Febrile nonhemolytic transfusion reactions (FNHTR) | Mild fever (<1.5°C rise), chills, urticaria | Can be difficult to distinguish from AIHR Consider bacterial infection Hemolytic workup (see AIHR) | Stop transfusion, check vital signs, O2 saturation, verify patient ID; administer acetaminophen for fever, antihistamine for mild urticaria Usually self-limited but can be life threatening in patients with tenuous cardiopulmonary status |
Acute intravascular hemolytic reaction (AIHR) vs bacterial infection | Fever, back pain, hematuria (hemoglobinuria), chills, "sense of doom," flushing, dyspnea, tachycardia, shock, renal failure, syncope, DIC Transfusion of blood contaminated with bacteria tends to precipitate a severe acute reaction with rapid onset of hyper- or hypotension, rigors and cardiovascular collapse | Save the blood unit, notify blood bank, retype and crossmatch, direct and indirect Coombs tests, CBC, creatinine, PT, aPTT, haptoglobin, indirect bilirubin, LDH, plasma free hemoglobin, blood cultures, UA | Stop transfusion, start IV hydration to maintain diuresis; diuretics if anuria or oliguria (<100 mL/h), start broad spectrum antibiotics if suspicious bacterial infection, treat DIC Cardiorespiratory support as indicated |
Allergic reaction/Anaphylaxis | Rapid onset, urticaria, pruritus, dyspnea, nausea, vomiting, syncope, headache, bronchospasm, angioedema, abdominal pain, hypotension | Notify blood bank For mild symptoms that resolve with antihistamines, no further workup needed | Stop transfusion and assess patient. If allergic reaction is mild, treat with antihistamines; if symptoms resolve, can restart transfusion If allergic reaction is severe, treat as anaphylaxis |
Fluid overload | Dyspnea, tachycardia, hypertension, headache, jugular venous distention, pulmonary rales, hypoxia, hypotension if volume overload is severe | ECG, chest x-ray, monitor CVP, urine output, blood gas as indicated by clinical situation | Stop transfusion [or decrease rate to 1 mL/kg/h if very mild symptoms], start diuretics (furosemide) |
Transfusion related acute lung injury (TRALI) | Dyspnea, nonproductive cough, acute respiratory distress syndrome (ARDS), hypotension, fever/chills, monocytopenia/neutropenia | Chest x-ray (bilateral nodular infiltrates, batwing pattern) | Stop transfusion, consult hematology, treat as ARDS |
Complications from massive transfusion | Bleeding, hypothermia, citrate toxicity, hypocalcaemia or hypomagnesaemia | Monitor temperature, coagulation parameters, acid base balance, serum potassium and calcium | Use blood warmers for hypothermia; administer warm isotonic fluid, additional PRBC, FFP, cryoprecipitate, and platelet as clinically indicated, treat symptomatic hypocalcaemia or hypomagnesaemia |