Level 1 of 6Core
Transfusion reactions: recognition and immediate management
The core to-do list — diagnose and manage, at a glance
Diagnose— recognise it
- Observe deliberately: record baseline observations before the unit starts and watch the patient directly for the first 15 minutes of every unit — most acute reactions declare themselves then. Every serious reaction opens the same way — fever, rigors, a feeling that something is wrong — and the diagnosis is made in the next minutes from BP, breathing, skin, pain and urine colour.
- Acute haemolytic reaction: onset within minutes, often after as little as 10–15 mL — rigors, loin or lumbar pain, dyspnoea, hypotension and haemoglobinuria, with impending doom. Loin pain during a transfusion must never be blamed on positioning. Bedside haemolysis test: clear red or cola urine that does not settle; a dipstick strongly positive for blood with no red cells on microscopy means free haemoglobin, not bleeding.
- Febrile non-haemolytic vs septic: FNHTR comes 30 minutes–2 hours in, fever ≥38°C or a rise of ≥1°C from baseline, in a patient who is normotensive, well perfused, not hypoxic and not in pain — a label earned only after the dangerous diagnoses are excluded. A septic reaction is abrupt and violent: temperature often above 39°C, rigors, vomiting, rapidly progressive hypotension, sometimes a discoloured, clotted or leaking pack.
- Allergic vs anaphylactic: urticaria, itch and flushing in an otherwise entirely well patient is a simple allergic reaction; hoarseness, stridor, tongue or lip swelling, wheeze, hypotension or collapse — usually with little or no fever — is anaphylaxis.
- TRALI vs TACO — fluid moves in opposite directions in the two commonest lethal reactions: TRALI begins within 6 hours — dyspnoea, hypoxaemia out of proportion to the film, BP normal or low, JVP not raised, no diuretic response. TACO begins during or within 6–12 hours — orthopnoea, bibasal crackles, raised JVP, and the discriminating sign: hypertension with a widened pulse pressure, improving on sitting up and a diuretic.
- Red flags = treat as life-threatening: systolic fall over 30 mmHg or any shock; loin, back, chest or abdominal pain; red or brown urine; oozing from puncture sites; stridor, tongue swelling or wheeze; RR above 30 or SpO2 below 92% despite oxygen; temperature above 39°C or a 2°C rise with rigors; any identity discrepancy. The anaesthetised patient loses every symptom — unexplained hypotension, surgical-field oozing and dark urine in the catheter bag may be all there is; hypotension in a child is pre-terminal.
Manage now— do this, in order
- Stop at the first suspicion, not at the point of diagnosis — severity tracks the volume infused and slowing the rate does not stop the injury. A mild allergic reaction can be restarted; an incompatible unit cannot be un-transfused.
- Preserve venous access: disconnect the giving set at the cannula hub and attach a new set primed with 0.9% sodium chloride — never flush the blood standing in the old tubing into the patient, and never remove the cannula: the vein will be needed within seconds and is far harder to obtain once the patient shuts down.
- Re-check identity against the patient's stated name and date of birth, wristband, compatibility label and donation number — and alert the transfusion laboratory: a mismatch implies a second patient may be receiving the wrong unit at the same moment. Take all post-reaction samples from the opposite arm.
- Airway, breathing, circulation, and oxygen to maintain SpO2 94–98% (88–92% if at risk of hypercapnic respiratory failure).
- Acute haemolysis — crystalloid generously: 0.9% sodium chloride 500 mL IV over 15 minutes, repeated against BP, heart rate and urine output (250 mL aliquots in the frail or cardiac; child 10–20 mL/kg). Catheterise and measure urine hourly, target ≥1 mL/kg/h adult (1–2 mL/kg/h child) — volume, not diuretics, protects the kidney. Noradrenaline titrated to MAP ~65 mmHg if hypotension persists after volume; treat the predictable hyperkalaemia (calcium gluconate 10% 10 mL IV over 5–10 minutes for ECG changes; insulin 10 units in 25 g glucose over 15–30 minutes; nebulised salbutamol 10–20 mg).Doctor / Nurse
- Septic reaction — treat as septic shock: blood cultures plus culture of the pack and giving set before antibiotics, then broad-spectrum IV antibiotics within one hour — piperacillin–tazobactam 4.5 g IV 6–8-hourly (paediatric 90 mg/kg, max 4.5 g/dose), or ceftriaxone 2 g IV daily plus metronidazole 500 mg IV 8-hourly, or meropenem 1 g IV 8-hourly; in neonates avoid ceftriaxone — use cefotaxime 50 mg/kg IV 6–8-hourly.Doctor / NurseNot available at your setup — Blood culture.
- Anaphylaxis — adrenaline first and nothing must delay it: adrenaline 1:1000 IM anterolateral thigh — 500 micrograms (0.5 mL) adult and over 12 years, 300 micrograms 6–12 years, 150 micrograms 6 months–6 years, 100–150 micrograms under 6 months — repeated every 5 minutes; lie flat with legs elevated, high-flow oxygen, 0.9% sodium chloride 500–1000 mL IV rapidly (child 20 mL/kg). Never restart the unit.Doctor / Nurse
- TACO: sit upright with legs dependent, high-flow oxygen, stop all IV fluids, furosemide 20–40 mg IV slowly (40–80 mg if already on a loop diuretic or renally impaired; child 0.5–1 mg/kg, max 20 mg/dose); early CPAP or NIV is transformative. TRALI: oxygen targeting 94–98%, early escalation to ventilation — never a diuretic unless fluid overload has been positively demonstrated. If the TACO patient is hypotensive, reconsider the diagnosis before any diuretic.Doctor / Nurse
- Mild isolated urticaria: interrupt the transfusion, chlorphenamine 10 mg IV slowly, re-examine specifically for wheeze, stridor, hoarseness, angioedema, vomiting or hypotension — if truly isolated urticaria settles fully, restart at a slower rate under close observation. This is the only reaction in which restarting the same unit is routinely acceptable. FNHTR once dangerous diagnoses are excluded: paracetamol 1 g (paediatric 15 mg/kg, max 60 mg/kg/24 h), observe 15-minutely for an hour.Doctor / Nurse
| Feature | TRALI | TACO |
|---|---|---|
| Onset | Within 6 h (usually 1–2 h) | During, or within 6–12 h |
| Blood pressure | Normal or low | Hypertension, widened pulse pressure |
| JVP | Not raised | Raised |
| Diuretic response | None — do not give | Improves — give furosemide |
| Treatment | Oxygen, early ventilation | Sit up, stop fluids, furosemide, CPAP/NIV |
Refer / escalate
Escalate immediately to the transfusion laboratory and critical care for any shock state, loin or back pain with dark urine, oozing from puncture sites, stridor or airway swelling, SpO2 below 92% despite high-flow oxygen, temperature above 39°C or a 2°C rise with rigors and hypotension, any identity discrepancy, or any reaction in an anaesthetised patient — return the implicated unit with its giving set, every other pack, and a fresh sample from the opposite arm.
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