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Transfusion Reactions in Emergency Medicine Treatment & Management

  • Author: Eric M Kardon, MD, FACEP; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: Feb 29, 2016
 

Emergency Department Care

All patients receiving blood products should be placed on continuous cardiac monitoring and pulse oximetry.

Hemolytic transfusion reactions are treated as follows:

  • 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 reactions are treated as follows:

  • 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 reactions are treated as follows:

  • Stop the transfusion immediately
  • Support the airway and circulation as necessary
  • Administer epinephrine, diphenhydramine, and corticosteroids
  • Maintain intravascular volume

Minor allergic reactions are treated with 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 is treated as follows[6, 7, 8] :

  • Monitor oxygen saturation
  • Provide supplemental oxygen to maintain oxygen saturation above 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 [9]
  • The blood bank should be notified

For graft versus host disease, no effective th erapies currently exist. Emphasis needs to be placed on prevention.

Massive transfusion

To decrease the risk of hypothermia in patients receiving massive transfusion (commonly defined as ≥10 units of red blood cells [RBCs] in 24 h), administer the blood through a blood warmer. Do not place blood in a microwave oven to warm, as this causes hemolysis. Treat symptomatic hypocalcemia with calcium chloride or calcium gluconate.

Hemorrhage coupled with coagulopathy remains the leading cause of preventable in-hospital deaths in trauma patients and in the emergency setting, standard coagulation tests may be unavailable or unreliable. Consequently, a strategy of transfusing platelets, fresh frozen plasma, and RBCs in a fixed ratio of 1:1:1 has been widely adopted for use in patients requiring massive transfusions.[10, 11]

A 1:1:1 protocol has been associated with improved survival in retrospective studies in military and civilian settings, but those studies suffered from methodologic limitations.[10, 11] In addition, that protocol may lead to unnecessary exposure to blood components and an increased risk of complications.[11] However, two more recent studies, the randomized Trauma Lab versus Formula Pilot Trial (TR-FL) and the Pragmatic Randomized Optimum Platelet and Plasma Ratios (PROPPR) study, largely support the use of this protocol.[11, 12]

In TR-FL, the fixed-ratio transfusion protocol proved feasible, but was associated with increased plasma wastage.[11] In PROPPR, early administration of plasma, platelets, and RBCs in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis and fewer experienced death from exsanguination by 24 hours, with no other differences in safety between the two groups.[12]

 

 
 
Contributor Information and Disclosures
Author

Eric M Kardon, MD, FACEP Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Medical Association of Georgia

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jeffrey L Arnold, MD, FACEP Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center

Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Theodore J Gaeta, DO, MPH, FACEP Clinical Associate Professor, Department of Emergency Medicine, Weill Cornell Medical College; Vice Chairman and Program Director of Emergency Medicine Residency Program, Department of Emergency Medicine, New York Methodist Hospital; Academic Chair, Adjunct Professor, Department of Emergency Medicine, St George's University School of Medicine

Theodore J Gaeta, DO, MPH, FACEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, Society for Academic Emergency Medicine, Council of Emergency Medicine Residency Directors, Clerkship Directors in Emergency Medicine, Alliance for Clinical Education

Disclosure: Nothing to disclose.

References
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  2. The 2011 National Blood Collection and Utilization Survey Report. Report of the US Department of Health and Human Services. Available at http://www.hhs.gov/ash/bloodsafety/2011-nbcus.pdf. Accessed: October 14, 2014.

  3. Rohde JM, Dimcheff DE, Blumberg N, Saint S, Langa KM, Kuhn L, et al. Health care-associated infection after red blood cell transfusion: a systematic review and meta-analysis. JAMA. 2014 Apr 2. 311(13):1317-26. [Medline].

  4. Stramer SL, Hollinger FB, Katz LM, Kleinman S, Metzel PS, Gregory KR, et al. Emerging infectious disease agents and their potential threat to transfusion safety. Transfusion. 2009 Aug. 49 Suppl 2:1S-29S. [Medline].

  5. Fiebig EW, Busch MP. Emerging infections in transfusion medicine. Clin Lab Med. 2004 Sep. 24(3):797-823, viii. [Medline].

  6. Triulzi DJ. Transfusion-related acute lung injury: current concepts for the clinician. Anesth Analg. 2009 Mar. 108(3):770-6. [Medline].

  7. Tuinman PR, Vlaar AP, Binnenkade JM, Juffermans NP. The effect of aspirin in transfusion-related acute lung injury in critically ill patients*. Anaesthesia. 2012 Feb 11. [Medline].

  8. Tung JP, Fraser JF, Nataatmadja M, Colebourne KI, Barnett AG, Glenister KM, et al. Age of blood and recipient factors determine the severity of transfusion-related acute lung injury (TRALI). Crit Care. 2012 Feb 1. 16(1):R19. [Medline].

  9. Cherry T, Steciuk M, Reddy VV, Marques MB. Transfusion-related acute lung injury: past, present, and future. Am J Clin Pathol. 2008 Feb. 129(2):287-97. [Medline].

  10. Callum JL, Rizoli S. Assessment and management of massive bleeding: coagulation assessment, pharmacologic strategies, and transfusion management. Hematology Am Soc Hematol Educ Program. 2012. 2012:522-8. [Medline]. [Full Text].

  11. Nascimento B, Callum J, Tien H, Rubenfeld G, Pinto R, Lin Y, et al. Effect of a fixed-ratio (1:1:1) transfusion protocol versus laboratory-results-guided transfusion in patients with severe trauma: a randomized feasibility trial. CMAJ. 2013 Sep 3. 185 (12):E583-9. [Medline]. [Full Text].

  12. Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015 Feb 3. 313 (5):471-82. [Medline]. [Full Text].

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