Guidelines for Management of Mild Adverse Transfusion Reactions

First Mild Reaction

Symptoms:

• Mild febrile reaction
  • Temperature increase <1.5°C from baseline
  • Stable haemodynamics
  • No respiratory distress and no other symptoms

OR

• Mild allergic reaction
  • Occasional urticarial spots and no other symptoms

Action:

1. Check compatibility label and recipient identity.
2. Slow transfusion.
3. Call for medical assessment.
4. Medical staff may consider the need to prescribe paracetamol for pyrexia or antihistamines for urticaria.
5. Continue transfusion at a slower rate with increased monitoring, e.g., temp, pulse and BP at 15-30 minute intervals.
6. Send 1 x group and screen (EDTA) tube to Blood Bank + a completed Adverse Reaction Notification form (111F00901).
7. Document in patient's clinical notes.

If symptoms increase treat as a moderate or severe reaction.

Subsequent Transfusions and:

• Recurrence of mild febrile reactions

OR

• Recurrence of mild allergic reactions

Action:

1. Febrile reaction: consider giving premedication of an antipyretic (e.g., paracetamol).
2. Urticarial/allergic reaction: consider giving premedication of an antihistamine (e.g., oral phenergan). Slow transfusion administration rate.

Note: Hydrocortisone is not usually indicated.

Management of Moderate and Severe Adverse Transfusion Reactions

Moderate and Severe Adverse Transfusion Reactions may include any of these:

Symptoms may include:

• Fever: ≥1.5°C from baseline with or without rigors / chills
• Unexpected tachycardia or change in blood pressure
• Acute breathlessness, desaturation, wheeze, stridor or cyanosis

Facial oedema ± pharyngeal or laryngeal oedema

• Extensive erythematous or urticarial rash
• Acute pain up transfusion arm
• Chest or loin pain
• Severe apprehension
• JVP acutely elevated, onset of crepitations in lung
• Haemoglobinuria

Action if moderate or severe reaction is suspected:

1. Stop transfusion. THEN :
   • Check compatibility label and recipient identity information is correct.
   • Call for help: urgent medical review required.
   • Maintain ABC and monitor vital signs.
   • Comfort and keep patient informed.
2. Replace infusion set; administer saline to keep vein open and, or maintain blood pressure.
3. Treat and stabilize patient as per medical directives.
4. Obtain specimens based on clinical signs/symptoms (collect away from site of cannula):
   • Blood group serology: 1 x group and screen (EDTA) tube: send ASAP to blood bank with Adverse Reaction Notification form (111F00901) + infusion set + attached blood bag (sealed in a plastic bag).
   • If haemolysis suspected: send full blood count, blood film, coag screen to Haematology; Na, K, creatinine, haptoglobin, bilirubin, LDH to biochemistry and complete a ward urinalysis.
   • If sepsis is suspected: send blood cultures to microbiology.
   • If respiratory distress present: send blood gases to biochemistry.
5. Notify Blood Bank promptly by phone: Discuss further transfusion needs and/or any special requirements.
6. For all severe transfusion reactions: inform the NZBS Transfusion Medicine Specialist (TMS) or Clinical Haematologist immediately. They will provide clinical advice and support.
7. Document in patient’s clinical notes.

Additional treatment: depends on cause, clinical state, test results and TMS or Clinical Haematologist consultation:

• Sepsis likely: broad spectrum antibiotics as per severe sepsis antibiotic guidelines.
• Anaphylaxis/anaphylactoid reaction: as per anaphylaxis guidelines.
• Transfusion associated circulatory overload (TACO): diuretics and oxygen, positive airway pressure.
• Transfusion related acute lung injury (TRALI): respiratory support. NZBS will initiate blood donor investigation.
• If HLA antibodies suspected: the TMS or Clinical Haematologist will advise.
• Recurrent severe allergic reactions: discuss with TMS or Clinical Haematologist. Use of washed cellular components may be required.
• Acute haemolysis: discuss with TMS or Clinical Haematologist. Maintain blood pressure, force diuresis and alkalinize urine.