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Hematology & Blood Transfusion

Blood Transfusion Reactions

Adverse signs or symptoms occurring during or after a blood transfusion, ranging from mild allergic reactions to severe, life-threatening haemolytic reactions or infections.

Also known as: Transfusion Reaction, Adverse Transfusion Event

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Referral and warning signs

When to refer

ALL significant transfusion reactions require immediate medical assessment and management. Severe reactions (AHTR, Anaphylaxis, Sepsis, TRALI, severe TACO) require urgent specialist/critical care involvement.

Red flags

  • Any signs/symptoms starting within minutes of commencing transfusion
  • Hypotension / Shock
  • Respiratory distress / Hypoxia
  • Haemoglobinuria (red/dark urine)
  • Fever >39°C / Rigors
  • Generalized rash / Angioedema / Stridor
  • Back/chest pain during transfusion

Signs and symptoms

  • Acute Reactions (<24h): Fever, chills, rigors (FNHTR, AHTR, Sepsis). Itching, urticaria, rash (Allergic, Anaphylaxis). Respiratory distress, dyspnoea, wheezing, hypoxia (Anaphylaxis, TRALI, TACO). Hypotension, shock (AHTR, Sepsis, Anaphylaxis). Hypertension (TACO). Chest/back/loin pain (AHTR). Nausea/vomiting. Haemoglobinuria (AHTR). Bleeding/DIC (AHTR). Anxiety.
  • Delayed Reactions (>24h): Jaundice, falling Hb (DHTR). Fever. Positive Coomb's. Post-Transfusion Purpura (PTP). TA-GvHD (rare). TTIs.

Risk factors

  • ABO incompatibility (clerical error).
  • Pre-formed antibodies (RBCs, WBCs, platelets, proteins).
  • Previous transfusions/pregnancy (alloimmunization).
  • Rapid/Large volume transfusion (TACO risk).
  • Bacterial contamination.
  • Underlying conditions (cardiac/renal for TACO; IgA deficiency for anaphylaxis).

Diagnosis

Clinical assessment

Suspect based on new signs/symptoms during/after transfusion. Prompt recognition & differentiation needed.

Investigations

  • Immediate Steps: 1. STOP transfusion. Keep IV open (NS). 2. Check Clerical Info (Patient ID vs Unit Label). 3. Notify Clinician & Blood Bank. 4. Assess Patient (Vitals, Exam).
  • Laboratory Investigation (Send to Blood Bank): Implicated unit + set, Post-transfusion blood (EDTA for Group & Screen/DAT; Clotted for haemolysis), Post-transfusion urine (haemoglobinuria).
  • Specific Tests: AHTR (Repeat ABO/RhD, Crossmatch, DAT, Haemolysis screen). Sepsis (Gram stain/Culture unit & patient). Allergic (Tryptase). TRALI (CXR, ABG, donor/patient Abs). TACO (CXR, BNP).

Diagnostic criteria

Clinical picture + Lab findings (haemolysis, bacteria, allergy mediators) +/- Ruling out clerical error.

Management

Non-pharmacological management

  • Stop Transfusion Immediately (except perhaps very mild localized urticaria).
  • Maintain IV access with Normal Saline.
  • Supportive care based on reaction type/severity (Oxygen, positioning, monitoring).

Pharmacological treatment

  • Mild Allergic (Urticaria only):
  • - Antihistamine PO/IM/IV (e.g., Chlorpheniramine, Promethazine).
  • - May cautiously restart transfusion slowly if symptoms resolve completely, monitor closely.
  • Febrile Non-Haemolytic (FNHTR):
  • - Antipyretic (Paracetamol).
  • - Exclude other causes (haemolysis, sepsis).
  • - May restart transfusion cautiously if mild and other causes excluded.
  • Severe Allergic / Anaphylaxis:
  • - Adrenaline (Epinephrine) IM.
  • - IV fluids.
  • - Oxygen.
  • - Antihistamines (IV).
  • - Corticosteroids (IV Hydrocortisone).
  • - Bronchodilators (Nebulized Salbutamol) if wheezing.
  • - DO NOT RESTART TRANSFUSION.
  • Acute Haemolytic (AHTR):
  • - Aggressive IV Fluid resuscitation (Normal Saline) to maintain BP and renal perfusion.
  • - Maintain urine output (Furosemide may be needed).
  • - Treat DIC if present (FFP, Cryo, Platelets).
  • - Monitor renal function closely (risk of AKI).
  • - DO NOT RESTART TRANSFUSION.
  • Bacterial Sepsis:
  • - Broad-spectrum IV Antibiotics immediately.
  • - IV fluids / Vasopressors for shock.
  • - DO NOT RESTART TRANSFUSION.
  • Transfusion-Related Acute Lung Injury (TRALI):
  • - Supportive care (Oxygen, Mechanical Ventilation if needed).
  • - Diuretics generally NOT helpful (may worsen hypotension).
  • - DO NOT RESTART TRANSFUSION.
  • Transfusion-Associated Circulatory Overload (TACO):
  • - Sit patient upright.
  • - Oxygen.
  • - Diuretics (IV Furosemide).
  • - Slow or stop transfusion depending on severity.

Monitoring

Closely monitor vital signs, respiratory status, urine output, signs of bleeding/DIC, renal function during and after managing reaction.

Complications

  • Shock
  • Acute Kidney Injury / Renal failure
  • Disseminated Intravascular Coagulation (DIC)
  • Acute Respiratory Distress Syndrome (ARDS)
  • Death

Prevention

  • Strict adherence to patient identification and blood administration protocols.
  • Accurate ABO/RhD grouping and compatibility testing.
  • Leucoreduction of blood components (may reduce FNHTR, CMV risk).
  • Use of washed red cells/platelets (for recurrent severe allergic reactions).
  • Use of irradiated components (prevent TA-GvHD in high-risk patients).
  • Appropriate use of transfusion (avoid unnecessary exposure).

Patient education

  • Explanation of the reaction that occurred.
  • Importance of reporting any future reactions immediately.
  • Need for specific precautions in future transfusions if indicated (e.g., pre-medication, special components).

Uganda-specific notes

Clerical errors in patient/sample identification are a major risk. FNHTR and mild allergic reactions common. AHTR due to ABO incompatibility is preventable but catastrophic. Recognition and basic management (stop transfusion, fluids, antihistamines/paracetamol) crucial. Access to advanced diagnostics and specific components limited.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 11, Section 11.2.3

  • National Blood Transfusion Guidelines, MOH Uganda

    (Detailed management of reactions)

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