Blood Transfusion Reaction

at the bedside

stop the transfusion → keep the line with normal saline through a new giving set; keep the unit and its set for blood bank
airway, breathing, circulation; full vitals against the pre-transfusion set, cardiac monitor, SpO₂
identity check → wristband against the unit label at the bedside, now
which reaction → rash and itch only; fever; fever with hypotension, rigors or back pain; breathless with high or low BP; look at the urine color
tell blood bank about every suspected reaction

escalate now if

hypotension, back or loin pain, dark urine, fever within minutes → acute hemolytic reaction, wrong blood until proven otherwise
temperature up ≥ 2 °C, rigors, hypotension or vomiting → septic reaction, antibiotics now
stridor, wheeze, hypotension with urticaria → anaphylaxis, epinephrine IM
breathless with hypertension, raised JVP, crackles → circulatory overload (TACO)
breathless with hypoxia, normal or low BP, no overload, within 6 h → TRALI, no diuretic
shock or airway compromise → ICU now → hypotension

mild allergic → itch, urticaria, stable vitals
febrile non-hemolytic → fever ≥ 38 °C or a rise > 1 °C, no hypotension, settles when the unit stops; a diagnosis of exclusion
acute hemolytic → fever, hypotension, back pain, dark urine, oozing; ABO incompatibility
septic → high fever, rigors, hypotension; platelets (room temperature) carry the highest risk; a discolored or clumped unit
anaphylaxis → airway, breathing or circulation compromise with skin signs; IgA deficiency in recurrent cases
TACO → within 12 h, hypertensive, raised JVP, positive balance, heart or kidney failure
TRALI → within 6 h, hypoxia with bilateral infiltrates, no overload, often hypotensive
delayed hemolytic → 5–14 days later: falling hemoglobin, jaundice, low-grade fever, new positive antiglobulin test; mistaken for bleeding

timing → minutes into the unit, how much has gone in, which component
symptoms → itch or rash, fever or rigors, dyspnea, chest or back pain, dark urine, nausea
history → previous reactions, previous transfusions or pregnancies (antibodies), IgA deficiency, heart or kidney failure, fluid balance today
exam → stridor or wheeze, work of breathing; BP trend and JVP; urticaria, flushing, angioedema; crackles; urine color

to blood bank → the unit with its giving set, sealed; from the other arm: EDTA and clotted samples for direct antiglobulin test, repeat crossmatch and antibody screen
hemolysis screen → CBC, LDH, bilirubin, haptoglobin, plasma free hemoglobin, coagulation; first urine for hemoglobinuria
febrile or septic → blood cultures from the patient, peripheral and any central line; the unit goes for culture
anaphylaxis → tryptase at 1–3 h and 24 h, IgA level
hypoxic → CXR, VBG: overload or TRALI; NT-proBNP favors TACO

every reaction

unit stopped, line kept, identity checked, blood bank told, samples sent; oxygen if hypoxic, fluids if hypotensive
restart only a mild allergic or febrile reaction that has fully settled, slowly, with observation; anything else stays stopped

mild allergic, febrile non-hemolytic

itch or urticaria, stable → cetirizine 10 mg PO or loratadine 10 mg PO
fever, no compromise → paracetamol 1 g PO/IV; exclude hemolysis and sepsis before restarting; not settling after the antipyretic is not benign
routine premedication does not prevent reactions; recurrent reactions → hematology

acute hemolytic reaction

stop permanently; hematology and ICU now; re-verify the identity of every unit issued to the ward tonight
IV crystalloid to a urine output of ≥ 100 mL/h; watch K⁺ and coagulation, treat DIC → coagulation profile; cover for sepsis until excluded

septic reaction

blood cultures, then broad-spectrum IV antibiotics within the hour, as for neutropenic sepsis → fever, empiric antibiotics
blood bank now, so the rest of the donation is quarantined

anaphylaxis

epinephrine 0.5 mg IM mid-thigh, repeat every 5 min while not improving; lie flat, oxygen, crystalloid 500–1000 mL IV; full pathway → allergic reaction
never restart the unit; washed products and IgA testing for next time → hematology

TACO, circulatory overload

sit up, oxygen, furosemide 40 mg IV (80 mg if already on a loop diuretic); slow future units and give them with a diuretic → dyspnea

TRALI

oxygen and respiratory support as for ARDS, ICU early; no diuretic, no steroid → acute respiratory failure
hypertension points to TACO, hypotension to TRALI: that one observation decides whether furosemide is given

report → every serious reaction through the hospital transfusion committee and the national haemovigilance scheme
hand over → reaction type suspected, unit returned, samples sent, vitals trend, escalation trigger

source	type
AABB / ISBT transfusion reaction definitions (NHSN hemovigilance)	regulatory / safety update
BSH acute transfusion reaction guideline (no North American management guideline; used as fallback)	specialty-society guidance
2023 AAAAI/ACAAI anaphylaxis practice parameter	international guideline

Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.

free the on-call checklist covers the whole shift on one printable page.

studying for the IM exam? the IM Rapid Review covers this in the same format. see the sample chapter.

reviewed Jul 2026updated Oct 2026file complaint/blood-transfusion-reaction