Transfusion Reactions in Emergency Medicine Clinical Presentation

Updated: Dec 24, 2020
  • Author: Ross A Wanner, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
  • Print
Presentation

History

In acute hemolytic transfusion reactions (AHTR), symptoms usually occur before the unit is transfused completely. The classic triad is fever, flank pain, and gross hematuria, but these reactions are also associated with the following:

  • Chills
  • Back pain
  • Petechial rash
  • Flushing
  • Nausea

Extravascular hemolytic reactions are associated with fever and chills. Onset is often several hours after the transfusion and sometimes may be observed several days later.

Transfusion-related acute lung injury (TRALI) signs and symptoms start suddenly, while the blood products are being transfused or shortly thereafter. Dyspnea is the primary presenting symptom, but fevers, chills, and chest pain are also common, with clinical signs of pulmonary edema and hypoxemia.

Transfusion-associated circulatory overload (TACO) symptoms start within 6 to 12 hours of transfusion and most often consist of respiratory distress and orthopnea.

Anaphylactic reactions are characterized by rapid (within seconds to minutes) development of the following:

  • Chills
  • Abdominal cramps
  • Dyspnea
  • Vomiting
  • Diarrhea
  • Urticaria

Graft-versus-host disease (GVHD) almost universally presents as fever within the first week following transfusion, although it may be delayed up to several weeks. Other symptoms include the following:

  • Diffuse rash
  • Nausea
  • Vomiting
  • Diarrhea
  • Anorexia

Febrile nonhemolytic reactions (FNHR) do not occur as rapidly as acute hemolytic reactions. They develop between 1 and 6 hours after transfusions and are associated with the nonspecific symptoms of fever, chills, and malaise. Some patients may complain of dyspnea. These nonspecific symptoms also occur with other, more dangerous transfusion reactions, so FHNR should be a diagnosis of exclusion.

Next:

Physical

AHTR may present as any combination of the following clinical features:

  • Tachycardia
  • Tachypnea
  • Hypotension
  • Oozing from the intravenous (IV) access site, diffuse bleeding indicative of disseminated intravascular coagulation (DIC)
  • Hemoglobinuria, oliguria
  • Shock

TRALI nearly always presents as hypoxemia and pulmonary infiltrates on chest x-ray, but the following clinical features may also be evident:

  • Tachycardia
  • Fever
  • Hypotension

TACO, unlike many other transfusion reactions, will present as fluid overload findings, including the following:

  • Hypertension
  • Edema
  • Jugular venous distension
  • Rales

Anaphylactic reactions are associated with the following classic findings:

  • Tachycardia
  • Flushing
  • Urticaria
  • Wheezing
  • Laryngeal edema
  • Hypotension

GVHD often presents as follows:

  • Fever
  • Diffuse maculopapular rash
  • Hypotension
  • Hepatitis
Previous
Next:

Causes

Donor blood is routinely screened for hepatitis B, hepatitis C, HIV-1, HIV-2, human T-lymphotropic virus 1 (HTLV-1), HTLV-2, syphilis, West Nile virus, and Zika Virus. Bacterial contamination is the most common transfusion-related infection, especially in platelets, which are stored at room temperature and without a preservative.

According to the International Society for Infectious Diseases, on nucleic acid amplification testing (NAAT), rates of transmission per transfused unit of the following viruses are:

  • Hepatitis B: 1 per 843,000-1,200,000
  • Hepatitis C: 1 per 1,100,000
  • HIV-1 and HIV-2: 1 per 1,500,000
  • Cytomegalovirus (CMV) in susceptible patients: 1-3 per 100

Many other diseases are rarely reported to be transmitted via transfusion, including (but not limited to) the following:

  • West Nile virus infection
  • Syphilis
  • Lyme disease
  • Malaria
  • Toxoplasmosis
  • Chagas disease
  • Creutzfeldt-Jakob disease
  • Filariasis
  • Babesiosis

According to the World Health Organization, Severe Acute Respiratory Syndrome coronavirus–2 (SARS-CoV-2) has not been reported to be transmitted through blood or blood components. In a small study, blood components collected from donors in the pre-symptomatic phase of COVID-19 did not transmit the infection. [12]

Previous