Transfusion Reaction Management
A transfusion reaction typically stems from a major antigen-antibody reaction and can result from a single or massive transfusion of blood or blood products. It’s estimated that 1% to 2% of all patients who receive a transfusion of blood or blood products experience a transfusion reaction.1 Although many reactions occur during transfusion or within 96 hours afterward, infectious diseases transmitted during a transfusion may go undetected until days, weeks, or months later, when signs and symptoms appear.
A transfusion reaction requires immediate recognition and prompt nursing action to prevent further complications and, possibly, death—particularly if the patient is unconscious or so heavily sedated that he can’t report the common symptoms. (See Guide to transfusion reactions, pages 748 and 749.)
Equipment
Gloves ▪ normal saline solution ▪ IV administration set ▪ sterile urine specimen container ▪ supplies for blood collection (see “Venipuncture,” page 781) ▪ transfusion reaction report form ▪ stethoscope ▪ blood pressure cuff ▪ pulse oximeter ▪ thermometer ▪ laboratory specimen labels ▪ laboratory request form ▪ laboratory biohazard transport bags ▪ Optional: oxygen, epinephrine, hypothermia blanket, leukocyte removal filter.
Implementation
Confirm the patient’s identity using at least two patient identifiers according to your facility’s policy.5
As soon as you suspect an adverse reaction, stop the transfusion and notify the doctor and the blood bank.6,7
Prepare a normal saline infusion using a new macrodrip IV administration set.
Guide to Transfusion Reactions
Any patient receiving a transfusion of blood or blood products is at risk for a transfusion reaction. A transfusion reaction may be immediate, occurring during the transfusion or within several hours of the completion of the transfusion, or delayed. The chart below describes immediate and delayed reactions.
| Reaction | Causes | Signs and symptoms | Prevention | Nursing interventions | |||||
|---|---|---|---|---|---|---|---|---|---|
| Immediate Reactions | Acute hemolytic | Administration of incompatible blood | Chest pain, dyspnea, facial flushing, fever, chills, hypotension, flank pain, bloody oozing at the infusion or surgical incision site, nausea, tachycardia |
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| Bacterial contamination | Contamination of blood product | Chills, fever, vomiting, abdominal cramping, diarrhea, shock |
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| Febrile nonhemolytic | Bacterial lipopolysaccharides; antileukocyte recipient antibodies directed against donor white blood cells | Fever within 2 hours of transfusion, chills, rigors, headache, palpitation, cough, tachycardia |
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| Transfusion-related acute lung injury (TRALI) | Granulocyte antibodies in the donor or recipient cause complement and histamine release | Severe respiratory distress within 6 hours of transfusion, fever, chills, cyanosis, hypotension13,17 |
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| Allergic reaction | Allergen in donor blood | Urticaria, fever, nausea, vomiting, anaphylaxis (facial swelling, laryngeal edema, respiratory distress) in extreme cases |
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| Transfusion-associated circulatory overload (TACO) | Rapid infusion of blood; excessive volume of transfusion | Chest tightness, chills, dyspnea, tachypnea, hypoxemia, hypertension, jugular vein distention; occurs within 2 to 6 hours after transfusion |
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| Hypocalcemia | Rapid infusion of citrate-treated blood (citrate binds to calcium) | Arrhythmias, hypotension, muscle cramps, nausea and vomiting, seizures, prolonged Q-T interval |
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| Delayed Reactions | |||||||||
| Delayed hemolytic | Production of antibodies by red blood cells to antigens on transfused red blood cells | Fever, anemia, jaundice; occurs 5 to 10 days after transfusion |
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| Infection transmission | Transmission of infectious agent in the blood | Depends on infection transmitted |
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| Posttransfusion purpura | Destruction of autologous and allogenic platelets | Thrombocytopenia, bleeding; occurs 7 to 10 days after transfusion |
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| Graft-versus-host disease | T-lymphocytes in blood or blood product react against patient’s tissue antigens | Fever, skin rash and desquamation, diarrhea, pancytopenia; occurs 10 to 12 days after transfusion; usually fatal |
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