Investigation and management of non‐infectious transfusion reactions

Appropriate management of non‐infectious adverse transfusion reactions begins with recognition that a change in clinical status during or following a transfusion may represent an adverse event. Appropriate monitoring of patients during transfusion and explicit training of staff to recognize the signs and symptoms of adverse transfusion reactions is the key to diagnosis and to management. As some reactions may occur in the hours following transfusion, patient education and instruction on reporting relevant symptoms are also important. The typical symptoms that herald the onset of a transfusion‐related adverse event include fever, rash, shock and respiratory distress. Haemoglobinuria may also be a presenting feature. Early signs or symptoms may reflect more than one type of reaction. All transfusionists must be aware of the steps in acute management of a suspected adverse transfusion reaction. For those events that occur while the transfusion is ongoing, stopping the infusion and maintaining the intravenous access are the important first step. Rapid evaluation of the patient's vital signs, a bedside check of the unit and patient identification, as well as assessment of the appearance of the blood component, are early steps. Supportive care based on the patient's signs and symptoms must occur while additional laboratory and clinical investigations are initiated. In most cases of transfusion‐related adverse events, a ‘posttransfusion’ blood sample should be evaluated for the possibility of serological incompatibility. In addition, most moderate and severe reactions would be investigated with a blood count, renal and liver function tests and assessment of urine for haemoglobin. Other specific investigations depend on the presenting features and initial serologic findings. Based on the clinical, laboratory and/or imaging studies, most transfusion‐related adverse events can be classified into one of the categories of acute transfusion reactions. These include acute haemolytic transfusion reactions, febrile non‐haemolytic, allergic, anaphylactoid, septic, circulatory overload, hypotension and transfusion‐related acute lung injury. Transfusion‐associated graft‐versus‐host disease and posttransfusion purpura can be considered in some circumstances and delayed haemolytic transfusion reactions may be seen in the days to week following a transfusion. This diagnostic classification is important in optimizing acute management and may also contribute to decisions about component selection for subsequent transfusion. Reporting of adverse transfusion events is also an important part of management. Reporting to the hospital blood bank assists with diagnosis and decisions regarding future blood component therapy. The hospital transfusion committee may monitor transfusion reaction rates and trends as a quality indicator that can be used to change practices. The blood supplier must be notified of all reactions which may be attributable to a particular donor or donor unit, especially if recall or quarantine of associated blood components may be necessary. Regional or national haemovigilance programmes may require notification and can contribute to changes in standard practices to address common or serious adverse transfusion events and in early recognition of uncommon complications.

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