Blood and blood product transfusion reaction management

Revised: August 16, 2019

Introduction

A transfusion reaction is any unfavorable event that occurs in a patient during or after transfusion of blood or a
blood component that can be related to that transfusion. An estimated 5% to 6% of all blood transfusion
recipients suffer a recognizable adverse effect as a result of the transfusion.1

When caring for a patient who has received a blood or blood product transfusion, health care providers should
consider any adverse change in the patient's condition a possible symptom of a transfusion reaction and
promptly evaluate the patient to prevent further complications.1

Equipment

Gloves
Sterile cap
Normal saline solution
IV administration set
Supplies for blood collection (see the "Venipuncture" procedure)
Transfusion reaction report form
Stethoscope
Pulse oximeter and probe
Vital signs monitoring equipment
Laboratory specimen labels
Laboratory biohazard transport bags
Facility-approved disinfectant
Optional: oxygen, EPINEPHrine, hypothermia blanket, indwelling urinary catheter and insertion kit,
prescribed medications, prescribed IV fluid, resuscitation equipment

Preparation of Equipment

Inspect all IV equipment and supplies; if a product is expired, its integrity is compromised, or it's defective,
remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your
facility.2

Implementation

Gather and prepare the equipment.

Perform hand hygiene.3 4 5 6 7 8 9 10
Confirm the patient's identity using at least two patient identifiers.11
Provide privacy.12 13 14 15
Explain the procedure, as time allows, to the patient and family (if appropriate) according to their individual
communication and learning needs to increase their understanding, allay their fears, and enhance
cooperation.16
Raise the bed to waist level before providing care to prevent caregiver back strain.17
Perform hand hygiene.3 4 5 6 7 8 9 10
Put on gloves to comply with standard precautions.18 19 20 21 22
If you suspect a transfusion reaction, immediately stop the transfusion; don't allow the blood remaining in
the filter and tubing to infuse.1 23 (See Guide to transfusion reactions.)
Trace the blood administration tubing from the patient to its point of origin, disconnect it from the IV
catheter, and cover the hub with a sterile cap; don't discard the administration set or the blood product.1 24
 Prime a new IV administration set with normal saline solution, attach the administration set to the IV
catheter, and infuse normal saline solution at a keep-vein-open rate.1 Trace the tubing from the patient to
its point of origin to make sure that you've connected the tubing to the correct port.24
Remain with the patient, and immediately notify the patient's practitioner and transfusion services
personnel.
Closely monitor the patient's vital signs for signs of shock.1 Monitor oxygen saturation level using pulse
oximetry, and frequently assess cardiac and respiratory status, as indicated by the patient's condition and
the type of reaction.
Administer treatment, as prescribed, to provide symptomatic relief.1 23
Place the blood bag (even if it's empty), attached IV fluids, and administration set with the related forms
and labels in a laboratory biohazard transport bag18 and return them to transfusion services because
transfusion services personnel will test these materials to further evaluate the reaction.1
Perform a venipuncture in a different vein and obtain a blood sample for laboratory testing to inspect for
hemolysis; obtain a blood sample for repeat ABO group determination and direct antiglobulin test, as
ordered.1 The practitioner may order additional laboratory testing, such as blood cultures, if bacterial
contamination is suspected. The practitioner may also order blood urea nitrogen and creatinine levels to
monitor renal function as well as coagulation studies, such as prothrombin time, partial thromboplastin
time, fibrinogen level, and D-dimer, to identify red blood cell destruction and monitor for disseminated
intravascular coagulation. Notify the practitioner of critical test results within your facility's established time
frame to ensure prompt treatment.25

Clinical alert: Limit phlebotomy and blood loss from laboratory testing to reduce the risk of iatrogenic
anemia.26

Label all samples in the presence of the patient to prevent mislabeling.11

Complete and send the appropriate documentation, usually a transfusion reaction report form, to the
laboratory along with the samples in a laboratory biohazard transport bag.18
Discard used supplies in appropriate receptacles.18 19 27
Return the bed to the lowest position to prevent falls and maintain patient safety.28
Remove and discard your gloves.18 19 27
Perform hand hygiene.3 4 6 7 8 9 10
Closely monitor intake and output; insert an indwelling urinary catheter, if ordered, to monitor urine output in
a critically ill patient.29 Note evidence of oliguria or anuria because hemoglobin deposition in the renal tubes
can cause renal damage.
Make sure that the patient is comfortable.
Reassure the patient and family, as needed.
Clean and disinfect your stethoscope using a disinfectant pad.30 31
Perform hand hygiene.3 4 6 7 8 9 10
Put on gloves, as needed.
Clean and disinfect other reusable equipment according to the manufacturer's instructions to prevent the
spread of infection.30 31
Remove and discard your gloves, if worn.
Perform hand hygiene.3 4 6 7 8 9 10
Document the procedure.32 33 34 35 36

COMPLICATIONS

GUIDE TO TRANSFUSION REACTIONS

Any patient who receives a transfusion of blood or blood products is at risk for a transfusion reaction. A
transfusion reaction may be immediate, occurring during the transfusion or within several hours of
transfusion completion, or delayed. The chart below describes immediate and delayed reactions.1

Reaction and causes Signs and symptoms Nursing interventions

Immediate reactions

Acute hemolytic reaction—

administration of incompatible blood Chills Properly label all blood
Shaking samples in the presence of
Fever (temperature the patient.
increase of 2° F [1° C] or Positively identify the
more) patient and donor blood
Increased pulse rate types and groups before
Pain at the IV insertion the transfusion.1
site Use a two-person
Nausea verification process to
Vomiting verify the patient and
Chest tightness blood component.23
Headache Transfuse the blood slowly
Flank pain (at 2 mL/minute) for the
Hypotension first 15 minutes and
Renal failure or shock (if remain with the patient.23
allowed to progress) Save the donor blood to
reattempt crossmatching
with the patient's blood.1
If an acute hemolytic
reaction occurs, stop the
transfusion immediately
and notify transfusion
services personnel and the
patient's practitioner.23
Maintain patent IV access.
Monitor vital signs for
signs of shock.
Insert an indwelling urinary
catheter, if ordered, to
monitor urine output.1
Send a blood sample to
check for intravascular
hemolysis.
Assess for signs of
disseminated intravascular
coagulation.1
Provide supportive
medical therapies, as
ordered, to reverse shock.1

Bacterial sepsis—blood product

contamination Rigors Use sterile technique when
Chills collecting and
High fever (temperature administering blood
increase of 3.5° F [2° C] products.
or more)
 Shock Ensure that the transfusion
is started within the
facility's designated time
after removal from
transfusion services (for
example, 30 minutes).37
Complete the transfusion
in 4 hours or less.1 38
Don't reuse the filter or
tubing if the first unit of
blood takes 4 hours or
longer to infuse.
If signs or symptoms of
bacterial sepsis occur,
immediately stop the
transfusion.1
Immediately notify the
practitioner and
transfusion services
personnel.1
Treat the patient's fever, as
prescribed.1
Send blood samples from
the patient and blood
component for culture and
sensitivity testing.1
Administer antibiotics, as
prescribed.1

Febrile nonhemolytic reactions—

leukocyte or platelet antibodies, Fever (temperature Administer acetaminophen
plasma protein antibodies, cytokines increase of 2° F [1° C] or or an antihistamine before
from donor leukocytes more occurring during or the transfusion, as
shortly after a prescribed.1
transfusion in the Administer leukocyte-
absence of any other reduced red blood cells
stimulus for fever) (RBCs), as prescribed,
Chills because they're less likely
to cause a reaction.
If signs or symptoms
occur, immediately stop
the transfusion and notify
the practitioner and
transfusion services
personnel.1

Transfusion-related acute lung injury—

complement and histamine release Dyspnea Administer treatment to
caused by granulocyte antibodies in Pulmonary edema support blood pressure, as
donor or recipient Normal pulmonary artery prescribed.
wedge pressure Administer supplemental
oxygen, as prescribed.
Prepare for endotracheal
intubation and mechanical
 ventilation, if necessary.

Allergic reaction—allergen in donor's

plasma Urticaria Administer antihistamines
Flushing before the transfusion, as
Wheezing prescribed, if the patient
Dyspnea tends to experience
Laryngeal edema allergic reactions.1
If the patient develops mild
itching, reduce the
transfusion rate.1
If signs and symptoms are
more severe than mild
itching, immediately stop
the transfusion and notify
the practitioner and
transfusion services
personnel.1
Administer EPINEPHrine,
as prescribed, for
wheezing and anaphylactic
reactions.1
Restart the transfusion, as
ordered, if no other cause
or symptoms occur or if an
antihistamine provides
relief from itching.1
Don't restart the
transfusion if the patient
has a fever, pulmonary or
airway symptoms, or
anaphylaxis.1

Transfusion-associated circulatory
overload (TACO)—rapid infusion, Precordial pain Administer blood products
excessive volume of blood Dyspnea slowly.1
Crackles Use volume-reduced
Cyanosis platelets to prevent fluid
Dry cough overload.1
Jugular vein distention Administer the blood
product using an electronic
infusion device to maintain
flow rate.
Position the patient in a
semi-Fowler or upright
position to increase venous
resistance.1
If the patient develops
signs and symptoms of
TACO, immediately stop
the transfusion and notify
the practitioner and
transfusion services
personnel.1
 Delayed reactions

Delayed hemolytic reaction— Occurring 5 to 10 days after

production of antibodies by RBCs to transfusion Monitor laboratory test
antigens on transfused cells results for anemia and
Fever reduced benefit from
RBC destruction successive transfusions.1
If the patient develops
signs and symptoms of
delayed hemolytic
reaction, notify the
practitioner and
transfusion services
personnel.1

Posttransfusion purpura— Occurring 7 to 10 days after

sensitization caused by pregnancy or transfusion Administer high-dose
previous transfusion immune globulin IV, as
Sudden, dramatic prescribed.
thrombocytopenia Monitor the patient's
platelet count.

Transfusion-associated graft-versus- Typically developing 10 to 12

host disease—engrafting of the T days after transfusion Provide supportive care, as
lymphocytes from the donor's ordered.
component in the recipient that then Fever
react against the recipient's tissue Rash
antigens Diarrhea
Desquamation
Pancytopenia

Special Considerations
Hospital-acquired condition alert: Keep in mind that the Centers for Medicare and Medicaid Services
considers blood incompatibility errors a hospital-acquired condition because it can be reasonably prevented
using a variety of best practices. Be sure to follow evidence-based prevention practices (such as carefully
identifying the patient and blood sample for compatibility testing and participating in a two-person verification
process) before blood or blood product administration to reduce the risk of incompatibility errors.39 40 41

The Joint Commission considers a blood incompatibility error a sentinel event. A sentinel event is an
unexpected occurrence involving death or serious physical or psychological injury or the risk thereof.
Sentinel events require immediate investigation and response. Follow your facility's process for reporting a
suspected blood incompatibility error.42
Be aware that transfusion-related acute lung injury (TRALI) is a leading cause of transfusion-related
mortality. Monitor the patient closely for signs and symptoms of TRALI.1
Be alert for signs and symptoms of shock or cardiovascular collapse. Be prepared to intervene with
emergency medications and rapid fluid administration. Follow advanced cardiac life support protocols if
respiratory or cardiac arrest occurs.
Be aware that the compatibility testing facility must report recipient fatalities from transfusion of blood or
a blood product to the U.S. Food and Drug Administration (FDA) as soon as possible after the event by
phone (240-402-9160), e-mail (fatalities2@fda.hhs.gov), or fax (301-827-0333).
 The reporting facility must also send a written report within 7 days after the fatality addressed to the FDA
Center for Biologics Evaluation and Research Document Control Center, 10903 New Hampshire Avenue,
WO71, G112, Silver Spring, MD 20993-0002.43
The Joint Commission issued a sentinel event alert related to managing risk during transition to new
International Organization for Standardization tubing standards that were designed to prevent dangerous
tubing misconnections, which can lead to serious patient injury and death. During the transition, make sure
to trace each tubing and catheter from the patient to its point of origin before connecting or reconnecting
any device or infusion, at any care transition (such as to a new setting or service), and as part of the hand-
off process. In addition, route tubes and catheters with different purposes in different, standardized
directions; label tubing at both the distal and proximal ends when the patient has different access sites or
several bags hanging; use tubing and equipment only as intended; and store medications for different
delivery routes in separate locations.44

Patient Teaching

Because blood transfusion reactions can occur after completion of a transfusion, teach the patient the signs
and symptoms of transfusion reactions. Tell the patient to be alert to the possibility of a delayed reaction and to
report signs and symptoms promptly.

Documentation
Record the time and date that the transfusion was started, the type of blood component transfused, the unit
identification number, the patient's condition at the start of the transfusion, the patient's vital signs, and your
other assessment findings. Record the time the transfusion was stopped, the volume infused, the patient's
condition, the identity of the person who stopped the transfusion and observed the patient, the date and time the
practitioner was notified, prescribed interventions, and the patient's response to those interventions. Record any
samples sent to the laboratory for analysis, any nursing interventions performed, and the patient's response to
those interventions. If required by your facility, complete a transfusion reaction report form. Document teaching
provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up
teaching.

References
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Additional References
AABB, et al. (2016). "Circular of information for the use of cellular therapy products" [Online]. Accessed July 2019 via the Web at
http://www.aabb.org/aabbcct/coi/Documents/CT-Circular-of-Information.pdf (Level VII)
Crookston, K. P., et al. (2015). Transfusion reaction identification and management at the bedside. Journal of Infusion Nursing,
38, 104–113. (Level VII)
Fridey, J. L., et al. (2017). "A compendium of transfusion practice guidelines (3rd ed.)" [Online]. Accessed July 2019 via the Web
at http://success.redcross.org/success/file.php/1/TransfusionPractices-Compendium_3rdEdition.pdf (Level VII)
Menendez, J., & Edwards, B. (2016). Early identification of acute hemolytic transfusion reactions: Realistic implications for best
practice in patient monitoring. Medsurg Nursing, 25, 88–90, 109. (Level VII)