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Transfusion Reactions in Emergency Medicine Workup

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

Laboratory Studies

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  • When a hemolytic transfusion reaction is suspected, send the donor blood back to the blood bank to determine whether the correct unit of blood was administered to the intended recipient. In addition, the blood bank should perform a repeat type, crossmatch, antibody screen, and direct and indirect Coombs tests. Other considerations with a hemolytic transfusion reaction include the following:
    • Free serum hemoglobin appears as a pink color of the serum in a clotted centrifuged specimen. This may be observed with as little as 5-10 mL of hemolyzed blood.
    • Serum bilirubin level peaks in 3-6 hours as the free hemoglobin is metabolized.
    • Haptoglobin binds to hemoglobin and the serum hemoglobin level falls, reaching its nadir in 1-2 days.
    • Examine urine for hemoglobinuria.
  • A repeat hemoglobin and hematocrit (H/H) fails to show the expected rise in hematocrit in patients developing intravascular or extravascular hemolysis.
  • In acute transfusion-related acute lung injury, leukopenia and eosinophilia may be present.
  • In GVH disease, the CBC will demonstrate pancytopenia and elevated liver enzymes levels. Electrolyte disturbances related to the diarrhea may be present.
  • For the patient undergoing a massive transfusion, serially measure the following parameters:
    • Platelet count, prothrombin time (PT), and activated partial thromboplastin time (aPTT) should be checked after the transfusion of every 5 units of packed red cells and whenever signs or symptoms suggest a coagulopathy.
    • Potassium level
    • pH
    • Ionized calcium level should be measured in patients developing signs, symptoms, or ECG manifestations of hypocalcemia.
  • It is recommended that in the massively transfused patient, plasma and platelets be administered in response to the results of platelet count and coagulation function.
    • Plasma and platelets should never be given solely in response to the number of units of packed cells transfused.

Imaging Studies

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  • In transfusion-related acute lung disease, the chest radiograph is consistent with noncardiogenic pulmonary edema. The cardiac silhouette is not enlarged. Bilateral infiltrates are in an alveolar pattern.

Other Tests

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  • The electrocardiogram may demonstrate prolongation of the QT interval in the massively transfused patient who develops hypocalcemia.


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  • Endotracheal intubation may be required if respiratory insufficiency complicates a severe hemolytic or anaphylactic reaction.
  • Hypoxemia severe enough to require endotracheal intubation occurs in 70-75% of patients with transfusion-related acute lung injury.
  • Place a Foley catheter in all patients with an intravascular hemolytic reaction to ensure continuous measurement of urinary output.
  • A careful assessment will often aid in differentiating transfusion-associated volume overload from transfusion-related acute lung injury. In some cases, however, making the correct diagnosis may be very difficult. In these cases, Swan-Ganz catheterization may provide useful information.
Contributor Information and Disclosures

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.

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