Blood Transfusion Reaction

ABCs

fever alone: which reaction?

Temperature rise ≥ 2 °C from baseline, or fever with hypotension, rigors, or vomiting → septic until proven otherwise, not a simple febrile reaction.
Febrile non-hemolytic: fever (≥ 38 °C or rise > 1 °C) without hypotension; settles after stopping the unit and giving antipyretic.
Failure to settle after antipyretic → not benign.

stop the transfusion first, then think

keep IV access with normal saline through a new giving set
do not discard the unit: it goes back to blood bank with its giving set attached
recheck patient identity band against unit label at bedside
hypotension, hypoxia, stridor, back pain or dark urine → call for help and notify blood bank now

timing: how long after starting, how much has gone in
component: red cells, platelets, or plasma; platelets stored at room temperature carry highest bacterial risk
symptoms: itch or rash, fever or rigors, dyspnea, chest or back pain, dark urine, nausea
background: previous reactions, transfusions or pregnancies (alloantibodies), known IgA deficiency, cardiac or renal failure (overload risk)

airway and breathing: stridor, wheeze, work of breathing, SpO₂
circulation: BP trend, perfusion, JVP
skin: urticaria, flushing, angioedema
chest: crackles + raised JVP → overload; hypoxia with clear volume status → TRALI
urine: color; hemoglobinuria = hemolysis marker

return to lab: implicated unit with its giving set attached, sealed
from opposite arm: EDTA + clotted samples for direct antiglobulin test, repeat crossmatch, antibody screen
hemolysis screen: CBC, LDH, bilirubin, haptoglobin, plasma free Hb, coagulation profile
urine: first sample after reaction for hemoglobinuria
if febrile or septic: blood cultures from patient, peripheral and from any central line
if anaphylaxis: mast cell tryptase (immediate, 1-3 hr, 24 hr), IgA level
imaging: CXR if hypoxic: overload vs TRALI

every suspected reaction

septic reaction: bacterial contamination of the unit

features as in ABCs above → blood cultures from the patient; unit for culture
urgent broad-spectrum IV antibiotics, per local neutropenic sepsis policy, do not wait for cultures
notify blood bank immediately so rest of donation is quarantined

by reaction type

mild allergic (itch, urticaria, stable): cetirizine 10 mg PO or loratadine 10 mg PO. May restart slowly if fully settled
febrile non-hemolytic (fever, no compromise): antipyretic and monitor; exclude hemolysis and sepsis before restarting
acute hemolytic (fever, hypotension, back pain, dark urine): stop permanently; aggressive IV fluids to maintain urine output; treat DIC; cover for sepsis until excluded; urgent escalation
TACO (hypertension, raised JVP, crackles, within 12 hr): sit up, oxygen, furosemide IV; diuretics are correct here
TRALI (hypoxia within 6 hr, bilateral infiltrates, no overload): oxygen + respiratory support, manage as ARDS. Avoid diuretics
anaphylaxis: adrenaline 500 mcg IM (0.5 mL of 1:1000) anterolateral thigh, repeat after 5 minutes if ABC problems persist; do not restart the unit
- 500–1,000 mL rapid IV crystalloid, reassess after each bolus, repeat per response (smaller boluses if overload concern)
- oxygen, ICU referral

TACO vs TRALI

TACO: within 12 hr, hypertensive, raised JVP, positive fluid balance, responds to diuresis.
TRALI: within 6 hr, hypotensive or normotensive, PaO₂/FiO₂ < 300 or SpO₂ < 90 % on air, no overload. Diuretics worsen it; no role for steroids.
hypertension → TACO, hypotension → TRALI: that one observation decides whether furosemide is given

afterwards: reporting, restart rules, late reaction

Report serious reactions through hospital transfusion committee and national haemovigilance scheme. Formal requirement, not optional.
Restart only if symptoms fully resolved and serious causes excluded: slow rate, close monitoring, stop permanently if anything recurs.
Routine premedication (paracetamol or antihistamine) is not recommended: it does not prevent reactions; selective use is a hematology decision.
Delayed hemolytic reaction: 5-14 days later, unexplained falling hemoglobin or poor increment, jaundice, low-grade fever, newly positive antiglobulin test. Easily mistaken for bleeding.

escalation

now: hypotension, hypoxia, stridor, suspected hemolysis or sepsis
blood bank: every suspected reaction, immediately
ICU: airway compromise, refractory shock, ventilatory support
hematology: recurrent reactions, suspected IgA deficiency, planning future transfusion

source	type
BSH acute transfusion reaction guidance	specialty-society guidance
ISBT/AABB transfusion reaction definitions	regulatory / safety update
Resuscitation Council UK anaphylaxis guidance	specialty-society guidance

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 transfusion reactions in the same format. see the sample chapter.

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