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Information

Editors

JouniLauronen
MarjattaOkkonen
SusannaSainio

Blood Transfusion: Indications, Administration and Adverse Reactions

Essentials

  • The information presented in this article is based on the practice and policies in Finland. Local (national, regional) variation, instructions and regulations are likely to exist in other countries and should be taken into account.
  • Donated blood is processed into red blood cell, platelet and fresh frozen plasma components.
    • Red blood cells are transfused in anaemia to provide adequate oxygen delivery.
    • Platelets (thrombocytes) are indicated for the management of haemorrhage or in thrombocytopenia to promote haemostasis where either the number or functioning of platelets is insufficient.
    • Fresh frozen plasma (e.g. OctaplasLG® ) is transfused to replace coagulation factors in haemorrhage when associated with the simultaneous deficiency of several coagulation factors.
  • The treating unit should prepare for blood transfusion by
    • checking any instructions for blood transfusion previously given to the patient
    • ordering pre-transfusion tests
    • ordering the blood products.
  • In blood transfusions administered in the patient's home, all the codes of practice stipulated for blood transfusions must be closely adhered to. Home blood transfusion is only recommended for patients who have received previous problem-free transfusions in a hospital setting.
  • Basically, one product should be given at a time while monitoring the response.

Pre-transfusion testing

Essentials

  • Verification of the patient's identity when taking samples
  • Before transfusion of red blood cells, platelets or fresh frozen plasma, the patient's blood group (ABO and RhD) must be determined from two samples taken at separate times.
  • In addition, compatibility testing is needed for the transfusion of red blood cells. No compatibility testing is needed for the transfusion of platelets or fresh frozen plasma.
  • Pre-transfusion tests can be ordered well in advance, several weeks before the planned transfusion, for instance. Compatibility samples should be taken not more than 5 days before red blood cell transfusion.
  • Guidelines for blood transfusion in children, for example, may differ from those given below. Before ordering any tests, familiarise yourself with the blood transfusion guidelines used in your unit.

ABO and RhD typing

  • ABO and RhD characteristics remain unchanged throughout life (with the exception of allogeneic stem cell recipients, whose blood group will change to match the donor's blood group).
  • If blood group results cannot be found in the laboratory or blood transfusion data system, blood group determination and compatibility testing must be ordered and performed with samples taken at two separate times.
  • Blood group determination need not be reordered if it has already been done and the result can be found in the laboratory or blood transfusion data system. The blood group must be checked using the compatibility test sample.
  • For emergency transfusions the samples for blood group determination and compatibility testing can be taken at the same time, in which case two people must identify the patient.

Compatibility testing

  • Always perform before transfusion of red blood cells.
  • The same sample is used to check the blood group and for antibody screening. Should antibodies be detected, they must be identified.
  • Valid for 5 days
  • Can be done with an electronic system (Type and Screen).
  • Compatibility testing must always be done serologically if red blood cell antibodies have been detected or the patient has received an allogeneic stem cell or liver transplant.

Red blood cell transfusion Transfusion Thresholds for Guiding Allogeneic Red Blood Cell Transfusion

Indications in adults

  • Red blood cells should be given one unit at a time while assessing the response. One unit of red blood cells typically raises the Hb concentration in an adult by approximately 10 g/l.
  • Chronic or slowly developing anaemia
    • It is not possible to give exact haemoglobin (Hb) values as triggers for red blood cell transfusion since the decision depends on anaemia symptoms, the patient's age and the underlying diseases.
    • Red blood cell transfusion is always indicated when the Hb is below 50 g/l.
    • For hospitalized patients, a red blood cell transfusion threshold at 70 g/l is usually sufficient.
      • Anaemia in patients with heart or lung diseases and elderly patients with symptomatic anaemia should be treated earlier (at a haemoglobin level of 80-90 g/l).
    • In palliative treatment, red blood cell transfusion should be used only after careful consideration. Red blood cell transfusion may be considered if it would significantly improve the patient's independence or alleviate disabling symptoms.
  • Acute or massive haemorrhage
    • The replacement of blood loss in traumatic, surgical, obstetric or other haemorrhage often necessitates the use of platelets and fresh frozen plasma (OctaplasLG® ) and/or specific coagulation factors products in addition to red blood cell transfusion.
    • The decision to proceed with emergency or massive transfusion is the responsibility of the treating physician.
    • Guidelines issued specifically for each hospital and speciality, as regards the samples and tests required as well as blood products available, should be referred to.

Selecting red blood cells for transfusion

  • Essentials
    • As a general rule, the red blood cell units to be transfused should be identical with the recipient's ABO/RhD groups.
    • If products identical with the recipient's ABO/RhD group are not available, see local and national guidelines and picture .
    • The transfusion of ABO incompatible blood products may cause a life-threatening transfusion reaction if the patient has natural antibodies (isoagglutinins) against the transfused red blood cells.
    • RhD negative girls and women in fertile age should not receive RhD positive red blood cells except in life-threatening situations, in order to avoid production of anti-D antibodies in possible future pregnancies.
    • Exceptional situations in which RhD positive red blood cells may be transfused to an RhD negative person may include emergency blood transfusion, massive transfusion or other situations where RhD negative red blood cells are not available in sufficient quantities. This can be done if the patient has no known anti-D antibodies. Patient groups to whom RhD positive red blood cells can be transfused, if necessary, include men and all patients over 50 years of age. The decision to switch to RhD positive red blood cells is made by the hospital's blood centre. See also local policies and guidelines.
    • RhD negative red blood cells can safely be transfused to RhD positive patients. RhD negative red blood cells are usually in short supply compared to RhD positive red blood cells, and their transfusion to RhD positive recipients is only recommended in exceptional situations, for example when suitable RhD positive red blood cells are not available.
  • Additionally, K (Kell) negative red blood cell products should always be chosen for girls and women in fertile age, since anti-K antibodies may cause severe haemolytic disease of the foetus and newborn.
  • Phenotype matched red blood cells
    • ABO, Rh (D, C, c, E, e) and K blood groups are determined in all blood donors. In addition, some blood donors may be tested more extensively for other blood groups significant for blood transfusion. The label of a red blood cell product will state only the red blood cell antigens for which the donor is negative.
    • There may be limited availability of extensively phenotyped red blood cell products in your hospital's blood centre. Some more extensively phenotyped red blood cell products cannot even be found in blood service's store but donors may need to be called in separately, as need arises.
      • Patients who have clinically significant red blood cell antibodies
        • must receive red blood cells that are negative for the blood group (or antigens) against which the patient has antibodies
        • should also receive Kell negative red blood cells in order to avoid further immunisation.
    • Patients who are dependent on blood transfusions due to a hereditary haemolytic anaemia or haemoglobinopathy and who have an increased risk of developing red blood cell antibodies
    • Patients in whom panagglutinins (red blood cell antibodies that react with all red blood cells) interfere with transfusion tests and no suitable blood can be found, e.g. patients with autoimmune haemolytic anaemia (AIHA).
    • Patients who have a rare blood group
    • If the patient needs broadly typed red blood cell products, arrangements for transfusion should be made well in advance and the blood components should be ordered at least 3-5 days before the planned transfusion.

Special blood products

  • All basic red blood cell products have been filtered, i.e. the leukocytes have been removed.
  • The processing that the special blood products require delays their delivery and decreases their life time. Such products should be prescribed only to patients who are in absolute need of them.

Washed red blood cells

  • For patients with a confirmed deficiency of immunoglobulin A (serum IgA < 0.5 mg/l) and anti-IgA antibodies.
  • For patients who experience recurrent severe allergic-type transfusion reactions (such as generalised urticaria and/or dyspnoea) associated with red blood cell transfusions
  • Washed red blood cells must be used within 14 days after preparation.
  • Should washed red blood cells not be ready in time (washing takes 2-3 hours) due to the urgency of the transfusion, standard products should be used whilst being ready to manage a possible anaphylactic reaction.

Irradiated red blood cells

  • Irradiated blood products are used in special groups of patients, for example
    • severely immunocompromised patients
    • stem cell transplant recipients, some patients with other haematological diseases
    • very low birth weight premature infants (see hospital-specific guidelines)
  • The decision on the need for irradiation should always be made by the patient's doctor. He or she must make sure that the irradiation order for the patient and, if applicable, its annulment are recorded in the blood transfusion system.

Platelet transfusion

Indications

  • Platelets are mainly transfused in the event of a bleed or in the case of invasive procedures.
  • Prophylactic platelet transfusions may be needed for
    • supportive therapy to prevent bleeding in cancer or malignant haematological diseases if the patient has thrombocytopenia due to insufficient platelet production in the bone marrow
    • prevention of bleeding during medical interventions in patients with thrombocytopenia or platelet dysfunction.

Implementation

  • The transfusion threshold is considered to be 30-100 × 109 /l in case of a bleeding or invasive procedure, depending on the location of the bleed and the procedure.
  • Prophylactic platelet transfusions are given for thrombocytopenia due to bone-marrow depressing cytostatic chemotherapy usually when the platelet count is < 10-15 × 109 /l. However, the need for a platelet transfusion should be assessed on an individual basis, and the transfusion threshold may be set even higher if the patient has other factors that increase the risk of bleeding (e.g. antithrombotic medication) or has increased platelet consumption, as in sepsis.
  • In prophylactic transfusions, the patient is usually given one platelet concentrate at a time. The response to transfusion can be assessed by measuring the platelet count before the transfusion and about one hour after, or the next morning. After one hour, the expected post-transfusion platelet count increment following a transfusion of one unit is 20-25 × 109 /l of which about 60% should remain the following morning.
    • Reduced response to a transfusion may be due to various transient causes, such as fever, sepsis, DIC, splenomegaly, certain medicines, vasculitis and graft-versus-host reaction.
    • Immunological reasons, such as the presence of anti-HLA (common) or HPA- (rare) antibodies or platelet autoantibodies may result in long-lasting poor transfusion response.
  • Sufficient platelet transfusions should be used for the management of clinically significant haemorrhage in a thrombocytopenic patient.

Selecting platelets for transfusion

  • Platelets to be transfused should be identical with the recipient's ABO/RhD groups. No compatibility testing (cross matching) is carried out for platelets.
  • It is also possible to transfuse ABO non-identical platelets to manage an acute bleeding or other acute situations. Platelet transfusion guidelines regarding the ABO groups differ from those given for red blood cell transfusions. See local and national guidelines.
    • Modern platelet concentrates only contain a small amount of plasma. Therefore, the isoagglutinins in the product do not cause significant harm to the recipient. However, a transfusion that is incompatible with the recipient's isoagglutinins (for example, group A platelets given to a group O recipient) may slightly reduce the transfusion response.
    • If the patient has received an allogeneic stem cell transplant, the ABO group should be selected according to patient-specific instructions from the transplant centre.
  • Since platelet concentrate will also contain a small amount of red blood cells, attention must be paid to the RhD group when transfusing platelets.
    • An RhD negative patient may need to be transfused RhD positive platelets in exceptional circumstances, when no RhD negative platelets are available.
    • Transfusing RhD positive platelets may trigger the production of anti-D antibodies, which is particularly harmful for girls and women in fertile age.
    • The immunizing effect of RhD positive products may be prevented by anti-D-immunoglobulin. See local guidelines.
  • The majority of patients can be administered standard platelet products that are mainly made of whole blood pooled from 4 donors. The products must be irradiated to prevent graft-versus-host reactions if platelets are transfused to severely immunocompromised patients. See Irradiated red blood cells in the section Red blood cell transfusion here.
  • Patients in whom no transfusion response is achieved with standard platelets and who have anti-HLA and/or anti-HPA antibodies, must be transfused HLA and/or HPA matched platelets. These products are collected from specifically invited blood donors who have undergone HLA and/or HPA typing. Consult local instructions on how to order such products. For an acute haemorrhage, standard platelet products should be used, and in larger quantities if required.

Plasma transfusion

  • Fresh frozen plasma (FFP) is widely used. The frozen plasma product OctaplasLG® is used in some countries, also in Finland, where it is the only product in use. It is a registered medicinal product; see the Summary of Product Characteristics for more detailed information.
  • FFP products are transfused according to the ABO group. No compatibility testing (cross matching) is carried out. Since all red blood cells have been removed from the product, the RhD blood group is not considered.
    • In emergency situations, FFP blood group AB can be administered to all patients since it is devoid of anti-A and anti-B isoagglutinins.
    • It should be kept in mind that the transfusion guidelines regarding ABO groups are the opposite to those applied for red blood cell transfusion. See local regulations and policies.
    • The dosage of FFP is based on the clinical situation and on coagulation factor assays carried out on the patient.

Correct administration of a blood transfusion

  • Essentials
    • Correct identification of the patient and the product
    • Observation of the statutory obligation to maintain the traceability of the patient and the blood product.
  • A medical practitioner must prescribe a blood transfusion. The prescription must state
    • the type of the blood component (red blood cells, platelets, fresh frozen plasma) and the volume to be transfused
    • any special requirements, such as irradiation, washing, blood group or tissue type requirements
    • instructions regarding the speed of transfusion, any need to warm the product or any other factors to be considered, as necessary.
  • A checklist may be locally available.
  • Administration of a blood transfusion
    • A blood administration set with an integral 150-200 µm filter should be used to transfuse all blood products.
    • The patient's heart rate, blood pressure, temperature, as well as the start and end times of the transfusion, should be recorded. Oxygen saturation should be monitored if the patient shows respiratory distress or has been diagnosed with, or shows symptoms of, cardiac insufficiency before transfusion.
    • If possible, the transfusion should be started slowly with a biological test for compatibility.
      • Red blood cells are infused slowly (10-15 drops/min) during 10 minutes whilst carefully observing the patient.
    • The same administration set may be used to transfuse several units of red blood cells without interruption, but it is recommended that the administration set is changed after every four units or 12 hours in order to reduce the risk of bacterial contamination.
    • It is recommended that platelets are administered via a separate administration set, or they may be transfused first if the plan is to transfuse red blood cells and platelets consecutively.
    • Only an isotonic electrolyte solution without calcium (such as 0.9% sodium chloride) may be infused through the same cannula during transfusion or through the transfusion set tubing after transfusion.
    • Due to the possibility of adverse reactions, the patient must be monitored throughout and after the transfusion.
  • In normovolaemic anaemia, a unit of red blood cells can be infused over 2-3 hours. Red blood cell transfusion should be completed within six hours of removing the pack from the refrigerator to room temperature. In the case of acute haemorrhage, the speed of transfusion should be determined by the doctor in charge depending on the clinical situation.
  • It is recommended that a platelet unit is administered within 30-60 minutes. In case of acute bleeding, however, the platelets should be administered more rapidly in order to obtain optimal haemostasis.
  • It is recommended that the blood pack and the administration set are stored in a refrigerator after the transfusion for 24 hours in case of possible adverse reactions that occur after the transfusion.

Blood transfusion reactions, near miss events and incidents (incorrect blood component transfusions)

Terminology

  • Serious transfusion reaction is an event that
    • results in death or is life threatening
    • results in disability or work incapacity
    • results in, or prolongs, hospitalisation
    • results in, or prolongs, morbidity
  • A serious near miss event is
    • an incident that might have resulted in a serious transfusion reaction
  • Incident (incorrect blood component transfusion)
    • Patient transfused with blood of the wrong blood group
    • Patient transfused with a wrong component or product
    • Patient transfused with a product intended for another patient even if the blood group and other requirements were correct

Adverse reactions of blood transfusion

  • Every transfusion has the potential to cause an adverse reaction.
  • The health care unit must record all blood transfusion reactions, near miss events and incorrect blood component transfusions.
  • National and local surveillance procedures apply for the reporting of transfusion reactions, near miss events and incorrect blood component transfusions.
  • Any error or deviation from agreed procedures must be reported to the patient safety system at the treating unit.
    • Situations which could have led to incorrect blood component transfusion require additional reporting to the blood product supplier.
  • OctaplasLG® is a medicinal product, and regulations concerning such products also apply.
  • National and regional policies apply concerning the investigation and assessment of blood transfusion reactions and reporting to the authorities.
  • The majority of transfusion reactions are mild and harmless to the patient, and it is not possible to totally avoid them.
    • Treatment is symptomatic but it is important to find out the cause of serious adverse reactions to ensure the safety of future blood transfusions.
  • Incorrect blood component transfusion is often due to an error in the transfusion process.
    • Most commonly the patient was misidentified or not identified at all.

Symptoms of blood transfusion reactions

  • As the reaction begins, the patient often reports feeling uncomfortable and restless. Blood transfusion reactions of various causes have similar symptoms.
  • For classification of blood transfusion reactions by aetiology and for confirming investigations, please follow local and national guidelines.
  • For possible symptoms of blood transfusion reactions, see table T1
  • For differential diagnosis of blood transfusion reactions based on the main symptom, see table T2

Possible symptoms of blood transfusion reactions

SymptomPossible causeSerious symptoms
Fever, shivering, chillsAcute immunological reaction that may be due to the patient's red blood cell, platelet or leucocyte antibodies.High fever HASH(0x303d510) 39 °C or a temperature rise of HASH(0x303d510) 2 °C raise the suspicion of sepsis due to transfusion of a contaminated blood product.
Back and stomach ache, nausea, vomiting, diarrhoeaAcute intravascular haemolysisJaundice, haemoglobinuria, bleeding symptoms, disseminated intravascular coagulation (DIC)
Dyspnoea, obstruction, cough
  • Occur in severe reactions of various types
  • In allergic reactions due to respiratory obstruction.
  • In acute lung injury (TRALI) and circulatory overload (TACO) due to pulmonary oedema
Serious symptoms: hypoxaemia, oxygen saturation < 90%
Tachycardia, hypotension, hypertensionAnaphylaxis, sepsis, acute haemolysis and TRALI may proceed through hypotension to circulatory collapse.Impaired consciousness, shock
Urticaria Angioedema, anaphylaxis
Headache

Differential diagnosis of blood transfusion reactions based on the main symptom

Common symptomsDifferential diagnosisSpecific symptoms
Fever >38 °C and temperature rise >1 °CFever reactionShivering, chills
Acute haemolysisBack pain, hypotension, DIC
SepsisHigh fever HASH(0x303d510) 39 °C, hypotension, tachypnoea, impaired consciousness, deterioration of general condition, mottling of the skin
TRALIDyspnoea, decreased oxygen saturation, hypotension
DyspnoeaTACOTachycardia, hypertension, decrease in oxygen saturation, acute pulmonary oedema diagnosed clinically or with a chest X ray, or worsening of previous insufficiency
TRALIDecreased oxygen saturation, hypotension, fever, bilateral infiltrates in chest X-ray
TADOther causes excluded
AnaphylaxisExtensive skin symptoms, bronchial obstruction, angioedema, hypotension
SepsisHigh fever HASH(0x303d510) 39 °C, hypotension, shock, deterioration of general condition, mottling of the skin
Acute haemolysisBack pain, DIC, hypotension
Skin symptomsMild allergyUrticaria, itching
AnaphylaxisExtensive skin symptoms, bronchial obstruction, angioedema, hypotension

Measures when suspecting a transfusion reaction

Primary measures when suspecting an adverse transfusion reaction

  • Stop the transfusion and call for help.
    • Disconnect the transfusion set from the intravenous cannula and close the end of the transfusion set with a tight knot or stopper.
    • Leave the cannula in place and keep it patent by starting infusion of 0.9% NaCl solution or an isotonic solution without calcium.
  • Check the vital organ functions.
    • Airway, respiratory rate, SpO2, pulse, blood pressure, temperature, consciousness
    • In patients with a catheter, check if the urine has become bloody.
  • Inform the doctor.
  • In the case of a severe reaction, act immediately according to the resuscitation guidelines applicable in your unit; in the case of milder reactions, begin symptomatic treatment according to local or national guidelines, including for example
    • oxygen supplementation for dyspnoea
    • antipyretic medication (e.g. i.v. or p.o. paracetamol, for adults, normally 1 g)
    • an antihistamine (e.g. 10 mg cetirizine p.o.) or glucocorticoid (e.g. 100 mg hydrocortisone i.v.) for allergic symptoms
  • Check the compatibility of the blood product to be transfused with the patient's blood type.
    • ABO and RhD
    • Was the product prescribed for this patient?
    • In the case of a transfusion mix-up, prevent the transfusion of the wrong product to the other patient.
    • Condition and exterior characteristics of the blood product
    • If a RhD-negative patient has been accidentally given RhD-positive blood, assess the need for anti-D protection and consult a transfusion specialist, as necessary.

Further steps to be undertaken by the nursing staff in the case of a blood transfusion reaction

  • Enter in the patient record
    • time of transfusion
    • any symptoms of adverse reaction associated with the transfusion with their times.
  • Ensure appropriate further handling of the blood transfusion set and the transfused product.
    • Leave the transfusion set disconnected from the cannula attached to the product.
    • Make sure that the roller clamp is closed and the transfusion set tubing is tightly closed with a knot or a stopper at its patient end.
    • Place the unit with transfusion set in a disposable plastic bag and store it in a refrigerator until you send it to your hospital's blood centre or laboratory.
    • Store any remains of blood products transfused in the same situation in separate plastic bags.
  • Consult the hospital's blood centre if you suspect a sepsis associated with transfusion of a blood product.

Further steps to be undertaken by the physician responsible for treatment in the case of a blood transfusion reaction

  • Assess the type of transfusion reaction and whether it is serious here.
  • Order the required laboratory or X-ray studies depending on the suspected adverse reaction.
    • Haemolysis: Basic blood count with platelet count, lactate dehydrogenase, haptoglobin, creatinine, bilirubin, conjugated bilirubin haemoglobin (plasma and urine), direct Coombs test
    • If a coagulation disorder is suspected: prothrombin time/INR, APTT, fibrinogen, D-dimer assay
    • Fever: exclude haemolysis using the aforementioned haemolysis studies
    • Sepsis caused by contamination of blood product: Blood culture and CRP
    • TRALI/TACO: chest X-ray
    • Anaphylaxis or severe allergic reaction: plasma IgA concentration
      • If the result remains under the detection limit of the method used, an IgA deficiency test should be ordered.
      • Consult a transfusion specialist about whether washed blood products and IgA-deficient plasma should be used until the results are obtained. Inform the blood centre, where the instructions will be recorded in the blood transfusion data system.
    • Plan further treatment of the blood transfusion reaction according to the symptoms and the type of reaction; see table T2.
    • Ask the blood centre to examine the samples required to investigate the blood transfusion reaction.
      • 2 × 7 ml EDTA blood, or as advised by the local blood centre
    • Assess the immediate and possible future need for blood.
    • Inform the blood centre about the patient's further need for blood.
    • Consult a blood centre doctor or the consultant on call, as necessary, about the need for special blood products; inform the blood centre, where the instructions will be recorded in the blood transfusion data system.
    • Enter the blood transfusion reaction in the patient record.
    • See your unit's guidelines for reporting blood transfusion reactions.
    • Consider the results of investigations of blood transfusion reactions later on, and enter the instructions for future blood transfusion in the patient record and in the risk data included according to the hospital practice, as necessary; inform the blood centre, where the instructions will be recorded in the blood transfusion data system.

Treatment depending on the aetiology of the blood transfusion reaction

  • After initial measures and symptomatic treatment, the further treatment of a blood transfusion reaction depends on the type and severity of the reaction.
  • Transient elevation of body temperature and allergic reactions without hypotension are mild blood transfusion reactions. A more accurate cause can usually not be found, and these reactions are associated with the individual blood product. In such cases, transfusion of the same product can be continued once the symptoms have subsided, if this is considered appropriate and no replacement product is available.
  • If the reaction is serious, its cause must be investigated and considered in subsequent blood transfusions for the patient.
  • If the patient needs a blood transfusion, it is not always possible to wait for the results and blood transfusion must be continued using another product. In unclear cases, a blood centre physician can be consulted.

Mild febrile reaction

  • No specific cause can usually be found for mild, transient elevation of body temperature.
  • If the patient has repeatedly elevated body temperature in association with blood transfusion, paracetamol can be given in advance to treat it.

High fever HASH(0x303d510) 39 °C or a temperature rise of HASH(0x303d510) 2 °C

  • Arouses the suspicion of sepsis due to using a contaminated blood product. More commonly, however, bouts of fever and/or sepsis is attributable to something else in the patient's situation.
  • Empirical antimicrobial therapy must be started as soon as possible after taking a sample for blood culture.
  • Paracetamol can be used to lower fever in cases with suspected sepsis even before a sample has been taken for blood culture.

Dyspnoea

  • The treatment of dyspnoea, irrespective of its aetiology, is mostly symptomatic.
  • Check the airway and give the patient additional oxygen, as necessary.
  • Further treatment depends on the type and severity of respiratory distress; transfer the patient to high dependency unit/intensive care, as necessary.
  • Supplementary oxygen through a mask, high-flow oxygen therapy (e.g. OptiflowTM , AirvoTM ), continuous positive airway pressure (CPAP) or non-invasive ventilation (NIV) may be sufficient supportive treatments.
  • In severe gas exchange failure, intubation and invasive ventilation may be required.

Transfusion-related acute lung injury (TRALI) or transfusion-associated circulatory overload (TACO)

  • The differential diagnosis may be difficult.
  • TRALI: Diuretics may initially aggravate hypotension but they can be tried in haemodynamically stable patients. Glucocorticoids have not been shown to be useful.
  • TACO: Diuretics are effective in the treatment of circulatory overload. For high-risk patients, diuretics should be considered already as a preventive measure. Take into account any transfusions already prescribed for the patient; cancel them if necessary.

Allergic-type symptoms

  • Allergic-type symptoms, such as bronchial obstruction, should be treated with inhalable medication (bronchospasmolytics, such as salbutamol given through a nebulizer), glucocorticoids (such as 100 mg hydrocortisone i.v.) and antihistamine (such as 10 mg cetirizine p.o.).
  • If there have been recurrent symptoms in association with previous blood transfusions, medication can be given before transfusion already to prevent such symptoms.
  • Mild allergic reaction
    • There is no angioedema, dyspnoea or hypotension associated with the reaction.
    • No specific cause can usually be shown, the reaction being associated with an individual blood product.
    • It can be treated with an antihistamine and/or a glucocorticoid.
  • Anaphylactic shock or severe allergic reaction
    • See Anaphylaxis Anaphylaxis.
    • Recurrent, severe allergic reactions can be prevented by using washed red blood cell and platelet products. The use of these products requires a special agreement with the blood centre physician.
    • For patients with known IgA deficiency and anti-IgA antibodies, washed cell products and IgA-deficient FFP should be used for blood transfusion.
    • In association with recurrent blood transfusions, patients may become sensitive to other plasma proteins, as well, which may predispose them to severe allergic reactions.

Hypotension

  • Can be treated by fluid administration and vasoactive medication, as necessary.

Haemolytic transfusion reaction

  • There is no specific treatment for haemolysis. An attempt can be made to prevent the development of organ damage with sufficiently extensive fluid therapy.
  • If hyperkalaemia or any organ dysfunction develops, the heart and circulation must be carefully monitored. In the case of severe hyperkalaemia and acute renal damage, urgent renal dialysis may be necessary.
  • In massive haemolysis, generalized disseminated intravascular coagulopathy (DIC) may cause thrombosis in the microcirculation and, further, bleeding symptoms due to the consumption of coagulation factors and platelets.
  • Efforts can be made to prevent thrombosis by giving low molecular weight heparin.
  • Do not hesitate to consult specialized care for appropriate patient care and place of treatment.

Post-transfusion purpura (PTP)

  • Can be treated with intravenous immunoglobulin.
  • Platelet transfusion should be reserved for life-threatening haemorrhage.
  • The patient's platelet-specific antibodies (HPA-antibodies) are examined in samples sent for the investigation of adverse effects. Detected anti-HPA antibodies must be considered in the choice of future blood products. The attending physician should write instructions concerning the need for HPA-typed platelets in the patient record and inform the blood centre, where the instructions will be recorded in the hospital's blood transfusion data system.
  • Do not hesitate to consult specialized care for appropriate patient care and place of treatment.

Transfusion-associated graft-versus-host disease (TA-GVHD)

  • The treatment is symptomatic. Do not hesitate to consult specialized care for appropriate patient care and place of treatment.
  • The reaction can be avoided by irradiating blood products. The attending physician should write instructions concerning the need for irradiated blood products in the patient record and inform the blood centre, where the instructions will be recorded in the hospital's blood transfusion data system.
  • Certain blood products may be irradiated by default while others are not. Find out about the policies and practices of the local blood centre.

    References

    • Carson JL, Stanworth SJ, Guyatt G, et al. Red Blood Cell Transfusion: 2023 AABB International Guidelines. JAMA 2023;330(19):1892-1902[PubMed]
    • Abdallah R, Rai H, Panch SR. Transfusion Reactions and Adverse Events. Clin Lab Med 2021;41(4):669-696[PubMed]
    • Estcourt LJ, Birchall J, Allard S, et al. Guidelines for the use of platelet transfusions. Br J Haematol 2017;176(3):365-394[PubMed]