Transfusion reaction

These occur within 24 hours of transfusion, and often during the transfusion itself.

Acute haemolytic transfusion reactions, depending on severity, may be characterised by:[3]

Pain along the infused extremity
Abdominal, chest, or back pain, which can accompany generalised symptoms
Haemoglobinuria, which can manifest as red urine
Progression to hypotension, renal failure, and disseminated intravascular coagulation (DIC) in severe cases
Positive direct antiglobulin test
Evidence of haemolysis upon visual inspection of the plasma.

Febrile non-haemolytic transfusion reactions are a diagnosis of exclusion. They are characteristically:

Associated with fever, specifically a rise in temperature of at least 1°C (1.8°F) above 37°C (98.6°F) for which no other cause is identifiable
Benign, although they initially may be indistinguishable from the onset of an acute haemolytic transfusion reaction
Not associated with evidence of haemolysis.

Allergic reactions are diagnosed clinically. They are characterised by:

Pruritus, flushing, and dyspnoea
Symptoms within minutes of the initiation of transfusion
Urticaria that evolves; angio-oedema develops less commonly
Lack of evidence of haemolysis on lab tests
Anaphylaxis - a serious, potentially life-threatening, systemic allergic reaction - which may follow.[5] Anaphylaxis is generally rapid in onset, with variable signs and symptoms, and typically affects two or more body systems (e.g., cutaneous, respiratory, cardiovascular).[5] However, atypical presentations may only appear to affect a single system (e.g., isolated hypotension).[5] There may be features of respiratory compromise (e.g., dyspnoea, wheezing, stridor, hypoxaemia, reduced peak expiratory flow) and/or cardiovascular compromise or associated end-organ dysfunction (e.g., hypotension, hypotonia/collapse, syncope, incontinence).[5] Gastrointestinal symptoms may also be present (e.g., cramping abdominal pain, vomiting, diarrhoea).[5] It should be noted that typical cutaneous features of anaphylaxis (e.g., urticaria, flushing, pruritus, angio-oedema) are not always present.[5] The diagnosis of anaphylaxis is clinical, based on the clinical history and the signs and symptoms present during the event.[5] In cases where anaphylaxis occurs, testing for anti-IgA levels and serum tryptase levels should be performed (without delaying emergency management) to aid with post-acute confirmation of the diagnosis.[5][32] See Anaphylaxis (Diagnostic criteria).

Transfusion-related acute lung injury (TRALI) is characterised by:[38]

New onset of acute lung injury during or within 6 hours of transfusion of plasma-containing blood product(s)[7][8]
Absence of a temporal relationship to an alternative risk factor for acute lung injury (such as sepsis, aspiration pneumonitis, or pulmonary contusion)[8]
Acute lung injury
Criteria for acute lung injury, which include acute onset of symptoms, absence of circulatory overload, bilateral pulmonary infiltrates on chest x-ray, and hypoxaemia as demonstrated by PaO2/FIO2 <300 mmHg.[8]

These usually occur days to weeks from the transfusion event.

Delayed haemolytic transfusion reactions are characterised by:[3]

Fever or anaemia
Jaundice (in some patients)
Extravascular haemolysis (rarely causes acute renal failure or DIC)
Diagnosis supported by a new positive direct antiglobulin test and/or positive antibody screen, elevated LDH, and bilirubin.

Transfusion-associated graft-versus-host disease occurs 8 to 10 days after a transfusion and is characterised by:[9]

Post-transfusion purpura are characterised by:

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Criteria