Blood Transfusion Reaction

DRG Category:	916
Mean LOS:	2.1 days
Description:	MEDICAL: Allergic Reactions Without Major CC

Blood transfusion reactions are adverse responses to the infusion of any blood component, including red cells, white cells, platelets, plasma, cryoprecipitate, or factors. They may be classified as acute (within 24 hours of administration) or delayed (occurring days, weeks, months, or even years later). They range from mild urticarial reactions that may be treated easily to fatal hemolytic reactions. It is important to note that almost all fatal hemolytic reactions are attributable to human error. Blood transfusion reactions can be mediated by the immune system or by nonimmune factors (Table 1).

Classification of Transfusion Reactions by Type

Table 1. Classification of Transfusion Reactions by Type
TYPE	CAUSE	SIGNS AND SYMPTOMS
Allergic	Sensitivity to foreign proteins	Mild: Hives, urticaria, fever, flushing, itching
Acute nonhemolytic	Sensitization to donor white blood cells, platelets, plasma proteins	Fever, chills, headache, flushing, muscle aches, respiratory distress cardiac dysrhythmias
Acute hemolytic	ABO incompatibility reaction to red blood cell antigens	Fever, chills, low back pain, flushing, tachycardia, hypotension, vascular collapse, shock, cardiac arrest
Anaphylactic	Administration of donor’s immunoglobulin A (IgA) proteins to recipient with anti-IgA antibodies	Restlessness, urticaria, wheezing, shock, cardiac arrest
Delayed nonhemolytic	Exposure to infectious diseases Viral hepatitis Cytomegalovirus conversion HIV-1 Malaria Graft-versus-host disease Posttransfusion purpura	Patient develops symptoms of the disorder
Circulatory overload	Infusion of blood at a rapid rate that leads to fluid volume excess	Pulmonary congestion, restlessness, cough, shortness of breath, hypertension, distended neck veins
Bacteremia	Infusion of blood contaminated with bacteria	Chills, fever, hypotension, vomiting, diarrhea, septic shock

The immune system recognizes red blood cells, platelets, white blood cells, or immunoglobulins as “non-self” because the donor’s blood carries foreign proteins that are incompatible with the recipient’s antibodies. Typing, screening, and matching of blood units before administration eliminates most incompatibilities, but all potential incompatibilities cannot be screened out in the matching process.

One hemolytic transfusion reaction occurs per 40,000 transfused units of packed red blood cells, whereas nonhemolytic febrile reactions and minor allergic reactions occur in 3% to 4% of all transfusions. One anaphylactic reaction occurs per 20,000 transfused units. The risk of transfusion-related hepatitis B is 1 per 50,000 units transfused, the risk for hepatitis C is 1 per 3,000 to 4,000 units transfused, and the risk of transfusion-related HIV infection is 1 per 150,000 units transfused.

Nonimmune factors are usually related to improper storage. Complications to transfusion reactions include acute bronchospasm, respiratory failure, acute tubular necrosis, and acute renal failure. The most severe reactions can cause anaphylactic shock, vascular collapse, or disseminated intravascular coagulation. Also, current research shows that patients who receive transfusions have an increased risk of infection because the transfusion depresses the immune system for weeks and even months afterward.

Causes

The recipient’s immune system responds to some transfusions by directing an immune response to the proteins in the donor’s blood. Nonimmune factors are involved when the blood or components are handled, stored, or administered improperly. The most dreaded reaction is the hemolytic reaction, which occurs when the donor’s blood does not have ABO compatibility with the recipient’s blood.

Individuals at greatest risk for transfusion reactions are those who receive massive blood transfusions. The transfusions may be administered over a short period of time, such as with trauma victims with severe blood loss or recipients of liver transplants. Individuals who receive a great number of transfusions throughout a more extended period of time, such as leukemia patients, are also at greater risk. Over time, they develop more and more protective antibodies after each unit of blood is received. Eventually, they carry so many antibodies in their systems that they react much more readily than a person who is transfusion-naive.

Genetic considerations

Blood types are heritable. A person with blood type A must have inherited one or two copies of the A allele. The resulting genotype would be either AA or AO. Someone who is blood type B inherited one or two copies of the B allele and could have a genotype of either BB or BO. A person with blood type AB must have both the A and the B alleles, resulting in the AB genotype, and the genotype of a person who is type O must be OO. Each parent donates one of his or her two ABO alleles to each child. The Rh factor allele is inherited independently. An Rh-positive person has one or two Rh-positive alleles with a genotype of Rh+/Rh+ or Rh+/Rh−. An Rh-negative person has a genotype of Rh−/Rh−.

Gender, ethnic/racial, and life span considerations

Infants and the elderly are more likely to experience problems of fluid overload with transfusion, and children are more likely to develop transfusion-related HIV infections than are adults. The incidence of transfusion reactions does not appear to be based on gender. Nonhemolytic febrile reactions and extravascular hemolytic reactions are more common in females who have been pregnant. Ethnicity and race have no known effect on the risk of blood transfusion reaction.

Global health considerations

No data are available.

Assessment

History

Individuals who report a history of numerous allergies or previous transfusions should be monitored more carefully because they are at higher risk for transfusion reaction. A history of cardiovascular disease should be noted because those patients need to be monitored more carefully for fluid overload. Note also if a patient has a history of Raynaud’s disease or a cold agglutinin problem because, before being administered and with physician approval, the blood needs to be warmed. Once the transfusion is in process, the patient may report any of the following signs of transfusion reaction: heat or pain at the site of transfusion, fever, chills, flushing, chest tightness, lower back pain, abdominal pain, nausea, difficulty breathing, itching, and a feeling of impending doom.

Physical examination

A change in any vital sign can indicate the beginning of a transfusion reaction. Note if the urine becomes cloudy or reddish (hemolysis). Observe any change in skin color or the appearance of hives. Be alert for signs of edema, especially in the oropharynx and face. Auscultate the lungs before beginning the transfusion, and note any baseline adventitious sounds; then monitor for crackles or wheezes if the patient shows any signs of fluid overload, and inspect the patient’s neck veins for distention.

Psychosocial

Blood bank protocols have lowered the risk of HIV transmission from more than 25,000 cases before 1985 to a risk of 1 in 50,000 individuals to approximately 1 in 150,000 individuals currently. In spite of the decreased risk, however, many patients worry about contracting HIV when they need blood products. In reality, the risk of hepatitis B and C is much higher. If a blood transfusion reaction occurs, the fears and anxieties are compounded and may warrant specific interventions.

Diagnostic highlights

In the event of a transfusion reaction, immediately stop the transfusion. Send the unit of blood, or empty bag and tubing if the infusion is complete, along with samples of the patient’s blood and urine to the laboratory for analysis. Blood type and crossmatching are repeated to determine if mismatched blood was administered.

Test	Normal Result	Abnormality With Condition	Explanation
Free hemoglobin: Urine and plasma	Negative in urine < 3 mg/dL in blood	Free hemoglobin in urine and blood; hemoglobinuria occurs when > 150 mg/dL of free hemoglobin is present in blood	Transfusion reaction leads to escape of hemoglobin from red blood cells during intravascular hemolysis

Other Tests: Blood culture to rule out bacterial infection, urinalysis for presence of protein, serum bilirubin, haptoglobin, complete blood count, prothrombin time, partial thromboplastin time, fibrinogen, calcium, serum electrolytes

Primary nursing diagnosis

Diagnosis

Risk for ineffective airway clearance related to airway swelling and obstruction

Outcomes

Respiratory status: Gas exchange; Respiratory status: Ventilation; Comfort level; Infection status; Knowledge: Treatment regime

Interventions

Airway management; Airway insertion and stabilization; Airway suctioning; Anxiety reduction; Oxygen therapy; Respiratory monitoring

Planning and implementation

Collaborative

prevention.

Typing, screening, and matching of blood units before administration eliminates most, but not all, incompatibilities. If a transfusion reaction does occur, stop the transfusion immediately and replace the donor blood with normal saline solution. The severity of the reaction is usually related to the amount of blood received. Begin an assessment to determine the severity and type of reaction. In minor reactions (urticaria or fever), the transfusion may be restarted after discussion with the physician and after giving the patient an antipyretic, antihistamine, or anti-inflammatory agent. Ongoing monitoring during the rest of the transfusion is essential. If the patient develops anaphylaxis, the patient’s airway and breathing are maintained with oxygen supplement, intubation, and mechanical ventilation if needed.

Pharmacologic highlights

With an acute hemolytic reaction, there are three conditions to consider: renal failure, shock, and disseminated intravascular coagulation (DIC). To counteract shock and minimize renal failure, the physician prescribes aggressive normal saline or colloid intravenous infusion. Mannitol is often used to promote diuresis. Dopamine may be used if hypotension is a problem. Furosemide (Lasix) may be given to keep urine output at 50 to 100 mL/hr. For pyretic reactions, after the possibility of a hemolytic reaction is ruled out, an antipyretic such as acetaminophen may be given and the transfusion may be restarted with caution. For severe reactions, see the table that follows.

Medication or Drug Class	Dosage	Description	Rationale
Epinephrine	0.1–0.25 mg of 1:10,000 concentration IV over 5–10 min	Sympathomimetic; catecholamine	Given for severe reactions for its pressor effect and bronchodilation
Glucocorticoids	Varies by drug	Corticosteroid	Anti-inflammatory agents that limit laryngeal swelling

Other Drugs: Antihistamines may be given for minor allergic reactions, diuretics may be given to increase renal blood flow in hemolytic transfusion reactions and manage volume overload, and dopamine may be given to maintain cardiac output and renal blood flow.

Independent

Adhere strictly to the policies regarding typing, crossmatching, and administering blood. Check each unit before administration to make sure that it is not outdated, that the unit has been designated for the correct recipient, that the patient’s medical records number matches the number on the blood component, and that the blood type is appropriate for the patient. All patients should have their identification band checked by two people before the transfusion is begun. Notify the blood bank and withhold the transfusion for even the smallest discrepancy when checking the blood with the patient identification. If a transfusion reaction occurs, make sure the recipient’s blood sample is correctly labeled when it is sent to the laboratory. Maintain universal precautions when handling all blood products to protect yourself and dispose of used containers appropriately in the hazardous waste disposal.

Begin the transfusion at a rate of 75 mL or less per hour. Remain with the patient for the first 15 minutes of the transfusion to monitor for signs of a hemolytic reaction. If the patient develops a reaction, stop the transfusion immediately; evaluate the adequacy of the patient’s airway, breathing, and circulation; take the patient’s vital signs; notify the physician and blood bank; and return the unused portion of the blood to the blood bank for analysis. If the patient develops chills, monitor the patient’s temperature and cover him or her with a blanket unless the temperature is above 102°F. Remain with the patient and explain that a reaction has occurred from the transfusion. If the patient has excessive fears or concerns about the risk of HIV or hepatitis infection, provide specific information to him or her and arrange for a consultation as needed with either a physician or a counselor.

Evidence-Based Practice and Health Policy

Pedrosa, A.K., Pinto, F.J., Lins, L.D., & Deus, G.M. (2013). Blood transfusion reactions in children: Associated factors. Jornal de Pediatria, 89(4), 400–406.

A cross-sectional review of all pediatric admissions to an area hospital over a 7-month period revealed that 1,226 out of 5,437 children received blood transfusions, with a prevalence blood transfusion reaction rate of 3.8%. In this population sample, there were 57 transfusion incidents involving 47 children.
Approximately 12.3% of the reactions involved two or more blood products. Platelet concentrate was involved in more than half of the reactions, followed by packed red blood cells (33.3%), and fresh frozen plasma (5.3%).
Most of the transfusion reactions were mild, moderate, or severe allergic reactions (77.2%), and 14% were nonhemolytic febrile reactions.

Documentation guidelines

Response to transfusion: Description of symptoms; severity of symptoms; adequacy of airway, breathing, and circulation; location and description of any skin changes, vital signs, including temperature; complaints of pain or itching
Termination of transfusion: Amount infused, amount returned to blood bank, laboratory specimens sent, timing of reaction from start of transfusion

Discharge and home healthcare guidelines

follow-up.

Teach the patient to report any signs and symptoms of a delayed reaction, such as fever, jaundice, pallor, or fatigue. Explain that these reactions can occur anytime from 3 days after the transfusion to several months later.

Explain that the patient should notify the primary healthcare provider if she or he develops any discomfort in the first few months after transfusion. Attributing these signs to specific diseases may make the patient unnecessarily anxious, but the patient should know to notify the healthcare provider for anorexia, malaise, nausea, vomiting, concentrated urine, and jaundice within 4 to 6 weeks after transfusion (hepatitis B); jaundice, lethargy, and irritability with a milder intensity than that of hepatitis B (hepatitis C); or flu-like symptoms (HIV infection).