Transfusion Reactions in Emergency Medicine Treatment & Management

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

Emergency Department Care

Every patient receiving blood products should be placed on cardiac monitoring and continuous pulse oximetry. If a reaction is suspected, stop the transfusion and discontinue any plans for future transfusions. If applicable, alerting the blood bank of the reaction as immediately as possible will prevent incorrect transfusion of blood products into another patient, if products were accidentally exchanged.

Treatment of transfusion reactions is specific to the type of reaction, as outlined below.

Acute Hemolytic Transfusion Reactions (AHTR)

Treatment of AHTR is largely supportive and renal-protective resuscitation is imperative. Aiming for urine output of 100 mL/hour or more with intravenous (IV) fluids and adjunctive diuretics (eg, furosemide) will help protect intrinsic renal function. Serial measurement of hemoglobin, hematocrit, and lactate dehydrogense (LDH) will help characterize the degree of hemolysis and drive management until the hemolysis has ended.

Transfusion-related Acute Lung Injury (TRALI) 

TRALIis treated similar to ARDS patients, even if the patient has not progressed to this degree of pulmonary insult. After stopping the infusion, oxygenation is the primary concern and measures should be taken to improve arterial oxygen levels with lung-protective strategies. Low flow nasal cannula, high flow nasal cannula, non-invasive positive-pressure ventilation (NIPPV) (CPAP, specifically), and ultimately endotracheal intubation with mechanical ventilation at lung-protective tidal volumes (6-8mL/kg of ideal body weight) is the general progression of measures taken. There is no current evidence that steroids improve outcomes (13).

Transfusion-associated Circulatory Overload (TACO)

TACO is treated similarly to other syndromes of fluid overload. Hypoxemia from pulmonary edema can be improved with bilevel positive airway pressure (BPAP) in the short term, and diuretics such as furosemide can help with fluid management in the less immediate management. If the patient continues to decompensate, intubation with mechanical ventilation is often necessary.

Anaphylaxis

Anaphylaxisis treated in the usual manner. Intramuscular epinephrine 1:1,000 (1 mg/mL) concentration is given at 0.01 mg/kg every 2-5 minutes. In refractory cases, patients can be started on an epinephrine drip (0.1 mcg/kg/min) and resuscitated with IV fluids. Bronchodilators such as albuterol should be administered for patients with bronchospasm without evidence of upper airway swelling or angioedema. Antihistamines and steroids may be used as adjuncts, although evidence of their utility in the acute phase is limited. Endotracheal intubation with mechanical ventilation may be necessary if the condition continues to be refractory to medical treatment or the patient develops altered mental status or evidence of impending respiratory compromise.