Transfusion Reactions in Emergency Medicine Clinical Presentation

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

History

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  • In hemolytic transfusion reactions, symptoms usually occur after a small amount of blood has been transfused and almost always before the unit is transfused completely. These reactions are associated with the following:

    • Fever

    • Chills

    • Flushing

    • Nausea

    • Burning at the intravenous (IV) line site

    • Chest tightness

    • Restlessness

    • Apprehension

    • Joint pain

    • Back pain

  • Nonhemolytic febrile reactions do not occur as rapidly as acute hemolytic reactions. They occur between 1 and 6 hours of 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 a hemolytic transfusion reaction.

  • In anaphylactic reaction, symptoms usually occur with less than 10 mL of blood transfused and only rarely occur more insidiously. These reactions are associated with rapid development of the following:

    • Chills

    • Abdominal cramps

    • Dyspnea

    • Vomiting

    • Diarrhea

  • Minor allergic reactions are associated with urticaria.

  • Extravascular hemolytic reactions are associated with fever and chills. Symptoms often occur after several hours and sometimes may be observed several days after transfusion.

  • Symptoms of transfusion-related acute lung injury start suddenly while the blood products are being transfused or shortly thereafter. Dyspnea is the primary presenting symptom.

  • GVH disease often presents within the first week following transfusion, although it may be delayed up to several weeks following transfusion. Symptoms include the following:

    • Fever

    • Abdominal pain

    • Nausea

    • Vomiting

    • Diarrhea, often copious

    • Anorexia

  • Hypocalcemia from multiple transfusions may present with circumoral tingling and tremors of the skeletal muscles.

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Physical

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  • Hemolytic transfusion reactions are associated with the following signs, which usually occur after a small amount of blood has been transfused and almost always before the unit is transfused completely:

    • Tachycardia

    • Tachypnea

    • In severe cases, hypotension, oozing from the IV site, diffuse bleeding, hemoglobinuria, and shock

    • Oliguria may be seen in renal failure.

  • In unconscious or obtunded patients, the diagnosis of hemolysis is suggested by development of the following:

    • Hypotension

    • Dark urine

    • Oozing from an IV or other puncture sites

  • Nonhemolytic febrile reactions are associated with a fever.

  • Anaphylactic reactions are associated with the following:

    • Anaphylactic reactions are associated with the following:

    • Tachycardia

    • Flushing

    • Urticaria

    • In more severe cases, wheezing, laryngeal edema, and hypotension

  • Minor allergic reactions are associated with urticaria.

  • Extravascular hemolytic reactions are associated with fever.

    • Only rarely are signs of shock and renal failure noted.

    • Clinical signs may occur several days later.

  • Patients with transfusion-related acute lung injury will present with the following signs:

    • Fever

    • Tachycardia

    • Tachypnea

    • Rales

  • GVH disease often presents with the following signs:

    • Erythematous, maculopapular rash, which may progress to toxic epidermal necrolysis

    • Right upper quadrant tenderness

    • Hepatomegaly

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Causes

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  • Transfusion-related infectious diseases [4] caused by the presence of microorganisms in the donated blood include the following:

    • Hepatitis B

    • Hepatitis C

    • HIV-1

    • HIV-2

    • Cytomegalovirus (CMV)

    • West Nile virus [5]

  • Other diseases rarely reported to result from transfusion include the following:

    • Syphilis

    • Lyme disease

    • Malaria

    • Toxoplasmosis

    • Chagas disease

    • Jakob-Creutzfeldt disease

    • Filariasis

    • Babesiosis

  • Donor blood is routinely screened for hepatitis B, hepatitis C, HIV-1, HIV-2, HTLV-1, HTLV-2, syphilis, and West Nile virus. Some, but not all donors, are screened for cytomegalovirus (CMV). Despite screening, some risk of transmission still occurs, since the donor may have been in the window where he or she is infectious but has not yet developed a detectable immunologic response at the time of donation.

  • Transmission of HIV has occurred with the transfusion of only one unit, although greater risk exists with transfusion of multiple units.

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