What do you do if you think your patient is having a transfusion reaction? It can be hard to know what steps to take especially in a patient who is in critical need of the blood product.
Immediate Management of Suspected Transfusion Reaction
If called about a suspected transfusion reaction, the first step is to have the RN stop the blood product transfusion. Have him or her confirm that it is the right product for the right patient.
Your immediate concern when assessing the patient is assessment and management of ABCs. Stabilize the patient first. Your patient may need oxygen therapy if hypoxemic or fluids if hypotensive.
Additionally, have someone call the blood bank if you are suspecting a transfusion reaction. They are incredibly helpful and can help you determine if any labs need to be ordered.
OK- My patient is stable. How do I figure out what's going on and what to do?
When trying to rapidly diagnose and manage a likely transfusion reaction, determine the predominant symptom. Is your patient febrile, dyspneic, or is it a new rash?
Febrile Transfusion Reactions
Febrile transfusion reactions can be very severe. There are three main categories of ACUTE febrile transfusion reactions:
Acute Hemolytic Transfusion Reaction
Febrile Nonhemolytic Transfusion Reaction
Sepsis
All febrile transfusion reactions should be worked up with a CMP, CBC, Haptoglobin, Coombs, LDH, PT, PTT, fibrinogen, blood culture, and gram stains from patient and sample, and a type and cross. Call the blood bank to confirm no additional orders are needed.
To differentiate between the three, look at your patient's blood pressure and perfusion status. (Heart rate will be less reliable because it should be elevated given fever and possibly underlying anemia).
If your patient is perfusing normally with an appropriate blood pressure, this is likely a febrile nonhemolytic transfusion reaction (FNHTR). This is the most common transfusion reaction and occurs secondary to the leukocyte-derived cytokines that develop during erythrocyte and platelet storage. You will see this reaction any time after the start of the transfusion but classically it starts from 1 to 8 hours post-transfusion. As the name implies, fever is the predominant symptom but patients can have rigors & chills. Dyspnea can be present but this is typically far less severe than seen in TACO/TRALI. (You should still get a CXR to check if dyspnea is noted).
Management involves supportive care. Treat with Tylenol. If rigors are present, you can treat with meperidine. Once more serious transfusion reactions are ruled out, you can resume the transfusion but it is also appropriate to not resume, if you want to be safe.
If your patient is hypotensive, you are dealing with a serious reaction. Bolus immediately and order a STAT Direct Coombs.
If your coombs is positive or other labs are consistent with hemolysis (hemoglobinuria, elevated bilirubin, DIC, schistocytes on smear or high LDH), this is an Acute Hemolytic Transfusion Reaction. This is the most severe reaction: it occurs most commonly with ABO compatibility generally from error. It will occur within minutes of starting the transfusion. Patients are generally very sick: in addition to fever and hypotension, they will have dyspnea, chills, back pain, coagulopathy, back or flank pain, and red urine. They can develop renal failure and shock as well.
The goals of management are to reduce the inflammatory cascade and prevent kidney injury secondary to hypoperfusion and DIC-induced thrombi. As such, aggressive IV hydration is key: goal is for UOP > 1 cc/kg/hr. Diuretic therapy can be used to augment urine output if the patient is oliguric. However, make sure the patient is euvolemic to hypervolemic before resorting to diuretic therapy and diuretics should be stopped if there is no response or persistent hypotension within 4 hours of therapy.
If patients are persistently hypotensive, pressors may be needed. Dopamine is preferred given the theoretically benefit of renal vasodilation.
If DIC is diagnosed, FFP should be given for a PT >1.5, cryoprecipitate for fibrinogen levels <1g/L, platelets if counts are below 50K.
Again, make sure you have stopped the transfusion. You will want to check serial CBCs and monitor the patient in an ICU.
What if your patient is febrile & hypotensive without evidence of hemolysis? Your patient is likely septic, especially if he or she got platelets as these are stored at room temperature. Patients present within minutes to hours after the transfusion. Make sure to start broad-spectrum antibiotics after culturing both the patient's blood and the transfused product.
OK: What if my patient is complaining largely of dyspnea?
Get a STAT CXR and do a good examination of the lungs and airway.
Let's say your patient is wheezing and stridulous: don't wait for the CXR to return. Be concerned for anaphylaxis. This will typically occur within seconds to minutes of a transfusion starting and presents as the sudden onset of respiratory distress/bronchospasm, angioedema, nausea, vomiting, rash, abdominal pain, and/or tachycardia. Management consists of supportive care, IM epinephrine (be careful if patient is on a beta blocker! They will need glucagon and a re-dose of the IM epinephrine), antihistamine, and likely ICU transfer.
However, if your patient is in respiratory distress and has bilateral infiltrates on CXR, the diagnosis is either TRALI or TACO. Look at the blood pressure and volume status.
If hypotensive, patient is more likely to have Transfusion-Related Acute Lung Injury (TRALI). TRALI is the leading cause of mortality in transfusions. According to current consesus statements, TRALI is defined as new lung injury within 6 hours of a transfusion, hypoxemia, and a CXR with infiltrates and no other risk factors. It presents with fever, hypoxia, and new, diffuse bilateral infiltrates on CXR within 6 hours of a transfusion of FFP, PRBC, or platelets. Patients have a rapid escalation of symptoms.
Beware: while the CXR can be helpful, findings can range from a small amount of bilateral infiltrate to an entire white-out.
Management focuses on supportive care: 70-90% require mechanical ventilation and patients can require vasosupport as well. However, most patients recover with a mortality of 5-10%.
If your patient is hypertensive or hypervolemic or normotensive, this is likely transfusion-associated circulatory overload (TACO). This is much more common and it develops toward the completion of a transfusion or within hours of a transfusion. Symptoms include dyspnea, hypoxia, tachycardia, headache, and hypertension and the physical exam should be consistent with volume overload. Risk factors for TACO include age over 60, CKD, CHF, and high transfusion requirements.
If you suspect TACO, sit your patient upright and provide supplemental oxygen therapy. Diuretic therapy should be started immediately. NIPPV can be helpful in severe cases.
What if my patient has developed a rash?
In patients who get a rash during transfusion, your primary concern should be anaphylaxis. If other organ systems are involved or the patient has hypotension, presume this and treat as above.
However, if there is only a rash this is likely an urticarial reaction. Urticarial transfusion reactions occur because of recipient IgE antibodies with reactivity to allergens in the plasma of the transfused product. Patients develop a rash generally with pruritus too but NO other symptoms. Management centers on antihistamine therapy: once anaphylaxis has been ruled out, you can resume the transfusion.
What about delayed transfusion reactions?
There are many delayed transfusion reactions that we will not focus on here, including GVHD.
However, we will mention the Delayed Hemolytic Transfusion Reaction, which occurs 2 to 10 days later (i.e. no product is transfusing!). It is caused by anamnestic alloantibody response upon re-exposure to an erythrocyte antigen. Symptoms are the same as an acute reaction, but slower onset and less severe: they still include fever + hypotension, chills, dyspnea, red urine, and back or flank pain. Treatment is supportive (IV fluids and close monitoring).
References
https://ddxof.com/transfusion-reactions/
http://www.emdocs.net/severe-transfusion-reactions-ed-focused-management/
MKSAP 17: Transfusion.
Adewoyin, A., & Oyewale, O. (2015). Complications of Allogeneic Blood Transfusion: Current Approach to Diagnosis and Management. International Blood Research & Reviews, 3(4), 135-151. doi:10.9734/ibrr/2015/17874
Dean L. Blood Groups and Red Cell Antigens [Internet]. Bethesda (MD): National Center for Biotechnology Information (US); 2005. Chapter 3, Blood transfusions and the immune system. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2265/
Vlaar, A. P., & Juffermans, N. P. (2013). Transfusion-related acute lung injury: a clinical review. The Lancet, 382(9896), 984-994. doi:10.1016/s0140-6736(12)62197-7
SB Moore. Transfusion-related acute lung injury (TRALI): clinical presentation, treatment, and prognosis Crit Care Med, 34 (2006), pp. S114–S117
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