Overview

Patients require monitoring during transfusions of blood or blood products due to the potential of reactions arising. This section covers some transfusion reactions that may occur.

They can be subdivided into 3 categories:

  • Acute immune-mediated reactions:
    • Occur within minutes to hours of transfusion
  • Delayed immune-mediated reactions:
    • Occur within days to weeks of transfusion
  • Non-immune-mediated reactions:
    • Reactions do not have an immune pathophysiology

Acute immune-mediated reactions

Acute haemolytic transfusion reaction

This is almost always due to human error and is the result of ABO red-cell incompatibility.

Febrile non-haemolytic transfusion reaction

The mechanism is not fully known. It is thought to be immune-mediated but in reality, is multifactorial. 

  • Presentation:
    • Fevers and chills
  • Management:
    • 1st-line: stop transfusion + antipyretic (paracetamol) + rule out haemolytic reaction
      • The patient should be given a new set of blood products after, not the same.

Non-anaphylactic allergic reaction

Usually due to the patient being sensitised to allergens in the donor’s blood. If severe enough, it can go on to become anaphylaxis.

  • Presentation:
    • Pruritus
    • Urticaria
    • No features of anaphylaxis – see below
  • Management:
    • 1st-line: stop transfusion + antihistamines (diphenhydramine) + continue if symptoms are relieved and haemolytic reaction ruled out

Anaphylaxis

Usually due to the release of IgE. Patients with low IgA secondary to anti-IgA antibodies can also have anaphylactoid reactions which present the same way.

  • Presentation – ABC:
    • A – airways: angioedema + swelling of the airways causing stridor
    • B – breathing: dyspnoea + wheeze
    • C – circulation: hypotension
    • Other features such as pruritus and urticaria may also be present
  • Management:
    • 1st-line: stop transfusion + IM adrenaline + ABCDE approach (oxygen + fluids)
      • The following may also be given:
        • Antihistamines – alongside the adrenaline
        • Corticosteroids – if severe/prolonged anaphylaxis
        • Salbutamol – for bronchospasm

Transfusion-related acute lung injury (TRALI)

Transfusion-related acute lung injury (TRALI) is due to granulocytes in the blood vessels of the lungs becoming activated leading to increased vascular permeability due to substances in the donor blood. It usually occurs 1-2 hours after the transfusion.

  • Presentation:
    • Hypoxia
    • Hypotension – due to increased pulmonary vasculature permeability (they are more ‘leaky’)
    • Chest x-ray shows pulmonary infiltrates
    • Fever
    • Tachycardia
  • Management:
    • 1st-line: stop transfusion + supportive care (e.g. oxygen)

Delayed immune-mediated reactions

Transfusion-Associated Graft-versus-Host Disease (TA-GvHD)

Due to lymphocytes in the donor blood recognising the recipient’s blood as foreign and mounting an immune response. It usually occurs 8-10 days following a transfusion.

  • Presentation:
    • Usually seen in people who are immunocompromised
    • Maculopapular rash
    • Fever
    • Diarrhoea
  • Management:
    • 1st-line: supportive care
    • The prognosis is poor: treatment is almost always unsuccessful and leads to death 

Non-immune-mediated reactions 

Transfusion-associated sepsis

Bacterial contamination is rare but can occur. Platelet transfusions carry a greater risk of infection due to being stored at higher temperatures than other blood products. Patients have features of sepsis.

Transfusion-associated circulatory overload (TACO)

Due to excess fluid in the circulatory system from transfusions. Patients with heart failure or those requiring large transfusions are at higher risk.

  • Presentation:
    • Pulmonary oedema
    • Hypertension – blood pressure is higher due to more fluid in the circulatory system, unlike TRALI.
  • Management:
    • 1st-line: stop transfusion + supportive care, oxygen, and consider IV loop diuretic (e.g. furosemide)

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