Transfusion reaction

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute transfusion reaction

acute hemolytic transfusion reaction

1st line – fluid resuscitation + supportive therapy + discontinuation of blood transfusion

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1st line –

fluid resuscitation + supportive therapy + discontinuation of blood transfusion

Blood transfusion should be immediately discontinued in the case of acute hemolytic reaction.

Generous fluid replacement with normal saline should be immediately initiated on any suspicion of an acute hemolytic reaction. Urine output goal is >0.5 to 1.0 mL/kg body weight per hour, to prevent oliguric renal failure.

Patients with a clinically significant hemolytic transfusion reaction should be managed in an intensive care unit.[3] Other supportive therapies that may be required include airway support with intubation and mechanical ventilation, hemodynamic invasive monitoring, and vasopressor administration.

Consider – forced diuresis

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Consider –

forced diuresis

Treatment recommended for SOME patients in selected patient group

Urine output goal is >0.5 to 1.0 mL/kg body weight per hour, to prevent oliguric renal failure.

If urine output is not adequate despite fluid resuscitation, forced diuresis may be attempted. Prior to initiating diuretic therapy, the presence of intravascular volume depletion should be excluded by monitoring of central venous pressure or pulmonary artery pressures.

Mannitol is often the preferred diuretic, though it should be used with caution in patients with anemia and cardiac comorbidities.[3]

Mannitol is used by monitoring the plasma osmolal gap every 4-6 hours. The infusion should be discontinued if the gap rises above 55 milliosmol/kg.

Titrate infusion according to urine output, may be discontinued once urine appears clear and hemolysis has clinically resolved.

Primary options

mannitol: children and adults: (20%) 0.5 g/kg intravenous bolus initially, followed by 0.1 g/kg/hour intravenous infusion, titrated according to response

Consider – dialysis

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Consider –

dialysis

Treatment recommended for SOME patients in selected patient group

Indicated for progressive acute renal failure. Typically initiated to assist in management of hyperkalemia, uremia, metabolic acidosis, and/or fluid overload refractory to medical management. Requires consultation with nephrologist.

anaphylactic reaction or severe allergic reaction

1st line – epinephrine (adrenaline) + supportive care + discontinuation of blood transfusion

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1st line –

epinephrine (adrenaline) + supportive care + discontinuation of blood transfusion

Administration of epinephrine is by the intramuscular route.[44] Epinephrine should be administered immediately on recognition of anaphylaxis as delayed administration has been implicated as a contributor to mortality and has also been linked to increased risk of biphasic reactions.[5][45] Intravenous epinephrine is reserved for situations of cardiac arrest or profound hypotension refractory to intramuscular injections.

Intensive care monitoring may be required.

The airway should be secured by intubation and initiation of mechanical ventilation if necessary. Supplemental oxygen should be considered for all patients with anaphylaxis regardless of their respiratory status, and must be administered to any patient with respiratory or cardiovascular compromise and to those who do not respond to initial treatment with epinephrine.[44]

Crystalloids should be administered to support circulation. See Anaphylaxis (Treatment algorithm).

Primary options

epinephrine (adrenaline): anaphylaxis: children: 0.01 mg/kg (1:1000 solution) intramuscularly every 5 minutes, maximum single dose 0.3 mg; adults: 0.3 to 0.5 mg (1:1000 solution) intramuscularly every 10-15 minutes

epinephrine (adrenaline): cardiac arrest: children: 0.01 mg/kg (1:10,000 solution) intravenously every 3-5 minutes, maximum 1 mg/dose; adults: 1 mg (1:10,000 solution) intravenously every 3-5 minutes

epinephrine (adrenaline): profound hypotension: children: 0.1 to 1 micrograms/kg/min intravenous infusion; adults: 1-10 micrograms/min intravenous infusion

Consider – inhaled bronchodilator

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Consider –

inhaled bronchodilator

Treatment recommended for SOME patients in selected patient group

Bronchospasm may benefit from the adjunctive use of an inhaled bronchodilator such as albuterol.

Primary options

albuterol inhaled: children: 0.63 mg to 5 mg every 4-6 hours when required; adults: 2.5 to 5 mg every 4-6 hours when required

Consider – glucagon

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Consider –

glucagon

Treatment recommended for SOME patients in selected patient group

Beta-blockers (and the underlying condition they are prescribed for, e.g., coronary artery disease [CAD]) may complicate the treatment of severe anaphylaxis.[5] Beta-blockers may cause resistance to treatment with epinephrine, manifested by refractory bradycardia and hypotension.[5] Glucagon may be used to overcome beta blockade, but the resulting tachycardia can be detrimental in patients with severe CAD.[46] Therefore, early consult of a cardiologist is warranted.

Primary options

glucagon: children: 0.02 to 0.03 mg/kg intravenous bolus, maximum 1 mg/dose; adults: 1-2 mg intravenous bolus, followed by 1-5 mg/hour intravenous infusion if required

Consider – antihistamine

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Consider –

antihistamine

Treatment recommended for SOME patients in selected patient group

Antihistamines may also be administered as an adjunct to epinephrine (adrenaline).[44]

Primary options

diphenhydramine: children: 1-2 mg/kg intravenously as a single dose; adults: 50-100 mg intravenously as a single dose

and

cimetidine: children: consult specialist for guidance on dose; adults: 300 mg intravenously as a single dose

Consider – corticosteroid

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Consider –

corticosteroid

Treatment recommended for SOME patients in selected patient group

Corticosteroid administration is not routinely recommended, as evidence is lacking for clear benefit in anaphylaxis, however it may be considered after initial resuscitation.[44][48]

Primary options

methylprednisolone sodium succinate: children: 1-2 mg/kg/day intravenously given in divided doses every 6 hours; adults: 10-40 mg intravenously, repeat according to response

urticarial reaction without anaphylaxis

1st line – antihistamine + temporary discontinuation of blood transfusion

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1st line –

antihistamine + temporary discontinuation of blood transfusion

The transfusion should be temporarily discontinued.

An antihistamine such as diphenhydramine is administered to relieve symptoms.[1]

Once symptoms have resolved, the transfusion may be resumed, and no further workup is necessary.

Primary options

diphenhydramine: children: 1-2 mg/kg intravenously as a single dose; adults: 50-100 mg intravenously as a single dose

Consider – possible permanent discontinuation of blood transfusion

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Consider –

possible permanent discontinuation of blood transfusion

Treatment recommended for SOME patients in selected patient group

The patient should be closely monitored for onset of anaphylaxis, which may progress rapidly. In such severe cases, the transfusion should not be resumed.

febrile nonhemolytic reaction

1st line – antipyretic + discontinuation of blood transfusion

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1st line –

antipyretic + discontinuation of blood transfusion

An antipyretic, such as acetaminophen, may be administered for patient comfort. Aspirin should be avoided in the setting of thrombocytopenia. The transfusion should be discontinued until a hemolytic reaction has been ruled out (although often the fever first develops following completion of the transfusion). If no clinical concern for hemolysis exists, transfusion may be resumed. Alternatively, the patient may be transfused with a new component.[1]

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

1st line – supportive care

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1st line –

supportive care

Management is supportive, and may range from supplemental oxygen by mask for a brief period to mechanical ventilation for a period of days, depending on the severity of the patient's respiratory insufficiency.

Resolution of the syndrome generally occurs rapidly, typically within fewer than 7 days following transfusion.

ONGOING

delayed transfusion reaction

delayed hemolytic transfusion reaction without brisk hemolysis

1st line – supportive care

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1st line –

supportive care

In the majority of cases, the hemolysis observed is extravascular, and relatively mild, including fever, drop in hematocrit, and/or mild increase in serum unconjugated bilirubin.

Usually no specific treatment is required.

delayed hemolytic transfusion reaction with brisk hemolysis

1st line – supportive care

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1st line –

supportive care

Generous fluid replacement with normal saline should be immediately initiated on any suspicion of a delayed hemolytic reaction with brisk hemolysis. Goal urine output is >0.5 to 1.0 mL/kg body weight per hour.

Patients with a clinically significant hemolytic transfusion reaction should be managed in an intensive care unit.[3]

Other supportive therapies that may be required include airway support with intubation and mechanical ventilation, hemodynamic invasive monitoring, and vasopressor administration.

Consider – forced diuresis

Back

Consider –

forced diuresis

Treatment recommended for SOME patients in selected patient group

Urine output goal is >0.5 to 1.0 mL/kg body weight per hour, to prevent oliguric renal failure.

If urine output is not adequate despite fluid resuscitation, forced diuresis may be attempted.

Prior to initiating diuretic therapy, the presence of intravascular volume depletion should be excluded (by monitoring of central venous pressure or pulmonary artery pressures).

Mannitol is often the preferred diuretic, though it should be used with caution in patients with anemia and cardiac comorbidities.[3]

Mannitol is used by monitoring the plasma osmolal gap every 4 to 6 hours, and the infusion should be discontinued if the gap rises above 55 milliosmol/kg.

Titrate infusion according to urine output; may be discontinued once urine appears clear and hemolysis has clinically resolved.

Primary options

mannitol: children and adults: (20%) 0.5 g/kg intravenous bolus initially, followed by 0.1 g/kg/hour intravenous infusion, titrated according to response

Consider – dialysis

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Consider –

dialysis

Treatment recommended for SOME patients in selected patient group

transfusion-associated graft-versus-host disease

1st line – supportive care

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1st line –

supportive care

Treatment is almost always unsuccessful and the disease almost always results in death.[9][30]

Corticosteroids, antithymocyte globulin, methotrexate, cyclosporine, azathioprine, serine protease inhibitors, chloroquine, and OKT3 have all been tried with poor results.[30]

Therefore, no specific immune suppressive treatment is recommended.

post-transfusion purpura

1st line – high-dose intravenous immune globulin (IVIG)

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1st line –

high-dose intravenous immune globulin (IVIG)

High-dose IVIG is the therapy of choice.[4]

Should correct the associated thrombocytopenia in a matter of days.[49][50]

Consultation with a hematologist is advised.

Primary options

immune globulin (human): 400-500 mg/kg intravenously once daily for 5 days

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