Significant, and sometimes life-threatening, complications are associated with transfusion therapy (Table 11-8). Adverse reactions can be classified into immunological and nonimmunological categories. Complications are described later. Notably, the three most common reported causes of mortality associated with transfusions are TRALI, hemolytic transfusion reactions, and transfusion-associated circulatory overload (TACO) (Hod & Francis, 2020). In Table 11-9, signs and symptoms, intervention, and prevention are listed in a quick-guide format.
| Viral Infection | Estimated Risks per Unit |
|---|---|
| HIV-1 and HIV-2 | 1:1,467,000 |
| Hepatitis B virus (HBV) | 1:843,000 to 1:1,208,000 |
| Hepatitis C virus (HCV) | 1:1,149,000 |
| Acute Transfusion Reactions <24 hours | |
| Hemolytic transfusion reactions | ABO/Rh mismatch: 1:40,000 Acute hemolytic transfusion reaction (AHTR): 1:76,000 Fatal HTRs: 1:1.8 million |
| Febrile nonhemolytic transfusion reaction | 0.1%-1% with universal leukocyte reduction |
| Minor allergic reaction | 1:100 to 1:33 (1%-3%) |
| Anaphylaxis | 1:20,000 to 1:50,000 |
| Transfusion-related acute lung injury (TRALI) | 1:1200 to 1:190,000 |
| Circulatory overload | 1% |
| Delayed Reactions | |
| Alloimmunization, red blood cell antigens | 1:100 (1%) |
| Alloimmunization, HLA antigens | 1:10 (10%) |
| Delayed hemolytic | 1:2500 to 1:11,000 |
Sources: Crowder et al., 2020; Hod & Francis, 2020.
| Transfusion Reaction | Etiology | Signs and Symptoms | Key Interventions | Prevention |
|---|---|---|---|---|
| Acute Immediate (<24 hours) | ||||
| Acute hemolytic transfusion reaction (AHTR) | Transfusion of ABO-incompatible red blood cells (RBCs). Hemolysis occurs when antibodies in plasma attach to antigens on the donor's RBCs. | Fever with/without chills Tachycardia Abdominal, chest, flank, back pain Hypotension Shortness of breath Red/dark urine Shock | STOP TRANSFUSION! Rapid response team. Change administration set and infuse 0.9% sodium chloride. Keep urine output >1 mL/kg/hr with fluids/diuretics. Vasopressors for hypotension. Hemostatic components to manage bleeding. | Exercise extreme care during the entire identification process. Start transfusion slowly and monitor for first 15 minutes. |
| Febrile nonhemolytic reaction | Occurs as a result of antibodies directed against leukocytes or platelets. | Fever rise of >1°C (2°F) during or shortly after transfusion Chills Headache Vomiting | Stop the transfusion. Change administration set and infuse 0.9% sodium chloride. Notify the provider. Monitor vital signs. Anticipate order for antipyretic agents. If ordered, restart transfusion slowly. | Use leukocyte-reduced blood component. Antipyretic premedication (acetaminophen, no aspirin) |
| Allergic reactions (mild) | Caused by recipient sensitivity to allergens in the blood component. | Pruritus Urticaria Facial flushing Mild wheezing | Stop the transfusion. Keep vein open with normal saline. Notify the provider. Monitor vital signs. Anticipate antihistamine order. If ordered, restart transfusion slowly. Mild reactions can precede severe allergic reactions. | If known mild allergic reaction occurs with blood transfusion, may premedicate with diphenhydramine 30 minutes before the transfusion. |
| Severe allergic reactions: Anaphylaxis | Antibodies to donor blood plasma (e.g., immunoglobulin A [IgA] proteins are transfused into an IgA-deficient recipient who has developed IgA antibody). | Hypotension Tachycardia Urticaria Bronchospasm Anxiety Shock Nausea, vomiting, diarrhea, abdominal pain | Stop the transfusion. Keep the vein open with normal saline. Administer cardiopulmonary resuscitation (CPR) if necessary. Anticipate order for epinephrine and steroids. | Use autologous blood. Use blood from donors who are IgA deficient, or administer only well-washed RBCs in which all plasma has been extracted. |
| Transfusion-related acute lung injury (TRALI) | WBC antibodies usually from donor and WBC-activating agents in blood components. Source of antibodies from the donor: Antibodies formed after exposure to foreign antigens via pregnancy, transfusion, and transplantation. | Fever Respiratory failure Hypoxemia Hypotension Pulmonary edema | Stop transfusion. Provide respiratory support. Administer oxygen. Most often requires mechanical ventilation. Administer vasopressor agents. | Collect plasma, whole blood, platelets from male donors, never pregnant female donors, previously pregnant females who are negative for HLA antibodies |
| Transfusion-associated circulatory overload (TACO) | Volume overload. Greatest risk in patients older than 70 and in infants. | Dyspnea Orthopnea Cyanosis Tachycardia Jugular venous distention Increased BP Cough | Stop the transfusion. Place patient in sitting position. Notify the provider. Administer diuretics. Administer oxygen. | Monitor patient frequently. Reduce flow rate in high-risk patients. Monitor intake and output. |
| Complications of Massive Transfusions | ||||
| Citrate toxicity | Rare. High-rate infusions, liver unable to keep up with the rapid administration and cannot metabolize the citrate (which chelates calcium), reducing the ionized calcium concentration in the recipient's blood. | Cardiac dysrhythmias Perioral and peripheral tingling Muscular cramps Shivering Light-headedness | Slow rate of infusion. Administer calcium chloride or calcium gluconate based upon symptoms of hypocalcemia. | Monitor patients with hepatic impairment. |
| Hyperkalemia/hypokalemia | Rare. Administration of blood that has been stored. Related to release of potassium from the RBCs as they go through lysis. Increased risk in patients with renal failure, in premature and newborn infants. | Elevated/low potassium levels Slow, irregular heart rate Nausea Muscle weakness Electrocardiographic (ECG) changes Diarrhea Renal failure | Stop or slow the transfusion. Monitor the ECG. Notify the provider for further interventions. | No preventive strategy. |
| Hemostatic abnormalities in massive transfusions | Coagulopathy related to massive transfusions. Caused by dilution of platelets and clotting factors. | Occurs after replacement of 2-3 blood volumes Clinical evidence of bleeding Platelet count <50,000 Shock and disseminated intravascular coagulation (DIC) | Intraoperative laboratory testing. | No specific guidelines. |
| Delayed Transfusion Reactions | ||||
| Delayed hemolytic transfusion reaction | Result of RBC antigen incompatibility other than the ABO group. Occurs due to destruction of transfused RBCs by alloantibodies not discovered during the crossmatch procedures. | Occurs days to weeks after transfusion Fever (continual, low grade) Malaise Jaundice (mild) Malaise Decreased hemoglobin | No acute treatment required. Monitor Hgb level. Renal function. Coagulation profile. Notify transfusion services. | Identify antibodies and transfuse compatible RBCs in future. |
| Transfusion-associated graft-versus-host disease (TA-GVHD) | Rare and fatal. Viable T lymphocytes in transfusion component engraft in recipient and react against recipient tissue antigens. Highest risk in the immunocompromised patient. | Fever Maculopapular rash Increased levels on hepatic function tests Watery diarrhea Pancytopenia | No effective therapy. Treatment of symptoms. | Administer irradiated blood products in immunocompromised patients. |
| Iron overload | Multiple units (usually >100) of RBCs chronically transfused. | Development of organ failure Signs and symptoms associated with heart failure, cirrhosis, diabetes | Iron chelation. | Iron chelation. Therapeutic phlebotomy. |
| Infection-Related Complications | ||||
| Bacterial contamination | Occurs at the time of donation or in preparing the component for infusion. Highest risk in platelets. | High fever Severe chills Hypotension Flushing Shock Hemoglobinuria Renal failure DIC | Stop transfusion. Aggressively treat shock and anticipate order of steroids and antibiotics. Culture patient's blood, component, and all IV solutions. | Preventable. Exercise proper care of blood product from procurement through administration. Pay attention to skin antisepsis prior to venipuncture during blood donation process. Inspect unit before administration and do not administer if clots, bubbles, leaks in bag, or discoloration of the blood or plasma is present. Complete transfusion within 4 hours. |
Sources: AABB, 2013; Hod & Francis, 2020
Summary: Patient-Focused Interventions
1.Stop the transfusion immediately but keep the line open with saline. Because the blood setup contains a significant amount of blood, in some cases it is necessary to replace the saline-primed administration set (e.g., acute hemolytic transfusion reaction).
2.Reconfirm that the unit of blood is being administered to the intended recipient; document this recheck of identification. The labels on the component, patient records, and patient identification should be examined to detect any identification errors. Transfusion facilities may require repeat ABO and Rh typing of the patient on a new sample.
3.Contact the treating provider immediately for instructions for patient care.
Summary: Component-Focused Interventions
1.Contact the transfusion service for directions for investigation.
2.Follow organizational policy for return of the remaining component and complete IV setup (fluid and tubing) (Jorgenson, 2020).
Acute or Immediate Transfusion Reactions
Acute or immediate adverse reactions to blood or blood products are those that occur within 24 hours of transfusion and may occur during the transfusion. The clinical significance of an acute reaction often cannot be determined by clinical history or signs and symptoms alone but requires laboratory evaluation. Signs and symptoms may be associated with more than one type of adverse reaction. In general, signs and symptoms indicative of a reaction include:
- Fever
- Chills with or without rigors
- Respiratory distress: Wheezing, coughing, dyspnea
- Hypertension or hypotension
- Abdominal, chest, flank, or back pain
- Infusion site pain
- Skin reactions: Urticaria, rash, flushing, pruritus, localized edema
- Jaundice/hemoglobinuria
- Nausea/vomiting
- Abnormal bleeding
- Oliguria/anuria (Hod & Francis, 2020)
Acute Hemolytic Transfusion Reactions
The most serious and potentially life-threatening reaction is acute hemolytic transfusion reaction (AHTR), which occurs when the donor's RBCs are incompatible with the patient's plasma as a result of identification errors during the transfusion process. As little as 10 mL of the wrong blood can produce AHTR symptoms. Death from AHTR is estimated to occur in 1:1.8 million transfusions (Hod & Francis, 2020).
Extreme care during the entire identification process is the first step in prevention. Clerical and human errors involving proper patient, sample, and blood unit identification are the most common causes of AHTR. The transfusion must be started slowly, and evaluation of the patient for reactions during the first 15 minutes is needed to monitor for initial AHTR.
NURSING FAST FACT!If AHTR is suspected, you must not give the recipient another drop of donor blood. |
Febrile Nonhemolytic Transfusion Reactions
The nonhemolytic febrile reaction is manifested by a rise in temperature of 1°C (2°F) or greater to 38°C (100.4°) or greater in association with transfusion but without any other explanation (Hod & Francis, 2020). It usually occurs as a result of reactions to antibodies directed against leukocytes or platelets. Febrile reactions occur in only 1% of transfusions; repeat reactions are uncommon. Such reactions can occur immediately or within 1 to 2 hours after transfusion is completed. Patients who experience repeated, severe febrile reactions may benefit from leukocyte-reduced components.
NOTE: The remainder of the implicated component should not be transfused.
Allergic Reactions
In their mild forms, allergic reactions are a common type of reaction. They are probably caused by allergens in the component or, less often, by antibodies from an allergic donor (Hod & Francis, 2020). The patient may experience mild localized urticaria, pruritus, and flushing. Allergic reactions usually occur within seconds to minutes of starting the transfusion. Most reactions respond to antihistamines. Severe anaphylactic reactions include symptoms of urticaria and angioedema but progress to severe hypotension, shock, and loss of consciousness.
NURSING FAST FACT!Mild allergic reaction characterized by urticaria is the only transfusion reaction in which administration of the component may be resumed after treatment (Hod & Francis, 2020). |
Transfusion-Related Acute Lung Injury
TRALI is a severe and life-threatening reaction characterized by tachypnea, tachycardia, and hypoxia. Pulmonary edema occurs secondary to leakage of protein-rich fluid into the alveolar space (Hod & Francis, 2020). It most often begins within 1 to 2 hours after transfusion but can occur up to 6 hours after transfusion. TRALI is a clinical diagnosis without specific diagnostic tests; rather, it is a diagnosis of exclusion (Hod & Francis, 2020).
Although the exact mechanism for TRALI is not known, it is associated with antibodies to leukocyte antigens and the infusion of biological response modifiers. Infusion of either is thought to initiate a sequence of events that results in cellular activation and damage of the basement membrane. TRALI has been associated with transfusion of blood components from female donors with HLA and human neutrophil antigen (HNA) antibodies (Hod & Francis, 2020). Studies have found an increased prevalence of HLA antibodies in female blood donors with history of pregnancy (Hod & Francis, 2020).
NOTE: TRALI is a life-threatening complication.
Transfusion-Associated Circulatory Overload
The rapid administration of any blood product can lead to TACO, which is also life threatening. Patients at greatest risk are infants and adults older than 70 years (Hod & Francis, 2020). Individuals with compromised cardiac or pulmonary function are also at risk. Signs and symptoms generally occur within 1 to 2 hours of transfusion. Treatment includes stopping the transfusion, placing patient in a seated position if possible, oxygen, and diuretics administered.
Patients identified as being at risk for TACO should have blood infused at a reduced rate. Recommendations include administration at a rate of 2 to 4 mL/min and 1 mL/kg of body weight per hour (Hod & Francis, 2020). Monitor vital signs and intake and output throughout the transfusion.