Transfusion Reaction Work-Up

Norm of Transfusion Reaction Work-Up

Not applicable.
Note: Treatment choice(s) depend(s) on client's history and condition and episode history.
Mild Febrile Reaction

Slight, nonsustained temperature increase <1 degree C
Urticaria, rash, or hives
Mild chills
Slow the transfusion rate. Verify that the information on the client's blood band, hospital bracelet, blood bag, and blood transfusion requisition all correspond properly and notify the physician.
If all information matches properly, possible courses of action available to the physician include:

Continue the transfusion while monitoring the recipient closely for further development of hemolytic or nonhemolytic reaction.
Add a microaggregate filter to filter the blood if not already being used.
Administer antipyretic and antihistamine and continue the transfusion while monitoring the client closely for further development of hemolytic or nonhemolytic reaction.
Stop the transfusion, and return the blood to the blood bank.
Stop the transfusion, and complete the transfusion reaction blood work and urine tests as described below.


Hemolytic Reaction

Early signs

Sustained rise in temperature >1 degree C
Nausea or vomiting
Monitor vital signs every 5–15 minutes
Pronounced chills and shivering
Pain in the chest or low back
Infusion-site tenderness and warmth

Progressive signs

Bleeding tendencies (disseminated intravascular coagulation)
Acute renal failure
Stop the transfusion immediately, and leave a normal saline infusion at a keep-open rate. Notify the physician immediately.
Completely fill a red-topped tube and a lavender-topped tube with a blood sample.
Obtain a 50-mL random, fresh urine sample in a clean container.
Document pretransfusion and posttransfusion vital signs on the blood bank requisition.
Return the blood bank requisition, laboratory requisition for the transfusion reaction work-up, the bag of blood, the urine specimen, and the red-topped and lavender-topped tubes to the blood bank promptly.
If DIC is suspected, additional testing should include fibrinogen level, fibrin split products, platelet count, PT/PTT, and thrombin time.
Prepare for the administration of RH immune globulin if the reaction was caused by transfusion of RH-incompatible blood


Acute Nonimmune Febrile Reaction

Sustained rise in temperature >1 degree C
In addition to following the procedures described above for a hemolytic reaction:

Draw blood for aerobic and anaerobic culture and Gram stain.


Anaphylactic Reaction

Dyspnea, wheezing (bronchospasm and upper airway edema)
Urticaria, hives
Circulatory collapse
Bowel spasm, with diarrhea
In addition to following the procedures described above for a hemolytic reaction:

Have an emergency cart readily available.
Maintain a patent airway and blood pressure.
Administer epinephrine intravenously as follows:
Bolus with epinephrine 0.2–0.5 mg of 1:1000
dilution mixed in 10 mL of 0.9% saline over 5–10 minutes.
Follow the bolus with a continuous infusion of epinephrine at 1–4 mg/minute.
Other drugs used to treat anaphylaxis may include aminophylline, atropine (for bradycardia), cimetidine, diphenhydramine, and hydrocortisone.
Use IgA-deficient blood or plasma-deficient blood for future transfusions.


Transfusion-Related Acute Lung Injury (TRALI)

Increased capillary permeability
Pulmonary edema
In addition to following the procedures described above for a hemolytic reaction:

Have an emergency cart readily available.
Maintain a patent airway and blood pressure.
Prepare for blood gas measurement.
Provide supportive care and usual transfer to intensive care setting.


Usage of Transfusion Reaction Work-Up

Helps determine the cause of transfusion reaction.


Description of Transfusion Reaction Work-Up

An acute transfusion reaction work-up is indicated whenever an unexpected reaction to transfusion of blood products is noted. Symptoms are most likely to occur within the first 15–30 minutes of transfusion and may be stimulated by as little as 10 mL of incompatible blood. Recombinant erythropoietin should be considered as an alternative to transfusion for anemic clients with nonmyeloid cancers.
Mild febrile reactions and urticaria may occur in clients who have been immunized to blood protein constituents through past receipt of donor blood or past pregnancies. A microaggregate filter used with transfusion can minimize the transfusion of such blood constituents.
Hemolytic transfusion reaction: With correctly administered blood, a hemolytic transfusion reaction may be attributable to recipient antibodies reacting to donor antigens not identified during type-and-crossmatch or type-and-screen procedures. Reactions are more likely to occur in clients who have had recent transfusions of blood because new antibodies to past donor blood may have developed since the last type-and-crossmatch procedure was performed. In blood administered incorrectly (that is, to the wrong recipient), a transfusion reaction is most likely caused by ABO incompatibility or antigen-antibody reactions. An incompatible or contaminated transfusion may cause fatal hemolytic reactions and disseminated intravascular coagulation. Thus it is important to observe recipients closely for early signs of reaction, so that the transfusion may be promptly stopped and complications minimized.
Acute nonimmune febrile reactions may be caused by bacterial contamination of the donor blood. This type of reaction may cause fever and erythrocyte hemolysis and may progress to shock and sepsis.
Anaphylactic transfusion reactions may occur in clients with subnormal immunoglobulin A (IgA) who have a history of recurrent infections. The receipt of IgA in donor blood stimulates an antibody response to IgA that causes anaphylaxis.
Delayed transfusion reactions include delayed hemolytic reactions, graft-versus-host disease, purpura, hemosiderosis, and transfusion-related acute lung injury (TRALI). Delayed hemolytic reactions usually are caused by recipient anti-Rh antibodies, anti-Duffy antibodies, and anti-Kidd antibodies that were not detected during type-and-crossmatch procedures. TRALI is thought to occur when a client with a preexisting systemic inflammatory condition experiences an antigen-antibody attack either from or against the contents of the blood product. A transfusion of blood containing these antigens causes delayed hemolysis and continued anemia. Graft-versus-host disease is usually fatal and occurs in immunosuppressed clients whose immune systems are unable to provide resistance against donor lymphocytes. Purpura with thrombocytopenia may develop about 7 days after transfusion in clients deficient in and who have developed antibodies to platelet antigen PLA-1. Hemosiderosis (iron overload) may occur in clients receiving multiple transfusions over a short period of time.
Laboratory procedures for an acute transfusion reaction work-up include direct Coombs' testing; repeated type and crossmatch on original recipient and donor samples; type and crossmatch on post-reaction recipient sample with donor sample; hemoglobin and hematocrit level; serum haptoglobin; urea nitrogen, plasma or serum; recipient and donor blood culture and Gram stain; and urine measurement of bilirubin, hemoglobin, urobilinogen, and hemosiderin.


Professional Considerations of Transfusion Reaction Work-Up

Consent form NOT required.

  1. Assess the client during the transfusion for signs of a transfusion reaction listed previously.



  1. Follow procedures described under Treatment.


Postprocedure Care

  1. Continue monitoring vital signs every 5–15 minutes until they are stable.


Client and Family Teaching

  1. Complete results may take several days.
  2. See Other Data and provide information appropriate to the type of reaction that occurred.


Factors That Affect Results

  1. See individual test listings.


Other Data

  1. For delayed transfusion reactions, the following should be performed if future transfusions are needed:
    • a. Delayed hemolytic reactions: The client should be advised to carry the information in writing that any blood transfusions received must be negative for Rh (c and E), Duffy, and Kidd antigens.
    • b. Graft-versus-host disease: If the client survives this complication, future donor blood should be irradiated before transfusion.
    • c. Purpura: The client should be advised to carry the information in writing that any blood transfusions received must be PLA-1 negative.
    • d. Hemosiderosis: Hemosiderosis may be fatal. The risk for developing this complication may be minimized in clients who need multiple transfusions by performing lead chelation therapy.
  2. Card or slide hemagglutination or dipstick methods are available for use in ABO blood grouping at the bedside just before transfusion.