Acute Transfusion Reactions

Clinical Symptoms
and Laboratory
Investigation

Types of Transfusion Reactions

Acute

Allergic
Febrile
Hemolytic
Anaphylactic
Bacterial Contamination
(Sepsis)
Circulatory Overload
Transfusion Related Acute
Lung Injury (TRALI)

Delayed

Alloimmunization
Hemolytic
Transmissible Diseases
Graft vs Host Disease
Iron Overload
Post Transfusion Purpura

Definition

Acute Transfusion Reaction:

Reactions occurring at any time up to 24 hours

following a transfusion of blood or components.

The Most Common Cause of Acute

Immediate Intravascular Hemolysis

Failure to identify the patient with the donor unit

at the time of administration
Collecting pre-transfusion specimen from the
wrong patient

Incorrectly labelled specimens

Unlabelled specimens that are labelled after leaving
the bedside (in the lab or at the nursing station)

Administration Guidelines
(Preparation)
1.

2.
3.
4.

Have physician obtain informed consent and

document the indications for the transfusion in the
chart
Assess the patients understanding of the procedure
Describe the procedure, component, length of
transfusion and expected outcome to the patient
Instruct patient to report ANY unusual symptoms
immediately

Administration Guidelines
5.
6.

7.
8.
9.

(cont)

Obtain and record baseline vital signs

Assess for any pre-transfusion symptoms
which could be confused with a transfusion
reaction
Premedicate patient with prophylactic
medication as per physicians orders
Use appropriate equipment
Obtain the component from the lab

Administration Guidelines
10.

11.
12.

(cont)

Inspect the component for leaks, abnormal

cloudiness, color, clots, excessive air. Check that the
component is not expired. Mix well
Check the physicians order for transfusion. Ensure
component type is correct.
Do not underestimate the importance of patient and
product identification that MUST occur at the bedside

If the patient is not wearing a ID bracelet DO NOT proceed

Contact the lab if there are ANY discrepancies

Administration Guidelines
13.

Start the infusion slowly (5 mL/minute or less for first 15

minutes)

14.

Symptoms of a severe transfusion reaction are usually manifested

during the first 50 mL or less of blood infusion
If possible, remain with the patient the first 10-15 minutes of the
transfusion

Document the identifying individuals, date and time

transfusion initiated in the chart

15.

(cont)

The chart must also contain the unit identifying number, ABO/Rh

Keep all identification attached to the blood container until

the transfusion is completed

Administration Guidelines
16.

17.
18.

(cont)

Before leaving the bedside, remind the patient

to notify you immediately if they feel anything
unusual
Monitor and record vital signs as defined in
nursing policy
At the end of the transfusion, record end times,
volume transfused and immediate response
(i.e. no reaction noted, reaction noted)

When a Reaction is Suspected

Signs & Symptoms

GENERAL

Fever
Chills
Muscle ache,pain
Back pain
Chest pain
Headache
Heat at the site of infusion
or along vein

Nervous System

Apprehension, impending
sense of doom
Tingling, numbness

Respiratory

Tachypnea
Apnea
Dyspnea
Cough
wheezing

Signs & Symptoms

Gastrointestinal

Nausea
Vomiting
Pain, abdominal cramping
Diarrhea (may be bloody)

Renal

Changes in urine volume

Changes in urine color

Cardiovascular

Heart rate
Blood Pressure
Circulatory
Bleeding

Cutaneous

Rashes, Hives(urticaria)
Itching

Signs in an Unconscious Patient

Weak Pulse
Fever
Hypotension
Visible hemoglobinuria
Increased operative bleeding
Vasomotor instability

Tachycardia, brachycardia, hypotension

Oliguria/anuria

Remember
Reactions from different causes can exhibit
similar manifestations; therefore, every
symptom should be considered potentially
serious and transfusion should be discontinued
until the cause is determined

Immediate Actions to Take

1.
2.
3.
4.

Stop the Transfusion

Notify the attending physician and the laboratory
immediately
Do clerical check at bedside of identifying tags and numbers
If symptoms are urticaria and pruritis only, consider
administering antihistimine

5.
6.

If symptoms disappear continue transfusion

If additional symptoms or hives and itching do not disappear

discontinue transfusion
Collect blood specimen and first voided urine

Immediate Actions to Take

7.

Treat patient symptoms

as per physician instructions

Take vitals

8.

Pulse
Temperature
Blood Pressure

Document thoroughly

Complete reaction form

Send form, bag, tubing and set to laboratory

What Happens in the Lab

Laboratory Actions when Notified

of Suspected Reaction

Quarantine all other crossmatched units

When Reaction form, unit, set, tubing, urine
received

Centrifuge specimen
Clerical Check
Review Symptoms
To determine

extent of investigation required

Clerical Check

Check test results vs. interpretation

Check tag information with bag information
(unit number, ABO/Rh)
Check Pre-transfusion specimen information
with tag information (name, number)
Check that information on pre-transfusion
specimen is identical to post-transfusion

Visual Inspection

Compare plasma color of pre-transfusion and

post-transfusion specimens
Is post-transfusion specimen hemolyzed?

If yes, ensure that hemolysis is not due to difficult

collection (recollect if necessary)
If still yes, notify physician immediately
Check

contents of unit for hemolysis

Check blood in tubing for hemolysis

Direct Antiglobulin Test (DAT)

To determine if there is in vivo sensitization

May be negative if intravascular hemolysis has
occurred
If positive, perform monospecific DAT to
determine if it is IgG, C3 or both

Extended Testing

ABO/Rh on pre and post transfusion specimens

ABO/Rh on donor unit
Antibody screen on pre and post transfusion
specimens

Antibody Investigation, positive

DAT on pre transfusion specimen and donor unit

Reporting

Classified as to type of reaction given

symptoms and investigation outcome
Should be signed off by laboratory physician or
designate

Reference for follow up for any attending physician

questions regarding future transfusions given the
patients clinical need

Patient should be informed of reaction and

outcome

Reporting

Should include future pre medication or special

requirements, if applicable

Examples
Antihistamines
Anti

pyretics
Washed blood (when anaphylactic reactions are under
investigation and results are not back yet)
Antigen negative blood if a clinically significant antibody is
identified

Reporting

Hospitals should report all severe and fatal

reactions to the blood supplier

Health Canada requires that CBS Head Office

advise them within 24 hours of a fatal reactions and
as soon as possible (within 15 calendar days), of a
life-threatening or permanently disabling reaction. To
comply with this requirement, hospitals should
report these types of adverse reactions immediately
to their local CBS.

Future Transfusions

Patient should be notified if special

requirements are necessary

Antibody card

Transfusion reaction investigations and reports

should be retained indefinitely by the laboratory

Risk of Suffering a Transfusion

Reaction

RBC Alloimmunization: 1-2%

Febrile Non-Hemolytic

Allergic (mild): 1-3%

Circulatory Overload: 1%
Acute Hemolytic: 1:12,500

to Platelets: 20-30%
to RBC: 1%

Fatal: 1/600,000

Anaphylaxis: 1/25, 000

The Message

The risk of a severe transfusion reaction is low

but health care professionals must have
documented procedures for recognition and
identification of the adverse effects of
transfusion
The outcome

Better informed patients, nurses, physicians and

laboratory personnel resulting in quality patient care