Types of Transfusion Reactions (Tobian, 2024)

LIFE-THREATENING TRANSFUSION REACTIONS
TYPE OF REACTION	DESCRIPTION	TREATMENT
Transfusion-associated circulatory overload (TACO)	Pulmonary edema due to volume excess or circulatory overload Hypertension may be present Occurs during transfusion or within 12 hours of transfusion completion	Diuresis Supplemental oxygen Ventilatory support if severe
Transfusion-related acute lung injury (TRALI)	Fever, chills Respiratory distress Rales on auscultation Hypoxemia Hypotension Bilateral pulmonary edema on chest x-ray Occurs during transfusion or within 6 hours of transfusion completion	May require intubation and mechanical ventilation
Acute hemolytic transfusion reaction (AHTR)	Caused by acute intravascular hemolysis of transfused RBCs that may be due to ABO incompatibility Fever, chills Flank/back pain Oozing from IV site Hypotension Occurs during transfusion or within 24 hours of transfusion completion	Aggressive hydration Diuresis
Transfusion-associated sepsis (bacterial infection)	Caused by transfusion of a product that contains bacteria Fever, chills Hypotension (and other signs of shock) Occurs during transfusion or within 72 hours of transfusion completion	Broad-spectrum antibiotics Hemodynamic support
Anaphylactic transfusion reaction	Severe allergic reaction possibly due to IgA antibodies Angioedema, wheezing, and/or hypotension Occurs during transfusion or within 4 hours of transfusion completion	Epinephrine Antihistamines Vasopressors

 

NON LIFE-THREATENING TRANSFUSION REACTIONS
TYPE OF REACTION	DESCRIPTION	TREATMENT
Allergic transfusion reaction (ATR)	Caused by antigen-antibody reaction between patient and product Itching and hives Occurs during transfusion or within 4 hours of transfusion completion	Antihistamines (e.g., diphenhydramine) for treatment but not prophylaxis Transfusion may be continued if no other symptoms develop
Febrile non-hemolytic transfusion reaction (FNHTR)	Most common reaction caused by a release of cytokines from WBCs Fever, chills, and/or rigors without other systemic symptoms Occurs during transfusion or within 4 hours of transfusion completion	Antipyretics (e.g., acetaminophen) for fever Meperidine for severe chills or rigors
Hypotensive transfusion reaction	Drop in blood pressure (BP) without other causes Systolic BP decreases by 30 mm Hg or more and may drop to less than 80 mm Hg within one hour Usually occurs within the first 10 to 15 minutes of transfusion initiation	BP typically returns to baseline once the transfusion is stopped. Usually does not require specific treatment or prevention, except avoiding ACE inhibitors prior to transfusion or apheresis.

Initial Laboratory Testing

The provider should discuss with the transfusion/blood bank personnel whether laboratory testing should be ordered. Minor allergic reactions (e.g., hives) and TACO may not require laboratory tests. All patients with suspected AHTR, anaphylaxis, sepsis, and TRALI should have labs drawn or other tests (e.g., chest radiography) to determine the cause of the patient’s symptoms.

If ordered, a blood sample should be sent to the lab with the following information:

• Patient identifying information
• Underlying diagnosis and reason for transfusion
• Recent fever course
• Previous transfusion reactions
• Administration of any pre-transfusion medications, or new medications that could have caused an allergic reaction or drug-induced hemolysiS
• Time the transfusion was initiated
• Time symptoms began
• Time the transfusion was stopped
• Patient symptoms
• Patient vital signs

The blood bank or laboratory will perform the following:

• Verify the component container, label, paperwork, and patient sample used for typing and crossmatching
• Repeat ABO testing on the post-transfusion patient sample
• Visual check of pre- and post-transfusion patient samples for signs of hemolysis
• Direct antiglobulin (Coombs) test (DAT) on post-transfusion patient sample
• Antibody screen

Restarting the Transfusion after a Reaction

If the symptoms clear and the correct product has been verified by the transfusion service, the treating provider (and transfusion service) should decide if the transfusion may continue.

• Transfusion of the original product shouldn’t be continued if the suspected reaction was AHRT, anaphylaxis, sepsis, or TRALI.
• Transfusion of the same product may be continued if it was a minor allergic reaction or TACO that has resolved with diuresis or other treatments. If 4 hours has passed, the product should not be used.