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Hematology - Transfusion Reactions - Fast Facts | NEJM Resident 360

Blood product transfusion is ubiquitous in the hospital setting. All patients should be counseled about the risk of transfusion-associated reactions. (See a NEJM Video in Clinical Medicine for a summary of the indications, procedure, and complications of transfusion.) A simple categorization of transfusion reactions is based on the timing (acute or delayed) of the reaction as described in the table below.

(Source: What Every Physician Should Know about Transfusion Reactions. CMAJ 2007.)

Acute management: If a hemolytic reaction is suspected in an acute setting, stop the transfusion and employ the following algorithm for workup and management.

Clinical Manifestations, Laboratory Diagnosis, and Management of Hemolytic Transfusion Reactions

(Source: Hemolytic Transfusion Reactions. N Engl J Med 2019.)

If you suspect a transfusion reaction:

• STOPthe transfusion.

• Assess the patient for fever, cardiovascular and respiratory status, and urticaria/angioedema.

• Confirm with the blood bank that the correct product was used, and check for any clerical errors (e.g., blood-type mismatch or incorrect patient identifiers).

• Remember, preexisting fever is not a contraindication to transfusion.

• Treatment of most transfusion-related reactions is supportive and may include:

  • antibiotics for septic syndromes

  • diuretics for volume overload

  • transfer to the intensive care unit for transfusion-related acute lung injury (TRALI)

For information on the management of allergic reactions, including urticaria/angioedema and anaphylaxis, please refer to the Allergy/Immunology rotation guide.

Risk of transfusion-associated reactions: The magnitude of the risk of adverse transfusion reactions is summarized in the following graphic:

Infectious and Noninfectious Adverse Effects of Red-Cell Transfusions as Compared with Other, Unrelated Risks

Adverse effects of transfusions (black boxes) are shown per transfused unit of red cells, except for transfusion-associated circulatory overload (TACO), which is per transfusion episode. For unrelated risks (blue boxes), the risk of an airplane death is per flight, the risk of death from lightning is per year, the risk of death from a motor vehicle accident is per 10,000 persons, and the risk of death from medical error is per hospital admission.
Abbreviations: AHTR, acute hemolytic transfusion reaction; DHTR, delayed hemolytic transfusion reaction; FNHTR, febrile nonhemolytic transfusion reaction; HBV, hepatitis B virus; HCV, hepatitis C virus; TRALI, transfusion-related acute lung injury
(Source: Indications for and Adverse Effects of Red-Cell Transfusion. N Engl J Med 2017.)

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