Guidelines / Advice

Transfusion Reactions

Most of these can be avoided by crossmatch and compatibility testing and strict attention to details of patient name, number, and identification procedures at point of issue. The medical practitioner ordering blood should ensure strict specimen identification of patient name, hospital number, and folder and crossmatch protocol.

Haemovigilance programmes throughout the world (including South Africa) have identified administration of blood to the incorrect patient as one of the leading causes of error (and mortality) in transfusion medicine. For more information on the “Ordering and Administration of Blood” click here

Patients must be monitored at the start of the transfusion and every 15 minutes thereafter. Transfusions should be stopped immediately should there be any signs of an untoward reaction.

A transfusion reaction may be defined as "any potentially adverse sign or symptom which occurs after the start of any transfusion of blood or blood products". It stands to reason therefore that in order to notice any adverse effect, the patient's condition prior to, during and after the transfusion must be monitored.

Bearing in mind that "caution saves lives", it is good medical practice to be suspicious and to take action fast. The steps to be taken if there is any sign that a reaction may be occurring are simple and apply in all instances.

• Stop the transfusion immediately.
• Maintain venous access with normal saline in a new drip set.
• Contact the transfusion service for advice.

Whilst the investigation of the transfusion reaction proceeds, venous access should be maintained with a crystalloid solution for:

• Further transfusion therapy if required.
• Suitable therapy to combat the effects of the reaction.

The basic monitoring of the patient prior to the initial transfusion and during subsequent transfusion should cover:

• Pulse.
• Blood pressure.
• Temperature.
• Respiration rate.
• General visual observation.
• Verbal enquiry as to the patient's well being.

Any abnormal symptoms existing at the start of transfusion should be noted e.g. dyspnoea, chills, oliguria, etc. Changes in intensity of these symptoms may also indicate the potential for a transfusion reaction and should be assessed clinically.

In cases of severe haemorrhage the rate of transfusion precludes monitoring individual units at specific intervals, and the effect of one unit may only be seen at the time of the transfusion of the second or third unit. These patients are however usually closely monitored for changes in their primary condition and transfusion reactions are readily detected.

Extra care must be taken in the unconscious patient to monitor and react to changes in vital signs. Excessive oozing from the operative site or venous access points and unexplained hypotension may indicate that a haemolytic transfusion reaction is occurring.

• Chills/rigors
• Tachycardia/bradycardia
• Hypertension/hypotension
• Chest/flank pain
• Haemoglobinuria
• Agitation
• Fever/sweating
• Dyspnoea/bronchospasm
• Urticaria/pruritus
• Nausea/vomiting
• Oliguria/anuria
• Jaundice

The investigation of a reaction is primarily to exclude severe or life threatening situations. The transfusion service has a specific set of instructions for investigating reactions and it is the legal responsibility of the clinician to assist in this undertaking.

• Clotted blood sample.
• EDTA tube.
• Post transfusion urine sample depending on the nature of the reaction.
• Return the suspect unit/s and drip set to the nearest blood bank. If it is suspected that the reaction is due to bacterial contamination ensure that blood bank is informed so that cultures and gram stains are performed. Obtain blood for blood culture from the patient.
• Complete the reaction report form specifying patient details, reason for transfusion, pre- and post transfusion signs and symptoms.

The list of potential reactions is lengthy, and there are many different ways of classification. Reactions include those due to incompatibility, transmissible disease, bacterial contamination and storage lesions due to the age of the transfused blood products. However, for most practical purposes, the following are the most serious or the most frequently observed and are described fully. read more

The transfusion service should complete and send out a preliminary report of the reaction as soon as possible after receiving the specimens. A full report will be dispatched after completion of serological and/or bacteriological investigation, and will include advice for further transfusion therapy. The report must be inserted into the patient's file.

Beginning in 2000 the blood transfusion services have followed a formal haemovigilance program. The aim of the program is to gather in a structured manner information and reports on adverse events associated with the transfusion of blood products and to analyze and distribute the results. This enables the services and clinicians to direct action to the areas of greatest concern. Haemovigilance is therefore a quality assurance process with the aim of increasing the safety of blood transfusion. Reporting adverse transfusion reactions/effects by hospital staff is thus mandatory for the success of the program. The blood banks will supply forms for reporting such events and this is fed back to a haemovigilance officer at SANBS who collates and analyzes the national data.