV fluids, sit them up, and give oxygen and diuretics
  • TRALI: during or within 6 hours, usually within 1-2 hours. Don’t restart, give oxygen and supportive care, and get expert input on ventilation. Diuretics aren’t beneficial and may worsen it

Investigations

  • Isolated urticaria or other minor allergic reactions: none needed
  • Sepsis: blood cultures (+/- central line), septic screen for other sources, and send the pack and giving set for culture
  • Incompatibility: group, antibody screen and DAT on pre- and post-transfusion samples, plus a haemolytic screen (FBC, LDH, bilirubin, haptoglobin, electrolytes, creatinine, urinalysis)
  • DIC: aPTT, PT, fibrinogen, D-dimer
  • Anaphylaxis: serial tryptase, IgA +/- IgA antibodies, haptoglobin. Tryptase is ideally taken 30 minutes to 2 hours after onset but can still be useful up to 6 hours, with a baseline from before the event or at least 24 hours after it resolves. A rise of at least 20% + 2 ng/mL over baseline suggests mast cell activation4
  • TACO or TRALI: CXR (looking for Acute Pulmonary Oedema) and pro-BNP, and consider an echo. For TRALI, discuss HLA/HNA typing with Lifeblood

Preventing TACO

  • Do a risk assessment before transfusing, give single units with review in between, transfuse slowly and monitor fluid balance
  • ANZSBT says to consider diuretics in at-risk patients, although I couldn’t find an agent, dose or timing in the Australian sources I read. AABB says there isn’t enough data to support or refute it

Reporting in NSW

  • All suspected reactions: report to the pathology lab as per local procedure and enter into ims+, and it then gets tabled at the Blood Management Committee
  • Suspected transfusion-transmitted infection or TRALI: report to the Lifeblood 24-hour hotline on 1300 478 348
  • Plasma-derived products: report to Lifeblood and the TGA
  • ABO haemolytic reaction causing serious harm or death: this is a sentinel event, so needs a Reportable Incident Brief

Sources

Footnotes

  1. Lifeblood and ANZSBT agree on this, whereas a 2021 draft guide on the ACN site uses <39°C and/or a rise of 1-2°C. I don’t know if that draft was ever finalised ↩

  2. Lifeblood’s haemolytic reaction page says to induce diuresis with IV fluids and diuretics, whereas the KDIGO 2026 public review draft says to use crystalloid and doesn’t advise augmenting urine output with mannitol or loop diuretics. I couldn’t find a numeric urine output target in the Australian sources I read ↩

  3. The 2022 Victorian STIR guide uses six hours for reportable cases ↩

  4. From ASCIA’s mast cell paper, which isn’t specific to transfusion reactions ↩

Disclaimer: These notes are for educational purposes only and are not medical advice. I do not claim copyright for the content or images unless otherwise stated. For concerns or changes, create a new issue on GitHub.

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