7 ADVERSE REACTIONS TO

TRANSFUSION
Any adverse reaction to the transfusion of blood or blood components should be reported to Blood Bank
personnel as soon as possible.

Speed is essential in such situations because of the possible life-threatening nature of acute transfusion
reactions. The evaluation of all adverse reactions to transfusion is the responsibility of the medical staff
of the Blood Bank and the notification of such a reaction by the patient unit serves as a request for Blood
Bank physician consultation.

The Blood Bank is required to report any death resulting from transfusion to the Food and Drug
Administration.

Reactions may be separated into reactions that present in proximity to the transfusion and those that
present at some time subsequent to the transfusion. Suspected post-transfusion disease, which may
present at a considerable time following transfusion, must also be reported to the Blood Bank.
Investigation of these reports may result in identification of "carrier" donors who are removed from the
donor pool

A Blood Bank physician should be consulted regarding the evaluation of patients with reactions, as well
as selection of appropriate blood components for future transfusion.

In the case of a mild urticarial and febrile reactions, with no other signs or symptoms attributable to
blood transfusion, it may be possible to reinitiate the blood transfusion Such a decision must be arrived
at through consultation between the physician reporting the reaction and a Blood Bank physician

Premedication for Recipients of Granulocytes

It is suggested that patients receiving granulocytes who have a history of febrile reactions to blood
components be pretreated with antipyretic agents if there are no contraindications to the use of these
drugs. See Febrile Transfusion Reactions. In general, transfusion of Granulocytes should be terminated
only for such complications as severe flank pain, chest pain, hemoglobinemia and hemoglobinuria,
hypotension, laryngospasm, or acute pulmonary injury.

Reaction Type Symptoms Cause Frequency Prevention

Acute Hemolytic Fever, chills and fever, the Human error such as Rare proper identific
Reaction feeling of heat along the vein mislabeled of patients,
in which the blood is being pretransfusion pretransfusion
  transfused, pain in the lumbar specimen; the samples and bl
region, constricting pain in the transfusion of properly components at
chest, tachycardia, hypo- labeled blood to the time of transfu
tension, and hemoglobinemia wrong person, or
with subsequent hemoglo- clerical errors occurring
binuria and hyperbilirubin-
 emia. within the Blood Bank

A "feeling of impending transfused red cells

doom" is frequently reported react with circulating
by the patient as an early sign antibody in the recipient
of this reaction. with resultant
intravascular hemolysis
In an unconscious or anesthe-
tized patient: Uncontrollable  
bleeding due to disseminated
intravascular coagulation may Most likely to occur
be the only sign of a when a group O patient
hemolytic transfusion reaction is mistakenly transfused
with group A, B, or AB
blood. Patients
receiving a major ABO-
incompatible marrow or
stem cell transplant with
sufficient red cell
content will likely
develop an acute
hemolytic reaction

DELAYED the most common signs are a Many delayed Uncomon

HEMOLYTIC falling hematocrit (due to hemolytic reactions will
REACTIONDelayed extravascular destruction of go undetected because
Hemolytic Reaction the transfused red blood cells) the red cell destruction
and a positive direct occurs slowly
  antiglobulin (Coombs) test
(DAT). Delayed hemolytic
  reactions occur in
"delayed" hemolytic reactions patients who have
  commonly occurs about 4-8 developed antibodies
days after blood transfusion, from previous
  but may develop up to one transfusion or
month later. There may also pregnancy but, at the
  be hemoglobinuria and a mild time of pretransfusion
elevation of the serum testing, the antibody in
Notify the Blood bilirubin. . Symptomatic question is too weak to
Bank at the time the patients may manifest fever be detected by standard
reaction is suspected, and leukocytosis thus procedures. Subsequent
to allow prompt appearing to have an occult transfusion with red
investigation. Care infection. cells having the
must be taken that corresponding antigen
subsequently results in an anamnestic
transfused red cells antibody response and
lack the antigen hemolysis of transfused
corresponding to the red cells.
patient's antibody.

Febrile fever or chill fever A Cytokines and 1 in 8

 temperature rise of 1.8 F or antibodies to leukocyte transfusions
1.0 C from the baseline antigens reacting with
leukocytes or leukocyte
fragments

Allergic - urticaria allergic reactions may be this reaction is caused 1% of recipients

associated with laryngeal by foreign plasma
edema and bronchospasm. proteins

If coupled with another sign,

such as fever, evaluation for a
hemolytic reaction may be
indicated.

Allergic - anaphylactic or anaphylactoid may be due to anti-IgA Rare

Anaphylaxis Respiratory involvement with
dyspnea or stridor may be
more pronounced than is
usually seen in typical allergic
reactions.

Reactions manifest
cardiovascular instability that
includes hypotension,
tachycardia, loss of
consciousness, cardiac
arrhythmia, shock and cardiac
arrest.

TRALI abrupt onset of TRALI has been TRALI is a rare Most cases of T
noncardiogenic pulmonary associated with the though under resolve within
edema Severe cases may presence of antibodies recognized hours although
require assisted ventilation in the donor plasma complication of fatalities may o
with high FIO2.. reactive to recipient transfusion approximately
leukocyte antigens or percent of case
with the production of
inflammatory mediators
during storage of
cellular blood
components

Volume Overlead transfusion-related Infuse smaller

volume overload volumes more

Bacterial hypotension, shock, fever and Bacterial contamination rare but difficult
Contamination chills, nausea and vomiting, occurs when a small to detect prior to
and respiratory distress. number of bacteria enter transfusion
Diagnosis is established by a blood component Autologous blood
Gram stain and blood culture during collection or may be
of both the blood component processing.. During contaminated
and the recipient.distress storage, bacteria may with bacteria,
 proliferate, resulting in a particularly if the
large number of patient had an
organisms, and possible active infection at
endotoxin, being given the time of
with the transfusion donation.

Hypotension A drop of at least 10 mm Hg Some reactions have

in systolic or diastolic arterial been associated with
blood pressure in the absence angiotensin converting
of signs or symptoms of other enzyme (ACE) inhibitor
transfusion reactions drugs or the use of
leukocyte reduction
if the immediate filters.
pretransfusion blood pressure
is elevated from the patient’s Hypotensive reactions
typical blood pressure, and the have been associated
arterial pressure does not fall with red cell and platelet
below the patient’s usual transfusions.
blood pressure, it should not
be considered a hypotensive
reaction. The onset of
hypotension is during the
transfusion, and resolves
quickly with discontinuation
of the transfusion.

If hypotension persists beyond

30 minutes after discontinuing
the transfusion, another
diagnosis should be strongly
considered.

Graft-vs-Host rash, fever, diarrhea, viable T lymphocytes in Rare Irradiation of c

Disease GVHD cytopenia and liver blood components are components
dysfunction 3-4 weeks after transfused, engraft and
  transfusion react against the The Blood Ban
recipient's tissues and be apprised of
the recipient is unable to immune status,
reject the donor diagnosis, of th
lymphocytes because of patient so that c
immunodeficiency, components int
severe for transfusion
immunosuppression, or immunocompr
shared HLA antigens patients and blo
components fro
associated with bone directed (desig
marrow transplantation. donors will be
Transfusion associated irradiated. Irrad
GVHD occurs. It of blood red ce
typically. Transfusion containing
associated GVHD components de
 carries a very poor the red cell sur
prognosis. and increases t
potassium of th
component. Th
no apparent eff
platelet surviva
Fresh Frozen P
(FFP) and
cryoprecipitate
(CRYO) need n
irradiated beca
these compone
not contain eno
viable lymphoc
cause GVHD.

Non-immune hemoglobinemia and Lysis of red cells can Rare

Hemolysis hemoglobinuria Transient occur due to improper
hemodynamic, pulmonary and storage, handling, or
renal impairment may occur. transfusion conditions.
cardiac arrhythmia due to
yyperkalemia may occur, mishandling or storage
particularly in patients with of blood components
renal failure.
the contents of the blood
bags are available for
study. The blood bag
together with attached
tubing and intravenous
fluids should be saved
for further
investigations.

Post-transfusion thrombocytopenia that is the patient makes an Rare Platelet transfu

purpura (PTP) frequently profound, purpura, alloantibody in response of very little va
or bleeding to platelet antigens in PTP; however,
  the transfused blood that therapeutic pla
Febrile reactions have been for a period of time exchange may
  reported retrospectively with causes destruction of beneficial Sinc
the implicated transfusion autologous antigen autologous plat
negative platelets do not survive
thrombocytopenia typically 7- circulation, the
48 days after transfusion expectation tha
transfused plate
PTP must be differentiated regardless of an
from the far more common matching will d
alloimmunization to platelet better.
antigens. Consultation with a
Blood Bank physician is Reserved plate
recommended in evaluating transfusion for
 such patients. patients with ac
bleeding.

IF A TRANSFUSION REACTION IS SUSPECTED

Stop the transfusion immediately!

Disconnect the intravenous line from the needle. Do not disconnect the unit from the IV set. Attach a
new IV set and prime with saline, or flush the line with the normal saline used to initiate the transfusion
and reconnect the line. Open the line to a slow drip. In certain cases, such as a mild urticarial reaction or
the presence of repeated chill-fever reactions, it may be possible to restart the blood transfusion after
evaluation and treatment of the patient. To reinitiate the transfusion using a new IV tubing set, enter the
second port to reduce the chance of bacterial contamination.

Seek medical attention immediately. If the patient is suffering cardiopulmonary collapse, and medical
attention is not immediately available, press the blue "Code" button and telephone the Cardiac Arrest
Team (dial 911).

Check to ensure that the patient name and registration number on the blood bag label exactly with
information on the patient's identification

wristband attached to his/her wrist. DO NOT BYPASS THIS STEP BY ASSUMING THAT THE
PATIENT'S TRUE IDENTITY IS KNOWN.

Do not discard the unit of blood that has been discontinued because it may be necessary for the
investigation of the transfusion reaction.

 Notify the Blood Bank that a transfusion reaction has occurred and briefly describe the nature of the
reaction.
 Blood Bank personnel will identify the Pathology House officer or staff pathologist who will assume
responsibility for investigation of the reaction.

 Delay the transfusion of additional units until the possibility of serological incompatibility has been
investigated. Consult a Blood Bank physician if there is an urgent need or transfusion.
 Initiate the Transfusion Reaction Report Form after Blood Bank personnel have been notified of a
transfusion reaction. It is essential that this form be filled out completely, including the unit numbers of
all blood transfused. The form will serve as a written request for investigation of the reaction by a Blood
Bank physician.
 In the case of a suspected hemolytic transfusion reaction (not urticaria alone), the following items
should be submitted promptly to the Blood Bank:

completed Transfusion Reaction Form (white copy)

posttransfusion blood specimens (Adults: 7 mL Pink top tube, lesser volumes for pediatric
patients), and

incriminated unit(s) of blood and attached tubing.

  

Restarting a Transfusion If the Blood Bank physician, after review of the clinical information, believes
the transfusion can be restarted, do not disconnect the unit. This may apply to patients who might
manifest urticarial reactions or repeated chill-fever reactions.

Additional blood specimens may be requested, depending on the serological findings. The venipuncture
to obtain these blood specimens must not be traumatic. Small lumen catheters should not be used to
collect blood specimens for a transfusion reaction investigation. If red cells are hemolyzed during the
venipuncture or collection, the serum will turn pink and it may be erroneously concluded that
intravascular hemolysis has occurred.

The IV tubing used to transfuse the blood components should be clamped and sent without the needle
attached. A urine sample is not required for the routine evaluation of a transfusion reaction, but may be
requested by the Blood Bank physician in the course of further assessment.

Patient care personnel will be notified by telephone of significant findings of the reaction evaluation as
soon as possible. A written report of the investigation, on the Blood Transfusion Reaction Form, will be
returned to the patient care unit at a later date for inclusion in the patient's chart.

TREATMENT OF TRANSFUSION REACTIONS

The following guidelines should be tailored to suit individual cases.

Reaction Type Treatment - Adult Pediatric Follow-up

Acute Diuretic therapy: Initially, give 40-80 Pediatric dose: 1-2 Treat shock and disseminated
Hemolytic mg Furosemide (Lasix) intravenously. mg/kg/dose. May intravascular coagulation with app
Reactions Acute This dose can be repeated once. Lack repeat once at 2-4 measures if and when they appear
Hemolytic of response to furosemide in 2-3 hours mg/kg.
Reactions indicates the presence of acute renal
failure.

Water loading: The patient should be Pediatric patients

hydrated to maintain urinary output of should receive a
at least 100 mL/hr until urine is free of smaller loading
hemoglobin. volume of fluid in
proportion to their
Infuse a loading dose of 0.9% sodium body surface area.
chloride or 5% dextrose in 0.45%
sodium chloride. Chart hourly urine
output. Maintain the urine output by
administering intravenous fluid at 100
mL/hour until the urine is free of
hemoglobin. If the patient's urinary
output does not increase, with this
hydration any additional fluids should
be infused with caution.

Delayed Specific treatment generally is not Supplemental transfusion of blood

Hemolytic necessary lacking the antigen corresponding
Transfusion offending antibody may be necess
Reactions compensate for the transfused cel
have been removed from the circu

Allergic Antihistamines(e.g., Benadryl). Give Pediatric dose: 1-2 Routine use of Benadryl as preme
Transfusion 50-100 mg orally or intravenously. If mg/kg intramuscularly for all transfusions, regardless of
Reactions urticaria develops slowly, or intravenously for of allergic reactions, is discourage
antihistamines may be given orally. 25-50 mg per average
dose.

Aminophylline for wheezing, at a dose Pediatric dose: 3

of 125-250 mg intravenously slowly mg/kg/dose in
over a period of about five minutes intravenous drip over
of 20 minutes.

Epinephrine for severe, acute Pediatric dose: 0.03

reactions including laryngeal edema or mL/M2 (0.03 mg/M2
bronchospasm Give 0.1-0.5 mg (0.1- of a 1:1000 solution)
0.5 mL of a 1:1000 solution) given subcutaneously.
subcutaneously. Subcutaneous dose A single pediatric
may be repeated at 10-15 minute dose should not
intervals. The total subcutaneous dose exceed 0.3 mg.
in a 24-hour period, with rare
exception, should not exceed 5 mg.

Febrile Premedicate the patient with Aspirin will adversely affect the p
Transfusion acetaminophen or other antipyretic platelet function, so non-aspirin
agents when previous reactions have antipyretic agents are preferable.
Reactions been extremely bothersome. Pediatric
dose: 10 mg/kg to a maximum of 600
mg.

Severe shaking (rigors) can be controlled by the Note: Demerol may cause acute
chills sedative effect of Benadryl or Demerol respiratory arrest. An opiate antag
(25-50 mg given intramuscularly or (Narcan) should be immediately
intravenously available.

Sepsis Due to Treatment of septic shock includes:

Bacterial terminating the suspected transfusion
Contamination immediately, cardio-vascular and
of Donor Blood respiratory support, blood culture of
the patient, and administration of broad
spectrum antibiotics including anti-
pseudomonas coverage if the blood
component involved is Red Blood
Cells.