Transfusion Reactions in Emergency Medicine Treatment & Management
- Author: Eric M Kardon, MD, FACEP; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...
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 
The blood bank should be notified
For graft versus host disease, no effective th erapies currently exist. Emphasis needs to be placed on prevention.
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. 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. 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.
Porretti L, Cattaneo A, Coluccio E, Mantione E, Colombo F, Mariani M, et al. Implementation and outcomes of a transfusion-related acute lung injury surveillance programme and study of HLA/HNA alloimmunisation in blood donors. Blood Transfus. 2012 Feb 22. 1-9. [Medline].
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.
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].
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].
Fiebig EW, Busch MP. Emerging infections in transfusion medicine. Clin Lab Med. 2004 Sep. 24(3):797-823, viii. [Medline].
Triulzi DJ. Transfusion-related acute lung injury: current concepts for the clinician. Anesth Analg. 2009 Mar. 108(3):770-6. [Medline].
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].
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].
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].
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].
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].
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].
Miraflor E, Yeung L, Strumwasser A, Liu TH, Victorino GP. Emergency uncrossmatched transfusion effect on blood type alloantibodies. J Trauma Acute Care Surg. 2012 Jan. 72(1):48-53. [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].
Goodnough LT. Risks of blood transfusion. Anesthesiol Clin North America. 2005 Jun. 23(2):241-52, v. [Medline].
Looney MR, Gropper MA, Matthay MA. Transfusion-related acute lung injury: a review. Chest. 2004 Jul. 126(1):249-58. [Medline].
Spahn DR, Rossaint R. Coagulopathy and blood component transfusion in trauma. Br J Anaesth. 2005 Aug. 95(2):130-9. [Medline].
[Guideline] Stainsby D, MacLennan S, Thomas D, Isaac J, Hamilton PJ. Guidelines on the management of massive blood loss. Br J Haematol. 2006 Dec. 135(5):634-41. [Medline].
Stainsby D, Russell J, Cohen H, Lilleyman J. Reducing adverse events in blood transfusion. Br J Haematol. 2005 Oct. 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. 1997 Mar 26. 277(12):967-72. [Medline].