Transfusion Reactions in Emergency Medicine Treatment & Management

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

All patients receiving blood products should be placed on continuous cardiac monitoring and pulse oximetry.

Hemolytic transfusion reactions are treated as follows:

  • Stop transfusion as soon as a reaction is suspected
  • Replace the donor blood with normal saline
  • Examine the blood to determine if the patient was the intended recipient and then send the unit back to the blood bank
  • Furosemide may be administered to increase renal blood flow
  • Low-dose dopamine may be considered to improve renal blood flow
  • Make efforts to maintain urine output at 30-100 mL/h

Extravascular hemolytic reactions do not require any specific treatment. However, if clinically ruling out intravascular hemolysis is difficult, follow the same treatment.

Nonhemolytic transfusion reactions are treated as follows:

  • Aggressive treatment of simple febrile reactions is not necessary; however, because the nonspecific symptoms are similar to those of a hemolytic transfusion reaction, differentiating this entity from a hemolytic reaction is necessary
  • The transfusion should be terminated
  • Evaluate the patient for evidence of hemolysis
  • The patient's fever can be treated with acetaminophen

Anaphylactic reactions are treated as follows:

  • Stop the transfusion immediately
  • Support the airway and circulation as necessary
  • Administer epinephrine, diphenhydramine, and corticosteroids
  • Maintain intravascular volume

Minor allergic reactions are treated with antihistamines. Although the necessity of stopping the transfusion is unclear, in more severe cases and in uncertain cases, the transfusion should be stopped.

Transfusion-related acute lung injury is treated as follows [6, 7, 8] :

  • Monitor oxygen saturation
  • Provide supplemental oxygen to maintain oxygen saturation above 92%
  • Hypoxemia severe enough to require endotracheal intubation and positive-pressure ventilation occurs in 70-75% of patients
  • No evidence supports the routine use of corticosteroids [9]
  • The blood bank should be notified

For graft versus host disease, no effective th erapies currently exist. Emphasis needs to be placed on prevention.

Massive transfusion

To decrease the risk of hypothermia in patients receiving massive transfusion (commonly defined as ≥10 units of red blood cells [RBCs] in 24 h), administer the blood through a blood warmer. Do not place blood in a microwave oven to warm, as this causes hemolysis. Treat symptomatic hypocalcemia with calcium chloride or calcium gluconate.

Hemorrhage coupled with coagulopathy remains the leading cause of preventable in-hospital deaths in trauma patients and in the emergency setting, standard coagulation tests may be unavailable or unreliable. Consequently, a strategy of transfusing platelets, fresh frozen plasma, and RBCs in a fixed ratio of 1:1:1 has been widely adopted for use in patients requiring massive transfusions. [10, 11]

A 1:1:1 protocol has been associated with improved survival in retrospective studies in military and civilian settings, but those studies suffered from methodologic limitations. [10, 11] In addition, that protocol may lead to unnecessary exposure to blood components and an increased risk of complications. [11] However, two more recent studies, the randomized Trauma Lab versus Formula Pilot Trial (TR-FL) and the Pragmatic Randomized Optimum Platelet and Plasma Ratios (PROPPR) study, largely support the use of this protocol. [11, 12]

In TR-FL, the fixed-ratio transfusion protocol proved feasible, but was associated with increased plasma wastage. [11] In PROPPR, early administration of plasma, platelets, and RBCs in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis and fewer experienced death from exsanguination by 24 hours, with no other differences in safety between the two groups. [12]