Transfusion Reactions

Guideline on the investigation and management of acute transfusion reactions.

Prepared by the BCSH Blood Transfusion Task Force
Article in British Journal of Haematology 159(2):143-53 · August 2012 


Although acute non-haemolytic febrile or allergic reactions (ATRs) are a common complication of transfusion and often result in little or no morbidity, prompt recognition and management are essential.
The serious hazards of transfusion haemovigilance organisation (SHOT) receives 30–40 reports of anaphylactic reactions each year. Other serious complications of transfusion, such as acute haemolysis, bacterial contamination, transfusion-related acute lung injury (TRALI) or transfusion-associated circulatory overload (TACO) may present with similar clinical features to ATR.
This guideline describes the approach to a patient developing adverse symptoms and signs related to transfusion, including initial recognition, establishing a likely cause, treatment, investigations, planning future transfusion and reporting within the hospital and to haemovigilance organisations.
Key recommendations are that adrenaline should be used as first line treatment of anaphylaxis, and that transfusions should only be carried out where patients can be directly observed and where staff are trained in manging complications of transfusion, particularly anaphylaxis.
Management of ATRs is not dependent on classification but should be guided by symptoms and signs. Patients who have experienced an anaphylactic reaction should be discussed with an allergist or immunologist, in keeping with UK resuscitation council guidelines.

Recognition and initial management of acute transfusion reactions

Recognition and initial management of acute transfusion reactions
All patients should be transfused in clinical areas where they can be directly observed, and where staff are trained in the administration of blood components and the management of transfused patients, including the emergency treatment of anaphylaxis. (1C)

The recognition and immediate management of ATR should be incorporated into local transfusion policies and there should be mandatory transfusion training requirements for all clinical and laboratory staff involved in the transfusion process. (2C)

Patients should be asked to report symptoms that develop within 24 h of completion of the transfusion. (2C)

Initial clinical assessment
Initial clinical assessment of Transfusion reaction
Figure 1
Flow diagram to guide the recognition and initial management of suspected acute transfusion reactions. ID, identification details; ABC, airway, breathing and circulation; TPR, temperature, pulse and respiratory rate; BP, blood pressure; HTT, hospital transfusion team; HTC, hospital transfusion committee; SHOT, serious hazards of transfusion; MHRA, medicines and healthcare products regulatory agency.

In all cases, the transfusion must be stopped temporarily and venous access maintained with physiological saline. The patient's Airway, Breathing and Circulation (‘ABC’) must be assessed (Resuscitation Council (UK), 2008). Their core identification details must be checked to ensure they correspond with those on the blood component compatibility label – is the reaction due to transfusion of a component intended for another patient (British Committee for Standards in Haematology, 2009)? The component must be examined for unusual clumps or particulate matter, or discolouration suggestive of bacterial contamination. Provided that the reaction is not severe or life‐threatening, as defined in Fig 1, standard observations on the patient are then performed.

If a patient develops new symptoms or signs during a transfusion, this should be stopped temporarily, but venous access maintained. Identification details should be checked between the patient, their identity band and the compatibility label of the blood component. Perform visual inspection of the component and assess the patient with standard observations. (1C)

Severe reactions
If the presumed ATR is severe or life‐threatening, a doctor should be called immediately and the blood transfusion discontinued. Caution is required in bleeding patients where hypotension may be associated with haemorrhage and continuing the transfusion may be life‐saving.
If a patient being transfused for haemorrhage develops hypotension, careful clinical risk assessment is required. If the hypotension is caused by haemorrhage, continuation of the transfusion may be life‐saving. In contrast, if the blood component is considered the most likely cause of hypotension, the transfusion must be stopped or switched to an alternative component and appropriate management and investigation commenced. (1C)

Mild or moderate reactions
If the reaction is mild, for example an isolated rise in temperature without chills, rigours or other change in observations (Fig 1), medical staff should be informed but the transfusion may be restarted under direct supervision. In the case of reactions considered moderate, urgent medical advice should usually be sought before the transfusion is restarted. Exceptions to this would include reactions where there is an obvious alternative explanation for the symptoms/signs or the patient has a history of similar, previously investigated, non‐serious transfusion reactions.
For patients with mild reactions, such as pyrexia (temperature of ≥38°C AND rise of 1–2°C from baseline), and/or pruritus or rash but WITHOUT other features, the transfusion may be continued with appropriate treatment and direct observation. (2B)