Adverse Event Algorithm

PATIENT EXHIBITS SIGNS AND SYMPTOMS OF A TRANSFUSION REACTION

STOP AND DISCONNECT THE TRANSFUSION

1. Maintain IV patency with appropriate fluid.

2. Contact the AUTHORIZED PRESCRIBER (AP) for medical assessment and intervention.
3. Check vital signs every 15 minutes until stable.
SERIOUS signs and 4. Recheck the component/product label, blood transfusion services (BTS) tag and patient
symptoms pathway identification band/badge to ensure they match and the expiry date and time has not passed.

NEW onset of ANY symptom Clerical Discrepancy MINOR signs and symptoms
within the first 15 minutes: Temperature rise 1oC or more and at pathway
- Fever or above 38oC but no other signs or
- Chills/Rigors symptoms
- Hypotension/shock DO NOT RESTART THE
TRANSFUSION Hives/Rash over less Temperature rise 1oC or more
- Hypertension
than 1/4 of body but and under 38oC but no other
- Unexplained anxiety
NOTIFY BTS - NOTIFY BTS no respiratory symptoms
- Back / chest / flank pain
- Consult with AP on medicating with symptoms
- Severe headache
Treat as per Authorized antipyretics or analgesics
- Dyspnea/respiratory
Prescriber’s orders - Document clinical assessment and
distress - NOTIFY BTS
- Tea colored urine intervention - Consult AP for an order of antihistamines and /or antipyretics
Send the following to BTS: - Resume transfusion cautiously ONLY
- Bleeding / pain from IV site - Document clinical assessment and intervention
a. Blood work * as directed by AP
- Nausea/vomiting - Resume transfusion cautiously ONLY as directed by the AP
b. Completed BTS Tag - Patient should be directly observed for
- Tachycardia/arrhythmias - Patient should be directly observed for the first 5 minutes
c. Blood component/ product the first 5 minutes after resuming
- Generalized flushing after resuming transfusion then every 5 minutes for the next
and administration set/fluid transfusion then closely monitored for
- Hives/rash covering more 10 minutes
d. Copy of TAR and / or the next 10 minutes
than ¼ of body
progress notes, graphics
- Patient states they feel
sheet and medication
unwell If the patient develops any further signs and symptoms
records.
If the patient develops any further signs IMMEDIATELY stop the transfusion and follow the
NOTE: Consider bacterial and symptoms IMMEDIATELY stop the
Patient may also require: SERIOUS pathway
contamination if the patient transfusion and follow the SERIOUS
exhibits any of the following a. Blood cultures
pathway
during or within 4 hours post b. Chest x-ray
transfusion: c. EKG If remainder of transfusion is uneventful, return to BTS:
1. Temperature rise 1°C or d. Urine specimen a. Completed BTS Tag
more, and at or above 38°C If remainder of transfusion is uneventful, on
b. Copy of TAR and / or progress notes, graphics sheet and
PLUS any of the following: completion, send the following to BTS:
medication records
- rigors a. Blood work *
- hypotension CONSIDER: ACUTE b. Completed BTS Tag
- shock HEMOLYTIC, SEVERE c. Blood component/product and
- tachycardia ALLERGIC, administration set/fluid CONSIDER: FEBRILE NON-HEMOLYTIC or MINOR ALLERGIC
- dyspnea ANAPHYLACTIC/ d. Copy of TAR and / or progress notes,
- nausea/vomiting ANAPHYLACTOID, graphics sheet and medication records
2. Temperature rise over 39oC TRANSFUSION
and of 1oC or more; with or ASSOCIATED
CIRCULATORY FOR ALL REACTIONS:
without other signs or
symptoms OVERLOAD (TACO), ENSURE THE MOST CLINICALLY SIGNIFICANT INFORMATION IS DOCUMENTED ON THE
3. Fever unresponsive to
TRANSFUSION RELATED TRANSFUSION ADMINISTRATION RECORD (TAR) AND/OR PROGRESS NOTES, GRAPHIC SHEET AND
ACUTE LUNG INJURY MEDICATION RECORD AND SENT TO BTS.
antipyretics and/or suspicion (TRALI) OR BACTERIAL
of sepsis in absence of fever. CONTAMINATION * Possible exception for pediatric patients: lab testing to Production of this Transfusion Reaction Algorithm has been made possible
through a financial contribution from the Public Health Agency of Canada
be performed at discretion of Hematopathologist NSPBCT October 2018