Transfusion Reactions Clinical Presentation

Updated: Mar 15, 2023
  • Author: S Gerald Sandler, MD, FCAP, FACP; Chief Editor: Emmanuel C Besa, MD  more...
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A history of previous blood transfusions or pregnancy is often present but is not essential for the diagnosis of a febrile nonhemolytic transfusion. Acute transfusion reactions caused by ABO antibodies, transfusion-related acute lung injury (TRALI; from donor's antibodies), allergy, IgA/anti-IgA anaphylaxis, or sepsis may occur during the first transfusion or subsequent transfusions.

Persons known to have formed red cell alloantibodies as the result of previous transfusions or pregnancy should be informed and provided with a written report listing the antibodies to be presented to the transfusion service if additional transfusions are required at another hospital.

Red cell antibodies may decrease in titer and, although remaining clinically important, may not be detected by routine compatibility testing before future red cell transfusions. Ask patients scheduled for red cell transfusions about any history of previous transfusions and if they are aware of any complications or blood bank antibody problems. Obtain details of any previous transfusions during the medical history or when obtaining the patient's informed consent for a transfusion.

In individuals with sickle cell disease, clinical manifestations of delayed hemolytic transfusion reactions (DHTRs) usually appear 5–15 days after the triggering transfusion, and include hemoglobinuria, jaundice, and pallor due to acute hemolysis. In addition, patients may have signs and symptoms that mimic severe vaso-occlusive crisis (ie, pain, fever, and acute chest syndrome), as well as profound anemia, often with reticulocytopenia. If DHTR is misdiagnosed as vaso-occluisive crisis and the patient is treated with an additional transfusion, this may further exacerbate hemolysis and clinical symptoms and cause life-threatening multiorgan failure. [6, 7]


Physical Examination

Acute hemolytic reactions manifest as follows:

  • Early signs may include fever, hypotension, flushing, wheezing, anxiety, and/or red-colored urine
  • Late signs may include a generalized bleeding tendency (DIC) and/or hypotension

Nonhemolytic febrile reactions typically involve only fever. However, some patients also have severe rigors, shaking, chills, hypotension, and vomiting.

Allergic reactions typically comprise maculopapular rash and/or urticaria without fever or hypotension. Anaphylactic reactions manifest as follows:

  • Dyspnea
  • Wheezing
  • Anxiety
  • Hypotension without fever
  • Bronchospasm in severe cases

Transfusion-related acute lung injury (TRALI) manifests as rapid onset of shortness of breath, hypoxemia, and rales, without signs of acute cardiogenic pulmonary edema and fever.

Circulatory (volume) overload manifests as follows:

  • Shortness of breath
  • Rales
  • Orthopnea
  • Tachycardia
  • Distended jugular veins
  • Other evidence of cardiac decompensation

Continuous monitoring of vital signs during general anesthesia may prevent acute circulatory (volume) overload, but it may not detect early signs of other reactions (eg, acute hemolytic transfusion reactions). However, the onset of abnormal bleeding/generalized oozing during surgery in a transfused patient should raise the question of a hemolytic transfusion reaction with disseminated intravsacular coagulation (DIC).

Bacterial contamination manifests as high fever, shock, tachycardia, and weak pulse, without a clear focus of infection. Examination of the contents of the container of blood being transfused may reveal clots, discoloration, or a difference in color between the contents of the bag (hemolyzed by contaminating bacteria) and the contents of the segmented tubing attached to the bag (not hemolyzed, no bacteria). In a review of septic transfusion reactions resulting from bacterially contaminated platelets, Hong et al reported that the reactions developed 9 to 24 hours posttransfusion, and occurred only in neutropenic patients. [59]