eMedicine Specialties > Emergency Medicine > Hematology & Oncology
Transfusion Reactions: Treatment & Medication
Updated: Jul 2, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
All patients receiving blood products should be placed on continuous cardiac monitoring and pulse oximetry.
- Hemolytic transfusion reaction
- Stop transfusion as soon as a reaction is suspected.
- Replace the donor blood with normal saline.
- Examine the blood to determine if the patient was the intended recipient and then send the unit back to the blood bank.
- Furosemide may be administered to increase renal blood flow.
- Low-dose dopamine may be considered to improve renal blood flow.
- Make efforts to maintain urine output at 30-100 mL/h.
- Extravascular hemolytic reactions do not require any specific treatment. However, if clinically ruling out intravascular hemolysis is difficult, follow the same treatment.
- Nonhemolytic transfusion reaction
- Aggressive treatment of simple febrile reactions is not necessary. However, because the nonspecific symptoms are similar to those of a hemolytic transfusion reaction, differentiating this entity from a hemolytic reaction is necessary.
- The transfusion should be terminated.
- Evaluate the patient for evidence of hemolysis.
- The patient's fever can be treated with acetaminophen.
- Anaphylactic reaction
- Stop the transfusion immediately.
- Support the airway and circulation as necessary.
- Administer epinephrine, diphenhydramine, and corticosteroids.
- Maintain intravascular volume.
- Minor allergic reaction
- Administer antihistamines.
- Although the necessity of stopping the transfusion is unclear, in more severe cases and in uncertain cases, the transfusion should be stopped.
- Transfusion-related acute lung injury
- Monitor oxygen saturation.
- Provide supplemental oxygen to maintain oxygen saturation greater than 92%.
- Hypoxemia severe enough to require endotracheal intubation and positive-pressure ventilation occurs in 70-75% of patients.
- No evidence supports the routine use of corticosteroids.
- The blood bank should be notified.
- GVH disease
- No effective therapies currently exist.
- Emphasis needs to be placed on prevention.
- Massive transfusion
- To decrease the risk of hypothermia in patients receiving massive transfusion, administer the blood through a blood warmer. Do not place blood in a microwave oven to warm, as this causes hemolysis.
- Do not administer platelets and fresh frozen plasma routinely or by using a formula based on the number of units of packed cells transfused. Only administer with evidence of abnormal bleeding associated with thrombocytopenia or an elevated PT or aPTT.
- Treat symptomatic hypocalcemia with calcium chloride or calcium gluconate.
Medication
In hemolytic transfusion reactions, pharmacologic treatment is aimed at increasing renal blood flow and preserving urinary output. In anaphylaxis, the goals of therapy are to maintain hemodynamic stability and reverse the underlying process.
Diuretics
These agents are used to increase renal blood flow and preserve urinary output in hemolytic transfusion reactions. They also may be used in transfusion-related volume overload.
Furosemide (Lasix)
Increases excretion of water by interfering with chloride-binding cotransport system, which results in inhibition of sodium and chloride reabsorption in ascending loop of Henle and distal renal tubule. Individualize dose to patient. Depending on response, administer at increments of 20-40 mg, no sooner than 6-8 h after previous dose, until desired diuresis occurs.
Adult
20-40 mg/d IV/IM
Pediatric
Infants: Titrate with 1 mg/kg/dose IV increments until satisfactory effect achieved
Children: 1-2 mg/kg/dose PO/IV/IM; not to exceed 6 mg/kg/dose; do not administer more frequently than q6h
Metformin decreases concentrations; interferes with hypoglycemic effect of antidiabetic agents and antagonizes muscle-relaxing effect of tubocurarine; aminoglycosides increase auditory toxicity, hearing loss of varying degrees may occur; may enhance anticoagulant activity of warfarin; may increase plasma lithium levels and toxicity
Documented hypersensitivity; hepatic coma; anuria; severe electrolyte depletion
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
Perform frequent serum electrolyte, carbon dioxide, glucose, creatinine, uric acid, calcium, and BUN determinations during first few months of therapy and periodically thereafter
Vasopressors
These agents are used to increase renal blood flow and preserve urinary output in hemolytic transfusion reactions. In severe allergic reactions, epinephrine is used for its inotropic properties and ability to maintain perfusion of vital organs.
Dopamine (Intropin)
Stimulates both adrenergic and dopaminergic receptors. Hemodynamic effect depends on dose. Lower doses stimulate mainly dopaminergic receptors that produce renal and mesenteric vasodilation. Cardiac stimulation and renal vasodilation produced by higher doses.
Adult
1-5 mcg/kg/min IV; after initiating therapy, dose may be increased by 1-4 mcg/kg/min IV q10-30min until satisfactory response attained; maintenance doses <20 mcg/kg/min usually satisfactory for 50% of treated patients
Pediatric
Administer as in adults
Phenytoin, alpha- and beta-adrenergic blockers, general anesthetics, and MAOIs increase and prolong effects
Documented hypersensitivity, pheochromocytoma; ventricular fibrillation
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
Closely monitor urine flow, cardiac output, pulmonary wedge pressure, and BP during infusion; prior to infusion, correct hypovolemia with either whole blood or plasma, as indicated; monitoring central venous pressure or left ventricular filling pressure may be helpful in detecting and treating hypovolemia
Epinephrine (Adrenalin, Epinal, Epifrin)
DOC for treating anaphylaxis. Stimulates alpha-, beta1, and beta2-adrenergic receptors, which in turn results in bronchodilatation, increased peripheral vascular resistance, hypertension, increased chronotropic cardiac activity, and positive inotropic effects.
Adult
0.01 mL/kg of 1:1000 solution IM/SC initially; not to exceed 0.5 mL of 1:1000 solution (0.5 mg) IM/SC
Severe anaphylaxis: 10 mL of 1:100,000 dilution of aqueous epinephrine IV over 10 min
With no improvement, establish 1 mcg/min continuous IV infusion of 4 mcg/mL concentration; increase to 4 mcg/min prn
Pediatric
0.1 mcg/kg/min SC q15min for 2 doses then q4h with increments of 0.1 mcg/kg/min prn; not to exceed 1.5 mcg/kg/min
Increases toxicity of beta- and alpha-blocking agents and of halogenated inhalational anesthetics
Documented hypersensitivity; cardiac arrhythmias; angle-closure glaucoma; concurrent use with local anesthesia in areas such as fingers or toes because vasoconstriction may produce sloughing of tissue; do not use during labor (can delay second stage of labor)
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 with elderly patients, prostatic hypertrophy, hypertension, cardiovascular disease, diabetes mellitus, hyperthyroidism, cerebrovascular insufficiency; rapid IV infusions may cause death from cerebrovascular hemorrhage or cardiac arrhythmias
Antihistamines
Used to treat minor allergic reactions and anaphylaxis. Diphenhydramine may be used to pretreat patients with prior documentation of minor allergic reactions.
Diphenhydramine (Benadryl, Benylin, Bydramine)
Used for symptomatic relief of allergic symptoms caused by histamine released in response to allergens.
Adult
25-50 mg PO q6-8h prn; not to exceed 400 mg/d
10-50 mg IV/IM q6-8h prn; not to exceed 400 mg/d
Pediatric
12.5-25 mg PO tid/qid or 5 mg/kg/d PO or 150 mg/m2/d PO divided tid/qid; not to exceed 300 mg/d
5 mg/kg/d or 150 mg/m2/d IV/IM divided qid; not to exceed 300 mg/d
Potentiates effect of CNS depressants; due to alcohol content, do not administer syrup dosage form to patients taking medications that can cause disulfiram reactions
Documented hypersensitivity; MAOIs
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
May exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction
Cimetidine (Tagamet)
H2 antagonist that, when combined with H1 type, may be useful in treating itching and flushing in anaphylaxis, pruritus, urticaria, and contact dermatitis that do not respond to H1 antagonists alone. Use in addition to H1 antihistamines.
Adult
300 mg IV; when clinically possible, PO q6h for 2 d or for as long as clinically indicated
Pediatric
<16 years: 25-30 mg/kg/d IV in 6 divided doses; administer only if benefits outweigh risks
>16 years: 25-30 mg/kg/d IV in 6 divided doses
Can increase blood levels of theophylline, warfarin, tricyclic antidepressants, triamterene, phenytoin, quinidine, propranolol, metronidazole, procainamide, and lidocaine
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Elderly may suffer confusional states; may cause impotence and gynecomastia in young males due to weak antiandrogen properties; may increase levels of many drugs; if changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment
Corticosteroids
These agents have limited benefit in the initial acute treatment of rapidly deteriorating anaphylactic patient. However, they may benefit patients with persistent bronchospasm or hypotension. Onset of action is approximately 4-6 h following its administration.
Methylprednisolone (Solu-Medrol)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability. Useful in treatment of inflammatory and allergic reactions. By reversing increased capillary permeability and suppressing PMN activity, may decrease inflammation.
Adult
125-250 mg IV loading dose; followed by 0.5-1 mg/kg/dose q6h for up to 5 d
Pediatric
2 mg/kg IV initially; followed by 0.5-1 mg/kg/dose q6h for up to 5 d
Estrogens may decrease clearance; may increase digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism (consider increasing maintenance dose); monitor patients for hypokalemia with concurrent use of diuretics
Documented hypersensitivity; viral, fungal, or tubercular skin infections
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
Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, infections
More on Transfusion Reactions |
| Overview: Transfusion Reactions |
| Differential Diagnoses & Workup: Transfusion Reactions |
 Treatment & Medication: Transfusion Reactions |
| Follow-up: Transfusion Reactions |
| References |
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References
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Cherry T, Steciuk M, Reddy VV, Marques MB. Transfusion-related acute lung injury: past, present, and future. Am J Clin Pathol. Feb 2008;129(2):287-97. [Medline].
Dellinger EP, Anaya DA. Infectious and immunologic consequences of blood transfusion. Crit Care. 2004;8 Suppl 2:S18-23. [Medline].
Dodd RY, Leiby DA. Emerging infectious threats to the blood supply. Annu Rev Med. 2004;55:191-207. [Medline].
Fiebig EW, Busch MP. Emerging infections in transfusion medicine. Clin Lab Med. Sep 2004;24(3):797-823, viii. [Medline].
Goodnough LT. Risks of blood transfusion. Anesthesiol Clin North America. Jun 2005;23(2):241-52, v. [Medline].
Looney MR, Gropper MA, Matthay MA. Transfusion-related acute lung injury: a review. Chest. Jul 2004;126(1):249-58. [Medline].
Spahn DR, Rossaint R. Coagulopathy and blood component transfusion in trauma. Br J Anaesth. Aug 2005;95(2):130-9. [Medline].
Stainsby D, Russell J, Cohen H, Lilleyman J. Reducing adverse events in blood transfusion. Br J Haematol. Oct 2005;131(1):8-12. [Medline].
Williams AE, Thomson RA, Schreiber GB, et al. Estimates of infectious disease risk factors in US blood donors. Retrovirus Epidemiology Donor Study. JAMA. Mar 26 1997;277(12):967-72. [Medline].
Further Reading
Keywords
transfusion reaction, hemolytic transfusion reactions, nonhemolytic febrile reactions, anaphylactic reactions, graft-versus-host disease, GVH disease, massive transfusion complications, transfusion-related hepatitis C, chronic hepatitis, cirrhosis, blood replacement, symptomatic anemia, acute blood loss, blood transfusion, transfusion-related acute lung injury
