Diagnostics: Blood Transfusion Reactions
/In the era of modern medicine, blood transfusions are commonplace, especially in the emergency department. While they are a lifesaving staple of medicine, they also come with risks that emergency providers must be aware of. Transfusion reactions are a spectrum of adverse events that can occur with the transfusion of whole blood or any of its components. These reactions can vary from mildly uncomfortable to life-threatening. These reactions can be difficult to diagnose as they have many non-specific overlapping symptoms, however, there are several acute reactions that must be identified and treated quickly. Additionally, there are several risk factors that physicians should be aware of and steps after a transfusion reaction occurs that should be taken to expedite further workup.
With the variety of patient backgrounds, medical history and presenting conditions, it can be difficult to determine who may be at increased risk for a blood transfusion reaction. While there are no factors that increase risk of a transfusion reaction occurring to the point that they be avoided, there are several factors that physicians should be mindful of while deciding who and when to give transfusions. One of the major risk factors is receiving a blood transfusion in the past. These patients are at four times or more greater risk of having a transfusion reaction. This may be due to the immune system’s increased sensitization and production of antibodies to certain cell antigens after the prior transfusions. Patients receiving packed red blood cells are also at greater risk than patients receiving platelets, FFP, or whole blood. Other factors that could be readily elicited on history include a previous abortion in women and a diagnosis of malignancy in the patient being transfused. Receiving more than one unit of blood product is also associated with an increased risk for reaction. There are a few other factors as well that may increase risk for a transfusion reaction but are likely not readily available on patient history or are outside the physician’s control. These include the patient having type O blood and increased storage time of blood product being given. While these risk factors will not necessarily preclude a patient from receiving a transfusion, they do offer some guidance on who may be at greater risk for having an adverse transfusion reaction.
While the incidence of all transfusion reactions is somewhere around .25%, the incidence of severe transfusion reactions is about .09%. High enough to expect most emergency physicians to see them at some point in their career. Below we will discuss the frequency, timeline, presentation, and basic management of the most common acute transfusion reactions.
Mild Reactions
| Transfusion Reaction | Frequency | Timeline | Presentation | Management |
|---|---|---|---|---|
| Allergic | - 1-3% with platelet and plasma components - 0.1-0.3% with RBC components | Minutes to hours post transfusion | - Urticaria - Flushing - Pruritis - No anaphylactic signs | H1 blocker (diphenhydramine) |
| Febrile Non-hemolytic | 1% | Within 4 hours of transfusion | Mild fever | Acetaminophen |
Severe Reactions
| Transfusion Reaction | Frequency | Timeline | Presentation | Management |
|---|---|---|---|---|
| Acute hemolytic | 1:76,000 | During or shortly after transfusion | Rapid onset: - Fever - Chills - Flank pain - Tachycardia - Hypotension - Nausea and vomiting | - Supportive care - IV fluids - Vasopressors if needed |
| Anaphylaxis | 1:20,000 - 1:50,000 | Minutes to hours post transfusion | - Urticaria - Pruritis - Bronchospasm - Hypotension - Stridor - Flushing | - Epinephrine - Bronchodilators - H1 blockers - IV fluids - Supplemental oxygen/ventilation if needed |
| Bacterial contamination/ sepsis | - 1:50,000 with platelets - 1:5 million with RBCs | variable | - Fever - Chills - Rigors - Diaphoresis - Nausea - Tachypnea - Tachycardia - Hypotension - Altered mental status | - IV fluids - Broad spectrum antibiotics - Vasopressors if needed |
| Transfusion associated circulatory overload (TACO) | <1% | Between 0-6 hours after transfusion | - Acute dyspnea - Lung crackles - Hypoxemia - Hypertension | - Supportive oxygenation and ventilation - Diuresis - Afterload reduction if hypertensive |
| Transfusion related acute lung injury (TRALI) | <0.01% | Between 4-6 hours after transfusion | - Progressive dyspnea - Lung crackles - Hypoxemia - Hypotension | - Supportive oxygenation and ventilation |
| TACO | TRALI | |
|---|---|---|
| BP | Normal-high | Low-normal |
| Temp | Normal | Normal-elevated |
| CXR | Vascular Congestion | No congestion |
| BNP | High | Low |
| EF | Abnormal | Normal |
| Diuretic Response | Improved | Variable |
| CVP | High | Low |
It is often difficult to distinguish between TACO and TRALI and they both present with dyspnea, crackles on lung exam, and hypoxemia within a similar time period post-transfusion. Below are some expanded features that may aid in differentiating the two diagnoses.
Treatments
While the definitive treatment of the different transfusion reactions varies, many of the other steps you must take to ensure that the blood bank is properly informed, and the correct workup is underway are relatively similar. These next steps are important to understand as they will not only allow the patient to receive more blood product if necessary but also further necessitate the management of a patient undergoing a transfusion reaction.
The first thing to do when any severe transfusion reaction is suspected is to stop the transfusion and ensure the patient is being appropriately treated. Once this initial step has been completed, the blood bag and any tubing used should be returned to the blood bank. Following that, several steps should be taken depending on what type of transfusion reaction is suspected.
Acute hemolytic reaction
Resend a type and screen on both the patient and donor
Additional antibody studies
Coombs testing
Serum haptoglobin, lactate dehydrogenase, unconjugated bilirubin levels, basic metabolic panel, urinalysis
Coagulation panel including PT, aPTT, fibrinogen, and D-dimer
Serial hemoglobin testing to determine severity and need for further transfusions
Anaphylaxis
Resend a type and screen on both the patient and donor
Quantitative immunoglobulin A levels
Bacterial contamination/sepsis
Resend a type and screen on both the patient and donor
Gram stain on the donor product
Blood cultures from both the patient and donor product
Complete blood count
Respiratory distress (TACO vs. TRALI)
Chest x-ray
Brain natriuretic peptide
HLA typing
Pulmonary edema fluid analysis
While the transfusion of blood products can be life-saving, it is important to keep in mind that transfusion reactions can occur. When giving any type of blood product, always take the time to ensure there truly is an indication and need to give that blood product. Emergency physicians will give a significant amount of blood product over their careers and it is necessary to know the signs, symptoms, and management for the variety of transfusion reactions that can take place.
Emergency department steps when expecting a blood transfusion reaction
STOP transfusion if any suspicion
Check labeling and return blood bag and tubing to blood bank
Resend a type and screen
Assess airway, breathing, circulation and support the patient
Assess patient’s signs and symptoms and treat them appropriately
Reference Taming the SRU’s Transfusion Reaction
Post by Thomas Sprys-Tellner, MD
Dr. Sprys-Tellner is a PGY-1 in Emergency Medicine at the University of Cincinnati
Editing by Ryan LaFollette, MD
Dr. LaFollette is an Associate Professor in Emergency Medicine at the University of Cincinnati and co-editor of TamingtheSRU.com
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