eMedicine Specialties > Hematology > Transfusion Medicine

Transfusion Reactions: Treatment & Medication

Author: S Gerald Sandler, MD, FACP, FCAP, Professor of Medicine and Pathology; Director, Transfusion Medicine, Department of Laboratory Medicine, Georgetown University Hospital
Coauthor(s): Viviana V Johnson, MD, FCAP, Medical Director, Transfusion Services and Armed Services Blood Bank Center, National Naval Medical Center
Contributor Information and Disclosures

Updated: Oct 4, 2009

Treatment

Medical Care

Continuous monitoring of vital signs during generalized anesthesia may prevent acute circulatory (volume) overload, but it may not detect early signs of other reactions (eg, acute hemolytic transfusion reactions).

The onset of red-colored urine in a transfused patient should raise the question of a hemolytic transfusion reaction. When performing checks to confirm that the correct blood was transfused to the correct patient, centrifuge a urine sample to determine whether the red color represents hematuria or hemoglobinuria (see Image 1).

In addition, the onset of abnormal bleeding/generalized oozing during surgery in a transfused patient should raise the question of a hemolytic transfusion reaction with DIC.

  • Acute hemolytic reactions (antibody mediated)
    • Immediately discontinue the transfusion while maintaining venous access for emergency management.
    • Anticipate hypotension, renal failure, and DIC.
    • Prophylactic measures to reduce the risk of renal failure may include low-dose dopamine (1-5 mcg/kg/min), vigorous hydration with crystalloid solutions (3000 mL/m2/24 h), and osmotic diuresis with 20% mannitol (100 mL/m2/bolus, followed by 30 mL/m2/h for 12 h).
    • If DIC is documented and bleeding requires treatment, transfusions of frozen plasma, pooled cryoprecipitates for fibrinogen, and/or platelet concentrates may be indicated.
  • Acute hemolytic reactions (nonantibody mediated)
    • The transfusion of serologically compatible, although damaged, RBCs usually does not require rigorous management.
    • Diuresis induced by an infusion of 500 mL of 0.9% sodium chloride per hour, or as tolerated by the patient, until the intense red color of hemoglobinuria ceases is usually adequate treatment.
  • Febrile, nonhemolytic reactions: Usually, fever resolves in 15-30 minutes without specific treatment. If fever causes discomfort, oral acetaminophen (325-500 mg) may be administered. Avoid aspirin because of its prolonged adverse effect on platelet function.
  • Allergic reactions: Diphenhydramine is usually effective for relieving pruritus that is associated with hives or a rash. The route (oral or intravenous) and the dose (25-100 mg) depend on the severity of the reaction and the weight of the patient.
  • Anaphylactic reactions
    • A subcutaneous injection of epinephrine (0.3-0.5 mL of a 1:1000 aqueous solution) is standard treatment. If the patient is sufficiently hypotensive to raise the question of the efficacy of the subcutaneous route, epinephrine (0.5 mL of a 1:10,000 aqueous solution) may be administered intravenously.
    • In overt shock, epinephrine as a 1:1000 aqueous solution may be administered as an intracardiac injection. If the patient has not already received an antihistamine, a parenteral dose of diphenhydramine may be added.
    • Although no documented evidence exists that intravenous corticosteroids are beneficial for the management of acute anaphylactic transfusion reactions, theoretical considerations cause most clinicians to include an infusion of hydrocortisone or prednisolone if an immediate response to epinephrine does not occur.
  • TRALI
    • Immediately discontinue the transfusion while preserving venous access.
    • Patients with mild episodes should respond to oxygen administered by nasal catheter or mask. If shortness of breath persists after oxygen administration, transfer the patient to an intensive care setting where mechanical ventilation can be administered.
    • In the absence of signs of acute volume overload or cardiogenic pulmonary edema, diuretics are not indicated.
    • No evidence exists that corticosteroids or antihistamines are beneficial.
    • Treat complications with specific supportive measures.
  • Circulatory (volume) overload
    • Move the patient to a sitting position, and administer oxygen to facilitate breathing.
    • The most specific treatment is discontinuing the transfusion and removing the excessive fluid.
    • If practical, the unit of blood component being transfused may be lowered to reverse the flow and to decrease intravascular volume by a controlled phlebotomy.
    • Less urgent situations may be managed by a parenteral or oral diuretic (eg, furosemide).
    • If the patient has symptomatic anemia requiring additional transfusions of RBCs, select concentrated (ie, CPDA-1-anticoagulated) red cells (hematocrit = 80-85%). Avoid red cell components diluted with saline additives (ie, AS-1).
  • Bacterial contamination (sepsis)
    • Immediately discontinue the transfusion, including all tubing, filters, and administration sets, and save the transfusion materials for cultures, while preserving venous access.
    • After appropriate blood cultures have been obtained, initiate treatment with intravenous broad-spectrum antibiotics. If a microbiologic stain or a culture of the contents of the transfused product identifies an organism, the initial broad-spectrum antibacterial approach may be modified accordingly.

Consultations

  • The possibility of an acute transfusion reaction should trigger an immediate consultation with the medical director of the hospital's blood bank or a designee (eg, a clinical pathology resident, transfusion medicine fellow). Depending on the findings, the blood bank consultant may arrange for microbiologic stains and cultures of the residual contents of the blood product container, clerical checks for patient and product identification in the laboratory, repeat compatibility testing using a freshly collected blood sample from the recipient, or other pertinent diagnostic studies.
  • The diagnosis of an acute hemolytic transfusion reaction should trigger consultation with a nephrologist to ensure optimal prophylactic measures to prevent renal damage.47
  • A hematology consultation is appropriate if a hemolytic transfusion reaction or bacterial contamination precipitated DIC.
  • A clinical diagnosis of bacterial contamination of a transfused blood product should trigger an infectious diseases consultation.

Medication

Use an antihistamine to ameliorate allergic reactions to plasma. These agents serve as adjuncts to epinephrine and other standard measures for therapy of anaphylaxis related to transfusions of plasma-containing blood products.

Analgesics and antipyretics reduce fever that is associated with nonhemolytic transfusion reactions. An osmotic diuretic promotes urinary excretion of hemoglobin that results from an acute hemolytic transfusion reaction.

Antihistamines

Antihistamines prevent histamine response in sensory nerve endings and blood vessels. These agents are more effective in preventing histamine response than in reversing it.


Diphenhydramine hydrochloride (Benadryl, Diphen)

Antihistamine with anticholinergic effects that competes with histamine for receptor sites on effector cells. Among other indications, used to treat urticaria, pruritus, and other histamine-mediated manifestations of allergic reactions to blood products.

Adult

25-50 mg PO/IV/IM for management of acute allergic reaction to blood or plasma

Pediatric

<20 lb: Not established

>20 lb: 12.5-25 mg PO/IV/IM; alternatively, 5 mg/kg/d PO/IV/IM or 150 mg/m2/d PO/IV/IM; not to exceed 300 mg qd

MAOIs prolong and intensify anticholinergic effects; potentiates the effects of CNS depressants; due to alcohol content, do not administer the syrup dosage form to patients who are taking medications that can cause disulfiramlike reactions

Documented hypersensitivity; concurrent or recent administration of MAOI; should not be used in newborn or premature infants or in nursing mothers

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May exacerbate narrow-angle glaucoma, hyperthyroidism, stenosing peptic ulcer, pyloroduodenal obstruction, symptomatic prostatic hypertrophy, or bladder neck obstruction; may cause drowsiness: patients receiving a dose should not drive or operate machinery for 4 h

Analgesics and Antipyretics

Analgesics and antipyretics improve patient comfort and reduce fever.


Acetaminophen (Tylenol, Panadol)

Nonopiate, nonsalicylate analgesic and antipyretic. Reduces fever by acting directly on hypothalamic heat-regulating centers, which increase dissipation of body-heat via vasodilation and sweating.

Adult

325-650 mg (1-2, 325-mg tab) PO for fever associated with a nonhemolytic transfusion; if fever persists or increases, reconsider the diagnosis

Pediatric

<7 years: Not established

7-12 years: 10 mL elixir (120 mg/5 mL) or 325 mg tab PO

>12 years: Administer as in adults.

Rifampin can reduce the analgesic effects of acetaminophen; interactions that increase toxicity are not significant for 1- to 2-tab dose for fever; rifampin can reduce the analgesic effect.

Documented hypersensitivity; liver failure

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hepatotoxicity can occur in people with chronic alcoholism with various dose levels of acetaminophen; severe or recurrent pain or high or continued fever may indicate a serious illness.

Osmotic Diuretics

Osmotic agents increase the osmolarity of the glomerular filtrate and induce diuresis. This, in turn, hinders the tubular reabsorption of water, also causing sodium and chloride excretion to increase.


Mannitol injection 20% USP (Osmitrol)

An obligatory osmotic diuretic only slightly metabolized and excreted by the kidney. Induces diuresis by increasing the osmolarity of the glomerular filtrate, thereby hindering tubular reabsorption of water. Excretion of sodium and chloride is also enhanced.

Adult

100 g IV as a bolus dose using a blood administration filter to prevent infusion of mannitol crystals; dose is coincident with infusion of 0.9% sodium chloride to promote diuresis and excretion of hemoglobin

Pediatric

<12 years: Not established

>12 years: Administer as in adults.

Documented hypersensitivity; anuria; severe pulmonary congestion; progressive renal damage; severe dehydration; active intracranial bleeding; progressive heart failure

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Carefully evaluate the patient's cardiovascular status before rapid administration of mannitol, because a sudden increase in extracellular fluid may lead to fulminating CHF; avoid pseudoagglutination; when blood is administered simultaneously, add at least 20 mEq of sodium chloride to each liter of mannitol solution; electrolyte-free mannitol should not be administered conjointly with blood.

Vasopressors

Vasopressors are used to reverse the hemodynamic compromise that is associated with anaphylaxis or allergic reaction.


Epinephrine (Epi-Pen, Adrenaline)

A sympathomimetic that activates both alpha receptors and beta receptors. Causes bronchial smooth muscle relaxation and cardiac stimulation.

Adult

Severe anaphylaxis: 0.1-0.5 mg IM/SC; may repeat in 10- to 15-min intervals prn

Pediatric

Anaphylaxis: 0.01 mg/kg SC; not to exceed 0.5 mg

Concomitant sympathomimetics; MAOIs may increase the effects of epinephrine; beta blockers or alpha blockers may blunt the effect of epinephrine

Documented hypersensitivity; organic heart disease; cardiac dilatation; arrhythmia; narrow-angle glaucoma; hypertension; hyperthyroidism

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Rapid IV infusions may cause death from cerebrovascular hemorrhage or cardiac arrhythmias.


Dopamine (Intropin)

An immediate precursor to epinephrine, dopamine stimulates dopaminergic, beta-adrenergic, and alpha-adrenergic receptors.

Adult

1-5 mcg/kg/min IV infusion; as much as 50 mcg/kg/min

Pediatric

Not established

MAOIs may prolong the effects of dopamine; beta-blockers antagonize the effects of dopamine.

Documented hypersensitivity; pheochromocytoma; uncorrected ventricular arrhythmia

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid infusion through small peripheral veins to prevent extravasation.

Loop Diuretics

Diuretics may be used to alleviate volume overload that is caused by transfusion of blood products.


Furosemide (Lasix)

Acts by inhibiting sodium and chloride resorption in the ascending loop of Henle, promoting excretion of sodium, water, chloride, and potassium.

Adult

Acute pulmonary edema: 40 mg IV slowly

Pediatric

Acute pulmonary edema: 1 mg/kg IV/IM; not to exceed 6 mg/kg/d

Potentiates the effects of other antihypertensive agents; may interact with lithium, digoxin, indomethacin, probenecid, or other nephrotoxic or ototoxic drugs

Documented hypersensitivity; anuria; hepatic coma; electrolyte depletion; rising BUN/creatinine

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients who are hypersensitive to sulfonamides and patients with cirrhosis or ascites

More on Transfusion Reactions

Overview: Transfusion Reactions
Differential Diagnoses & Workup: Transfusion Reactions
Treatment & Medication: Transfusion Reactions
Follow-up: Transfusion Reactions
Multimedia: Transfusion Reactions
References
Further Reading
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Further Reading

Additional Resources

  • Brecher ME, ed. Technical Manual. 15th ed. Bethesda, Md: American Association of Blood Banks Press; 2005.
  • Hillyer CD, Silberstein LE, Ness PM, Anderson KC, Roback JD, eds. Blood Banking and Transfusion Medicine. 2nd ed. Philadelphia, Pa: Churchill Livingstone; 2007.
  • Hillyer C, Strauss RG, Luban NLC, eds.   Handbook of Pediatric Transfusion Medicine. San Diego, Calif: Elsevier Academic Press; 2004.
  • Petz LD, Garratty G, eds. Immune Hemolytic Anemias. 2nd ed. Philadelphia, Pa: Churchill Livingstone, 2004.

Related eMedicine Topics

Clinical Trials

Clinical Guidelines

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Keywords

transfusion reactions, blood transfusions, blood products, hemolytic transfusion, acute hemolytic transfusion reactions, transfusion complications, transfusion syndrome, blood product reactions, allergic transfusion reaction, blood type, blood group incompatibility, circulatory volume overload, anaphylactic transfusion reaction, blood anaphylaxis, hemolytic reactions, allergic reactions, anaphylactic reaction, anaphylaxis, transfusion-related acute lung injury, TRALI, transfusion-related lung injury, ABO antibody reaction, blood contamination, contaminated blood

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Contributor Information and Disclosures

Author

S Gerald Sandler, MD, FACP, FCAP, Professor of Medicine and Pathology; Director, Transfusion Medicine, Department of Laboratory Medicine, Georgetown University Hospital
S Gerald Sandler, MD, FACP, FCAP is a member of the following medical societies: American Association of Blood Banks, College of American Pathologists, International Society of Blood Transfusions, and Medical Society of the District of Columbia
Disclosure: Nothing to disclose.

Coauthor(s)

Viviana V Johnson, MD, FCAP, Medical Director, Transfusion Services and Armed Services Blood Bank Center, National Naval Medical Center
Viviana V Johnson, MD, FCAP is a member of the following medical societies: American Association of Blood Banks and College of American Pathologists
Disclosure: Nothing to disclose.

Medical Editor

Pradyumna D Phatak, MBBS, MD,, Chair, Division of Hematology and Medical Oncology, Rochester General Hospital; Clinical Professor of Oncology, Roswell Park Cancer Institute
Pradyumna D Phatak, MBBS, MD, is a member of the following medical societies: American Society of Hematology
Disclosure: Novartis Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Ronald A Sacher, MB, BCh, MD, FRCPC, Professor, Internal Medicine and Pathology, Director, Hoxworth Blood Center, University of Cincinnati Academic Health Center
Ronald A Sacher, MB, BCh, MD, FRCPC is a member of the following medical societies: American Society of Hematology
Disclosure: Glaxo Smith Kline Honoraria Speaking and teaching; Talecris Honoraria Board membership

CME Editor

Rajalaxmi McKenna, MD, FACP, Southwest Medical Consultants, SC, Department of Medicine, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Emmanuel C Besa, MD, Professor, Department of Medicine, Division of Hematologic Malignancies, Kimmel Cancer Center, Thomas Jefferson University
Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, and New York Academy of Sciences
Disclosure: Nothing to disclose.

 
 
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