Blood Transfusion Reactions: A Comprehensive Nursing Guide

Jan 16, 2022 | Critical care, Emergency (ER), HemOnc, ICU, Med-Surg, Medications & Therapies, New Nurse, Nursing Assessment, Procedures & Skills | 2 comments

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William J. Kelly, MSN, FNP-C
William J. Kelly, MSN, FNP-C

Author | Nurse Practitioner

Blood transfusion reactions are common within the hospital setting because so many blood products are given. Transfusing blood products that are lacking or actively being lost (i.e. GI bleed) is literally life-saving treatment.

In this article, we will talk about the different blood products, why they are given, and then dive into each type of blood transfusion reaction, what causes them, their signs and symptoms, and how to manage them as the nurse.

Acute Hemolytic Transfusion Reaction

What are blood products?

There are multiple different blood products that are transfused within the hospital, and each one can have adverse reactions called blood transfusion reactions.

Packed Red Blood Cells (PRBCs)

Packed Red Blood Cells or PRBCs are given to patients when their hemoglobin levels are low. This is called anemia. Some common causes of anemia that may need a transfusion include:

  • Acute and chronic blood loss (i.e. GI Bleed)
  • Untreated ongoing Anemia (Iron-deficiency anemia)
  • Destruction of blood cells
  • Decreased production of red blood cells (i.e. Chemotherapy, aplastic anemia)

PRBCs are usually ordered when hemoglobin levels drop below 7g/dL, but it depends on the nature of the patient’s anemia as well as their medical history and their hemodynamic stability (are their vital signs normal?)

1 to 2 units will be ordered of PRBCs depending on how low the patient’s hemoglobin level is, as well as if there is active blood loss. Each unit of PRBCs should increase the hemoglobin by about 1g/dL.

Before blood products are given, a type and screen is done to verify the patient’s blood type and screen for any antibodies that may require special blood. The exception is if the patient has significant ongoing hemorrhage and the patient needs emergent blood. In this case, O Negative blood is given as they are the universal donor.

Each unit of blood will take about 2 hours to transfuse, but the maximum amount of time is 4 hours when the blood will expire. In emergencies, blood can be run as fast as needed, often with pressure bags.

Fresh Frozen Plasma (FFP)

Fresh Frozen Plasma or just Plasma is the portion of whole blood that doesn’t include the red blood cells, which contains clotting factors.

Some reasons FFP may be ordered for your patient include:

  • Massive blood transfusions
  • Severe liver disease or DIC
  • Coumadin with bleeding or surgery (in addition to Vitamin KL when Kcentra not available)
  • Factor deficiency with bleeding or surgery

In massive transfusions, you replace 1 unit of FFP for every unit of PRBCs replaced (along with 1 unit of platelets).

Platelets

Platelets are a blood product that help the body form blood clots and prevent bleeding.

These can often become low from various autoimmune disorders, cancers and chemotherapies, medication reactions, and liver disease.

Platelets are replaced when platelet levels are low, termed thrombocytopenia. Platelets are usually ordered for:

  • Active bleeding with platelet count <50,000/microL
  • Thrombocytopenia in need of invasive procedure or surgery
  • To prevent spontaneous bleeding, usually when platelet levels <10,000/microL

Most platelets that are given are obtained by “apheresis”. One apheresis unit is equal to 4-6 “pooled random donor units”. 1 unit of platelets by apheresis should increase the platelets by about 30K.

Why are Blood products Given?

Blood products are given whenever the blood levels are too low, or when there is acute bleeding. While this will depend on each specific patient and clinician, blood products are generally given when:

  • PRBCs are given when hemoglobin is below 7 or there is ongoing blood loss with hemodynamic compromise
  • Platelets are given when active bleeding with levels <50K, or when <10K.
  • FFP is given with massive blood transfusions, severe liver disease or DIC, or as a coumadin reversal option.

Blood Transfusion Reactions

As with any medication or fluid, there are possible adverse reactions that can occur and that you need to monitor for.

Because we are infusing blood products from a donor, this adds an increased risk of adverse reactions to occur.

Because of this, nurses must monitor their patients very closely during blood product transfusions. The nurse must stay with the patient the first 15 minutes of a blood transfusion (may change depending on specific facility protocol), and frequently check vital signs.

There are common blood reactions, and then there are more rare and severe reactions that can occur.

Acute Hemolytic Transfusion Reaction

An acute hemolytic transfusion reaction is a rare life-threatening blood transfusion reaction to receiving blood, specifically PRBCs.

This happens when incompatible blood is accidentally infused with the patient. This is why the patient’s blood type is checked in the first place so that an appropriate donor can be given.

Compatible blood is outlined below:

Acute Hemolytic Transfusion Reaction

When having a true acute hemolytic reaction, the patient will quickly experience:

  • Fever and/or chills
  • Severe flank pain or back pain
  • Signs of DIC (like oozing form IV site)
  • Hypotension
  • Urine turning red or brown (hemoglobinuria)

This is a severe reaction as the patient’s own immune system and the donor’s immune system attack each other, destroying blood products and causing damage in the process. The patient may experience hemodynamic instability including life-threatening hypotension.

If this reaction occurs, the nurse should:

Acute Hemolytic Reaction: Nursing Steps

If an acute hemolytic reaction is suspected, the nurse should:

  1. Stop the blood immediately and check vitals
  2. Hang NS through a patent IV line. Pt should be ordered least 100-200ml/hr to prevent oliguria/renal failure, or boluses if hypotensive
  3. Notify the MD/APP and blood bank, or call an RRT if unstable
  4. Recheck identifying tags and numbers on blood
  5. Administer diuresis as ordered in those at risk for volume overload
  6. Additional testing may include DIC testing and additional blood compatibility and screenings.
  7. Transfer the patient if required

The Provider should guide treatment, but these are serious reactions and would likely need monitoring in the ICU.

Your facility should have a specific protocol in the event of significant blood transfusion reactions, which often involves re-testing the patient as well as re-testing the blood unit itself.

Acute Hemolytic Blood Transfusion Reaction

Anaphylactic Transfusion Reaction

An anaphylactic transfusion reaction is a severe allergic reaction to something within the blood product. These are rare, with an estimated 1 in 20-50K transfusions.

This reaction occurs seconds to minutes after starting the transfusion.

The recipient is severely allergic to something within the donor blood, which they may have antibodies against, specifically those who are IgA deficient or haptoglobin deficient.

Signs of an anaphylatic reaction include:

  • Urticaria
  • Wheezing and/or Respiratory Distress
  • Angioedema (facial swelling)
  • Hypotension with/without Shock

Treatment involves immediately stopping the transfusion, and then treatment with standard anaphylactic medications. These medications include:

  • Solumedrol 125mg IV STAT
  • Benadryl 50mg IV STAT
  • PEPCID 20mg IV STAT
  • IV Fluids

More significant interventions may be needed, including:

  • Epinephrine .3mg IM STAT +/- IV epinephrine drip with severe bronchospasm or airway edema
  • Vasopressors for hypotension
  • Oxygen and Intubation

The blood cannot be restarted, and additional testing will need to be performed, and blood from another donor will have to be given.

Anaphylactic Blood Transfusion Reaction

Urticarial Transfusion Reaction

An urticarial transfusion reaction is a less severe allergic reaction to a component within the blood products, but much more common, occurring in 1-3% of blood transfusions. This is an antigen-antibody interaction, usually with donor serum proteins.

Patients with this blood transfusion reaction will develop urticaria (hives) with no other allergic signs/symptoms such as wheezing, angioedema, or hypotension.

When an urticarial transfusion reaction occurs:

  1. Immediately stop the transfusion
  2. Check Vital signs and ask the patient for other symptoms (like trouble breathing or facial/throat swelling, dizziness, chest pain, etc)
  3. Notify the Provider
  4. Give IV antihistmine as ordered
  5. Restart blood if hives resolve and no other signs of allergic reaction develop

When an urticarial transfusion reaction is diagnosed, stop the blood for 15-30 minutes, give IV antihistamine like Benadryl, and then restart the infusion once hives resolve but slowly and cautiously. Check your specific facility’s protocol.

Urticarial Blood Transfusion Reaction

Febrile Non-Hemolytic Transfusion Reaction (FNHTR)

A febrile non-hemolytic transfusion reaction is exactly what it sounds like – the patient develops a fever after/during a transfusion, but they are not experiencing other signs of a hemolytic reaction.

This is usually due to a systemic response to cytokines which developed during the process of storing the blood.

These are very common, occurring in .1-1% of all transfusions.

This fever will occur 1-6 hours after the transfusion begins.

Signs/symptoms include:

  • Fever (38-39*+ C)
  • Chills
  • Severe Rigors
  • Mild dyspnea

If the temperature is more than 39°C or 102.2°F, consider a hemolytic transfusion reaction.

Whenever there is a fever present, the main thing to consider is if this could be the first sign of a more serious transfusion reaction such as a hemolytic reaction, TRALI (see below), or Sepsis.

If there is just a fever and no other significant reaction is suspected, antipyretics should be be given, usually Acetaminophen 650-975mg PO. The transfusion can usually be continued but monitored closely.

Future transfusions should be “leukocyte reduced”, which is a process that removes most of the white blood cells within the blood.

Febrile Non-Hemolytic Blood Transfusion reaction

Transfusion-Associated Acute Lung Injury (TRALI)

Transfusion-Associated Acute Lung Injury, known as TRALI, is a rare but one of the severe blood transfusion reactions that can occur after transfusion of a blood product.

This is when the transfused product activates the recipient’s neutrophils, causing acute lung damage.

Patients at risk for TRALI include patients with:

  • Liver transplants
  • Chronic ETOH abuse
  • Smokers
  • Volume overload
  • Shock

The patient will experience sudden and severe respiratory failure during or shortly after a transfusion, but up to 6 hours after the transfusion. This is often associated with:

  • Hypoxia
  • Fever
  • Hypotension
  • Cyanosis

New bilateral infiltrates on CXR are often seen.

TRALI: Nursing Actions

When TRALI is suspected, the nurse should:

  1. Stop the transfusion immediately
  2. Check vitals and ask patient their symptoms
  3. Call an Rapid Response if the patient is in respiratory distress and/or hypoxic/hypotensive (or notify Provider in ED/ICU).
  4. Support oxygen status (oxygen, intubation if needed)
  5. Support blood pressure (fluid boluses, vasopressors if needed)
  6. Notify the Blood Bank
  7. Obtain a Stat portable CXR
  8. Follow any additional orders / administer any additional medications

Sometimes steroids are given, although evidence is not great.

These patients may need to be intubated and will likely need to be transferred to the ICU and closely monitored.

They do not seem to be at increased risk for TRALI to occur again with a different transfusion in the future, however, donors who are implicated are banned from donating ever again.

TRALI

Transfusion-Associated Sepsis

Transfusion-Associated Sepsis is a life-threatening blood transfusion reaction that can occur with the administration of contaminated blood products which are infected with bacteria.

The patient will start developing signs or symptoms within 5 hours after the infusion, but usually around 30 minutes.

Signs/Symptoms of transfusion-associated sepsis includes:

  • Fever >39ºC or 102.2ºF, sometimes hypothermia
  • Rigors
  • Tachycardia >120bpm or >40bpm above baseline
  • Rise or fall of systolic BP 30mmHg
  • Abdominal pain or back pain
  • Nausea and vomiting

Remember that Transfusion-associated Sepsis, Acute Transfusion Hemolytic Reaction, and TRALI can all have similar symptoms.

SEPSIS: Nursing Actions

If transfusion-associated sepsis is suspected, the nurse should:

  1. Stop the transfusion immediately
  2. Check vitals and quickly assess the patient
  3. Notify the Provider (Call an RRT if patient unstable)
  4. Support oxygen and hemodynamic status with oxygen, fluids, etc
  5. Obtain blood work from opposite arm (blood cultures, Coombs test, plastma-free hgb, and repeat crossmatch
  6. Administer ordered antibiotics ASAP (Usually Vanco/Zosyn)
  7. Notify the Blood Bank
  8. Follow any additional orders / administer any additional medications
Transfusion Associated Sepsis

Transfusion-Associated Circulatory Overload (TACO)

Transfusion-Associated circulatory overload, also known as TACO, is when the patient develops acute volume overload after administration of blood products.

This blood transfusion reaction is fairly common, occurring in up to 1% or more of transfusions. This can occur up to 12 hours after the transfusion is given, and risk factors include patients with:

  • CHF
  • End-Stage Renal Failure (i.e. on dialysis)
  • Extremes of age
  • Small stature & low body weight

The more units transfused and the quicker transfused, the higher risk of TACO (just like with IV fluids).

Patients will develop symptoms of respiratory distress which include:

  • Dyspnea
  • Tachypnea
  • Hypoxia
  • Orthopnea

The patient will also usually develop hypertension.

Remember TRALI can have similar symptoms, as well as a pulmonary embolism.

TACO: Nursing Actions

When TACO is suspected, the nurse should:

  1. Stop the transfusion immediately
  2. Check vitals and quickly assess the patient (pay attention to respiratory status and breath sounds)
  3. Notify the Provider (Call an RRT if patient unstable)
  4. Support oxygen status with supplementary oxygen, BIPAP, or intubation if needed
  5. Make sure a STAT portable CXR is ordered/performed
  6. Administer diuretics as ordered (i.e. 40mg IV Lasix)
  7. Follow any additional orders / administer any additional medications

In milder cases, the patient may just require diuretics and supplemental oxygen. More severe cases may require Bipap or intubation.

  CLINICAL TIP

It is a smart idea for the Provider to order 20mg IV Lasix in-between units when multiple units of blood are ordered in someone with a history of CHF or who is very old. If it is not ordered and you feel it may benefit the patient, offer this suggestion to the Provider as it can prevent TACO from occurring.

“Hey this is Jan calling from Med-surg, I just wanted to make sure you didn’t want any Lasix in-between blood units for Mark Smith in 147-2, as they have a history of CHF?”

TACO blood transfusion Reaction

Primary Hypotensive Reactions

Primary hypotensive reactions are very rare, but occur when there is a sudden drop in systolic blood pressure >30 mmHg within minutes of starting a transfusion.

The blood pressure normalizes once the transfusion is stopped. While rare, other severe blood transfusion reactions can also have hypotension, so the patient will need to be evaluated to rule those out as well.

Patients who take an ACE inhibitor like lisinopril are at increased risk for this to occur.

This is also more common with platelet administration.

And those are the acute blood transfusion reactions that can occur when administering blood in the hospital.

Keep in mind that there can also be transmission of infections such as HIV and hepatitis, although very rare and will not present itself during the transfusion or shortly after.

REFERENCES

Kleinman, S., & Kor, D. (2022). Transfusion-related acute lung injury (TRALI). In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/transfusion-related-acute-lung-injury-trali

Silvergleid, A. (2022). Approach to the patient with a suspected acute transfusion reaction. In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/approach-to-the-patient-with-a-suspected-acute-transfusion-reaction

Silvergleid, A. (2022). Immunologic transfusion reactions. In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/immunologic-transfusion-reactions

Silvergleid, A. (2022). Transfusion-associated circulatory overload (TACO). In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/transfusion-associated-circulatory-overload-taco

Spelman, D., & MacLaren,G. (2022). Transfusion-transmitted bacterial infection. In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/transfusion-transmitted-bacterial-infection

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