management of acute transfusion reaction

Last reviewed 01/2018

management of acute transfusion reactions

Seek expert advice and check local guidelines.

Category 1: mild reactions

• immediate management
• slow the transfusion
• administer antihistamine IM (e.g. chlorpheniramine 0.1 mg/kg or equivalent)
• if no clinical improvement within 30 minutes or if signs and symptoms worsen, treat as Category 2 .

Category 2: moderately severe reactions

• immediate management
• stop the transfusion. Replace the infusion set and keep IV line open with normal saline
• notify the doctor responsible for the patient and the blood bank immediately
• send blood unit with infusion set, freshly collected urine and new blood samples (1 clotted and 1 anticoagulated) from vein opposite infusion site with appropriate request form to blood bank for laboratory investigations.
• administer antihistamine IM (e.g. chlorpheniramine 0.1 mg/kg or equivalent) and oral or rectal antipyretic (e.g. paracetamol 10 mg/kg: 500 mg – 1 g in adults). Avoid aspirin in thrombocytopenic patients
• give IV corticosteroids and bronchodilators if there are anaphylactoid features (e.g. broncospasm, stridor)
• collect urine for next 24 hours for evidence of haemolysis and send to laboratory.
• if clinical improvement, restart transfusion slowly with new blood unit and observe carefully
• if no clinical improvement within 15 minutes or if signs and symptoms worsen, treat as Category 3

Category 3: life threatening reactions

• immediate management
• stop the transfusion. Replace the infusion set and keep IV line open with normal saline
• infuse normal saline (initially 20–30 ml/kg) to maintain systolic BP. If hypotensive, give over 5 minutes and elevate patient’s legs
• maintain airway and give high flow oxygen by mask.
• give adrenaline (as 1:1000 solution) 0.01 mg/kg body weight by slow intramuscular injection
• give IV corticosteroids and bronchodilators if there are anaphylactoid features (e.g. broncospasm, stridor).
• give diuretic: e.g. frusemide 1 mg/kg IV or equivalent
• send blood unit with infusion set, fresh urine sample and new blood samples (1 clotted and 1 anticoagulated) from vein opposite infusion site with appropriate request form to blood bank for investigations
• check a fresh urine specimen visually for signs of haemoglobinuria
• start a 24-hour urine collection and fluid balance chart and record all intake and output. Maintain fluid balance
• assess for bleeding from puncture sites or wounds. If there is clinical or laboratory evidence of DIC , give platelets (adult: 5–6 units) and either cryoprecipitate (adult: 12 units) or fresh frozen plasma (adult: 3 units)
• reassess. If hypotensive:
• give further saline 20–30 ml/kg over 5 minutes
• give inotrope, if available
• if urine output falling or laboratory evidence of acute renal failure (rising K+, urea, creatinine):
• maintain fluid balance accurately
• give further frusemide
• consider dopamine infusion, if available
• seek expert help: the patient may need renal dialysis
• if bacteraemia is suspected (rigors, fever, collapse, no evidence of a haemolytic reaction), start broad-spectrum antibiotics IV

Reference:

• (1) World Health Organization (WHO). The clinical use of blood - Handbook