Blood transfusion reactions occur when a recipient’s immune system reacts negatively to transfused blood. These reactions can range from mild to severe and may happen during or after the transfusion. Here are some common types:
Types of Blood Transfusion Reactions
- Febrile Reaction: Characterized by fever and chills, often due to white blood cell incompatibility.
- Allergic Reaction: Symptoms include itching, hives, and swelling, usually caused by proteins in donor plasma.
- Hemolytic Reaction: A serious reaction where the immune system attacks transfused red blood cells, leading to dark urine, back pain, and low blood pressure.
- Iron Overload: Occurs with repeated transfusions, potentially affecting the heart and liver.
- Infectious Reaction: Rare but possible if contaminated blood is transfused.
Transfusion Reactions and Its Nursing Management
| Reaction | Signs and symptoms | Nursing management | |
| 1. | Allergic reaction | Hives Itching Anaphylaxis | Stop transfusion immediately and keep vein patent with normal saline. Notify physician immediately. Administer antihistamine parenterally as necessary. |
| 2. | Febrile reaction: fever developing during infusion | Fever and chills Headache Malaise | Stop transfusion immediately and keep vein patent with normal saline. Notify physician. Treat symptoms. |
| 3. | Hemolytic transfusion reaction: Incompatibility of blood product | Immediate onset Facial flushing Fever, chills Headache Low back pain Shock | Stop infusion immediately and keep vein open with normal saline. Notify physician immediately. Obtain blood samples from site. Obtain first voided urine. Treat shock if present. Send remaining blood in bag, tubing and filter to laboratory. Draw blood sample for serologic testing. |
| 4. | Circulatory overload: | Dyspnea, dry cough Pulmonary edema | Slow/stop infusion. Monitor vital signs. Notify physician.Place patient in upright position with feet dependent. |
| 5. | Bacterial reaction: Bacteria present in blood | Fever Hypertension Dry, flushed skin Abdominal pain | Stop transfusion immediately. Obtain culture of patient’s blood and return blood bag to laboratory. Monitor vital signs. Notify physician. Administer antibiotics immediately. |
Procedure
| Nursing action | Rationale | |
| 1. | Immediately stop the transfusion. | Reduces risk of further reaction. |
| 2. | Using gloved hands, remove tubing with blood and replace with new tubing. | Prevents blood in the tubing from being infused. |
| 3. | Maintain the IV line patent with normal saline. Do not use any solutions containing dextrose. | Ensures that fluids/medications can be given in the event of anaphylaxis. Dextrose is incompatible with blood. |
| 4. | Obtain vital signs including oxygen saturation. | Assess patient’s hemodynamic stability. |
| 5. | Remove gloves and wash hands. | Maintains aseptic techniques. |
| 6. | Notify physician of patient’s transfusion reaction, including vital signs and specific symptoms with severity of reaction and time frame. Administer oxygen and place in Trendelenburg position if shock occurs. | Transfusion reaction needs prompt medical attention with efficient and accurate communication of the event. |
| 7. | Monitor patient’s vital signs at least every 15 minutes. | Assess patients’ cardiopulmonary status. |
| 8. | Read the blood component bag to ensure that correct unit was given to the correct patient. | Patient may have received incompatible blood intended for another patient. |
| 9. | Administer medications as prescribed: | |
| Diphenhydramine | Antihistamine given IV, counteracts some allergic responses. | |
| Epinephrine | Epinephrine stimulates alpha receptors and beta receptors in the sympathetic nervous system and decreases respiratory distress in anaphylactic reactions. | |
| Broad spectrum antibiotics | Antibiotics are given when bacterial sepsis is suspected. | |
| Intravenous fluids | IV fluids counteracts symptoms of septic shock. | |
| 10. | Start cardiopulmonary resuscitation if indicated. | Prompt resuscitation may reverse cardiopulmonary arrest. |
| 11. | Obtain two blood samples from the other arm. | First sample is for cross-match to ensure that the correct ABO matched blood was given. In the second sample, the serum is tested for free hemoglobin which indicates hemolysis. |
| 12. | Return the remaining blood and tubing to blood bank. | A sample of blood will be cross-matched with the patient’s samples before and after the transfusion to check for any error in cross-matching. |
| 13. | Obtain first voided urine (within one hour of reaction). | If hemoglobinuria occurs with hemolysis, the urine may be red/black. Renal damage requires prompt treatment to promote diuresis and to prevent renal tubular damage. |
Special Considerations
Caring for a patient experiencing blood transfusion reactions requires immediate intervention and careful monitoring. Here are some special considerations:
- Immediate Response: Stop the transfusion immediately if a reaction is suspected and activate emergency procedures.
- Vital Signs Monitoring: Continuously assess blood pressure, heart rate, oxygen saturation, and temperature to detect worsening symptoms.
- Intravenous (IV) Access: Maintain IV access but do not flush the existing line—use a new IV line if needed.
- Clerical & Identity Checks: Verify that the correct blood product was administered to the right patient.
- Medical Notification: Inform the medical officer and transfusion service provider promptly.
- Symptom Management: Address fever, chills, hypotension, or allergic reactions with appropriate medications and supportive care.
- Hemolytic Reaction Precautions: If hemolysis is suspected, monitor for dark urine, back pain, and low blood pressure, and provide aggressive supportive care.
- Documentation & Reporting: Record all findings and report adverse reactions to the appropriate hemovigilance organizations
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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