History and physical examination
Patients with symptoms coincident with a transfusion may have reactions ranging from mild febrile, nonhemolytic transfusion reaction (FNHTR) to life threatening anaphylaxis or hemolysis. Three common signs are below and are highlighted to show which types of reactions may underlie the sign:
If hemolysis is possible, give intravenous fluids and test for repeat blood cross-matching, direct Coombs' test (cross-matching only includes the indirect Coombs' test), plasma free hemoglobin, and urine hemoglobin.
Types of reactions
Febrile, nonhemolytic transfusion reaction (FNHTR)
FNHTR may include temperature elevation > 1°C, chills and/or rigors, headache, vomiting. This is a minor, acute reaction suggested by negative a Coombs' test, no free hemoglobin in the plasma, and no hemoglobin in the urine.
Hemolytic reactions due to blood group incompatibility is "mismatch between donor and recipient blood. Antibodies present in the recipient's serum are directed against antigens in the donor product. Such a mismatch may result in a transfusion reaction in which, for example, donor blood is hemolyzed."
Acute hemolytic transfusion reactions
Acute hemolytic transfusion reactions due to ABO incompatibility may show chills, fever, hypotension, renal failure, back pain, hemoglobinuria
Delayed hemolytic transfusion reactions
This reaction usually causes delayed hemolysis. This may be caused by Rh incompatibility.
Type 1 hypersensitivity (immediate hypersensitivity) reactions include:
- Anaphylactic transfusion reactions may occur, especially in patients with IgA-deficiency and may cause dyspnea from bronchospasm, hypotension, urticaria.
- Urticaria may occur due to the recipient's IgE reacting to antigens from the donor and cause urticaria, pruritis, and flushing.
Transfusion-related acute lung injury (pulmonary leukoagglutinin reaction) (TRALI) is an acute reaction that may include dyspnea, hypoxemia, respiratory failure, hypotension, and fever.
Posttransfusion purpura (PTP) is an immune thrombocytopenia. This is more common in women who have been pregnant.
Transfusion associated graft-versus-host disease (TA-GVHD) is when the donor's blood attacks the recipient's body.
Nonimmune hemolysis may be due to physical destruction of donor blood from heating or freezing.
- Hypocalcemia from citrate toxicity
- Metabolic alkalosis and hypokalemia due to citrate
Transmission of infection
Transfusion associated sepsis may manifest 'fever > 40°C and/or cardiovascular collapse.'
- Air embolus may manifest 'sudden dyspnea, cyanosis, chest pain, cough, hypotension, cardiac arrhythmia.' ICD9: 999.1
- Circulatory overload may cause dyspnea.
- Hypotension associated with leukoreduced blood and maybe angiotensin-converting enzyme may cause flushing and hypotension.
- Sanders RP, Geiger TL, Heddle N, Pui CH, Howard SC (April 2007). "A revised classification scheme for acute transfusion reactions". Transfusion 47 (4): 621–8. DOI:10.1111/j.1537-2995.2007.01163.x. PMID 17381620. Research Blogging.
- Anonymous (2023), Blood group incompatibility (English). Medical Subject Headings. U.S. National Library of Medicine.