Medical Care
Management of transfusion reactions varies according to the type of reaction. [62] Acute hemolytic reactions (antibody mediated) are managed as follows:
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Immediately discontinue the transfusion while maintaining venous access for emergency management.
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Anticipate hypotension, acute kidney injury AKI), and disseminated intravascular coagulation (DIC).
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Prophylactic measures to reduce the risk of AKI may include low-dose dopamine (1-5 mcg/kg/min), vigorous hydration with crystalloid solutions (3000 mL/m2/24 h), and osmotic diuresis with 20% mannitol (100 mL/m2/bolus, followed by 30 mL/m2/h for 12 h).
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If DIC is documented and bleeding requires treatment, transfusions of frozen plasma, pooled cryoprecipitates for fibrinogen, and/or platelet concentrates may be indicated.
Acute hemolytic reactions (nonantibody mediated) are managed as follows:
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The transfusion of serologically compatible, although damaged, red blood cells (RBCs) usually does not require rigorous management.
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Diuresis induced by an infusion of 500 mL of 0.9% sodium chloride per hour, or as tolerated by the patient, until the intense red color of hemoglobinuria ceases is usually adequate treatment.
In febrile, nonhemolytic reactions, fever usually resolves in 15-30 minutes without specific treatment. If fever causes discomfort, oral acetaminophen (325-500 mg) may be administered. Avoid aspirin because of its prolonged adverse effect on platelet function.
In allergic reactions, diphenhydramine is usually effective for relieving pruritus that is associated with hives or a rash. The route (oral or intravenous) and the dose (25-100 mg) depend on the severity of the reaction and the weight of the patient.
In anaphylactic reactions, a subcutaneous injection of epinephrine (0.3-0.5 mL of a 1:1000 aqueous solution) is standard treatment. If the patient is sufficiently hypotensive to raise the question of the efficacy of the subcutaneous route, epinephrine (0.5 mL of a 1:10,000 aqueous solution) may be administered intravenously. Although no documented evidence exists that intravenous corticosteroids are beneficial for the management of acute anaphylactic transfusion reactions, theoretical considerations cause most clinicians to include an infusion of hydrocortisone or prednisolone if the patient does not have an immediate response to epinephrine. In view of the rare but serious risk of a biphasic anaphylactic reaction, in which symptoms resolve but then recur some hours later, patients should be monitored for up to 24 hours after the resolution of symptoms. [26]
Transfusion-related acute lung injury (TRALI) is managed as follows:
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Immediately discontinue the transfusion while preserving venous access.
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Patients with mild episodes should respond to oxygen administered by nasal catheter or mask. If shortness of breath persists after oxygen administration, transfer the patient to an intensive care setting where mechanical ventilation can be employed.
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In the absence of signs of acute volume overload or cardiogenic pulmonary edema, diuretics are not indicated.
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No evidence exists that corticosteroids or antihistamines are beneficial.
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Treat complications with specific supportive measures.
Circulatory (volume) overload is managed as follows:
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Move the patient into a sitting position and administer oxygen to facilitate breathing.
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The most specific treatment is discontinuing the transfusion and removing the excessive fluid.
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If practical, the unit of blood component being transfused may be lowered to reverse the flow and to decrease intravascular volume by a controlled phlebotomy.
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Less urgent situations may be managed by a parenteral or oral diuretic (eg, furosemide).
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If the patient has symptomatic anemia requiring additional transfusions of RBCs, select concentrated (ie, CPDA-1-anticoagulated) red cells (hematocrit = 80-85%). Avoid red cell components diluted with saline additives (ie, AS-1).
Bacterial contamination (sepsis) is managed as follows:
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Immediately discontinue the transfusion, including all tubing, filters, and administration sets, and save the transfusion materials for cultures, while preserving venous access.
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After appropriate blood cultures have been obtained, initiate treatment with intravenous broad-spectrum antibiotics. If a microbiologic stain or a culture of the contents of the transfused product identifies an organism, the initial broad-spectrum antibacterial approach may be modified accordingly.
Randomized controlled studies of delayed hemolytic transfusion reactions have yet to be performed, so no validated treatment approaches or therapy guidelines exist. Off-label treatments described in the literature include the following, used alone or in combination [6, 7] :
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Intravenous immunoglobulin (IVIg)
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Recombinant erythropoietin (EPO)
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Corticosteroids
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Rituximab – For patients who have developed alloimmunization after DHTR, to prevent further alloimmunization
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Eculizumab - For some life-threatening episodes
An observational study by Noizat-Pirenne et al demonstrated that pre-transfusion administration of rituximab may have a preventive benefit in sickle cell disease patients with a history of severe delayed hemolytic transfusion reaction (DHTR). Five of the eight study patients did not develop DHTR, while the remaining three experienced only mild DHTR. No newly formed antibodies were detected in any patient. Because rituximab can have serious adverse effects, these authors suggest that this treatment be considered cautiously, and only when transfusion is absolutely necessary in such patients. [63]
Consultations
The possibility of an acute transfusion reaction should trigger an immediate consultation with the medical director of the hospital's blood bank or a designee (eg, a clinical pathology resident, transfusion medicine fellow). Depending on the findings, the blood bank consultant may arrange for microbiologic stains and cultures of the residual contents of the blood product container, clerical checks for patient and product identification in the laboratory, repeat compatibility testing using a freshly collected blood sample from the recipient, or other pertinent diagnostic studies.
The diagnosis of an acute hemolytic transfusion reaction should trigger consultation with a nephrologist to ensure optimal prophylactic measures to prevent acute kidney injury.
A hematology consultation is appropriate if a hemolytic transfusion reaction or bacterial contamination precipitates DIC.
A clinical diagnosis of bacterial contamination of a transfused blood product should trigger an infectious diseases consultation.
Prevention
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 that lists the antibodies. The report should be presented to the transfusion service if the person requires subsequent transfusions at another hospital.
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 cases of transfusion reaction, retype the donor and recipient RBCs. A discrepancy between the original ABO type and the repeat ABO typings should raise the urgent question of whether a mix-up of blood samples could place another patient at risk of a similar mismatched transfusion.
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Rapid test to distinguish hematuria from hemoglobinuria. The onset of red urine during or shortly after a blood transfusion may represent hemoglobinuria (indicating an acute hemolytic reaction) or hematuria (indicating bleeding in the lower urinary tract). If freshly collected urine from a patient with hematuria is centrifuged, red blood cells settle at the bottom of the tube, leaving a clear yellow urine supernatant. If the red color is due to hemoglobinuria, the urine sample remains clear red after centrifugation.
