Part of the ICU Emergencies Hub — browse every related guide in one place.
Blood transfusion errors are among the most preventable and deadly patient safety events. The pre-transfusion check requires TWO licensed nurses at the bedside verifying simultaneously:
| Time Point | Action | Rationale |
|---|---|---|
| Before starting | Baseline vitals (temp, HR, BP, RR, O2 sat, pain, urine color) | Detect changes during transfusion |
| First 15 minutes | Remain at bedside; start slowly (2 mL/min or per policy); recheck vitals at 15 min | Most severe reactions occur in first 15–50 mL; early detection = stop before more blood infused |
| During transfusion | Vitals q30–60 min per policy; educate patient to report chills, back/flank pain, itching, SOB, flushing | Ongoing monitoring for delayed reactions |
| End of transfusion | Final vitals; document volume infused and patient response; observe for any delayed symptoms | Documentation and completeness |
| Reaction | Mechanism | Signs & Symptoms | Onset |
|---|---|---|---|
| Acute Hemolytic (AHTR) | ABO incompatibility; IgM antibodies destroy RBCs; complement activation | Fever, chills, back/flank pain (hemolysis = HALLMARK flank pain), hypotension, dark red/brown urine (hemoglobinuria), DIC, acute renal failure, death | First few mL to first 15 min; immediate |
| Febrile Non-Hemolytic (FNHTR) | Recipient antibodies against donor WBC antigens; cytokines in stored blood | Fever (≥1°C rise from baseline), chills, headache, malaise; NO hemolysis | During or up to 4 hr after; common |
| Mild Allergic | IgE-mediated response to donor plasma proteins | Urticaria (hives), itching, flushing; NO systemic symptoms; NO fever | During transfusion; very common |
| Anaphylactic | IgA-deficient recipient has anti-IgA antibodies reacting to donor IgA | Bronchospasm, hypotension, angioedema, loss of consciousness; RAPID onset; life-threatening | First few mL; rapid |
| TRALI (Transfusion-Related Acute Lung Injury) | Donor antibodies activate recipient neutrophils → lung injury; non-cardiogenic pulmonary edema | Acute respiratory distress, hypoxia, bilateral pulmonary infiltrates on CXR within 6 hr; normal or LOW CVP/PCWP (non-cardiogenic); fever, hypotension | Within 6 hr; usually 1–2 hr |
| TACO (Transfusion-Associated Circulatory Overload) | Fluid overload from too-rapid or too-large volume transfusion | HTN, tachycardia, dyspnea, crackles, elevated CVP/PCWP, frothy sputum, pulmonary edema; responds to diuretics | During or up to 6 hr after |
| Delayed Hemolytic (DHTR) | Anamnestic antibody response; not detected by pre-transfusion crossmatch | Unexplained fall in hemoglobin 3–10 days post-transfusion; mild fever, jaundice | 3–10 days post-transfusion |
| Reaction | Additional Interventions |
|---|---|
| AHTR | Aggressive IV fluids (normal saline) to maintain urine output ≥100 mL/hr; furosemide to prevent renal failure; dopamine for hypotension; monitor for DIC; kidney support |
| FNHTR | Acetaminophen for fever (not aspirin); meperidine for rigors; premedicate with acetaminophen before future transfusions; consider leukoreduced products |
| Mild Allergic | Diphenhydramine (Benadryl) IM/IV; may RESTART transfusion slowly after symptoms resolve if ONLY urticaria (per provider order) |
| Anaphylaxis | Epinephrine 0.3–0.5 mg IM (vastus lateralis); airway support; IV fluids; steroids; use washed or IgA-deficient blood products for future transfusions |
| TRALI | Oxygen; mechanical ventilation if severe; supportive care; NO diuretics (preload-dependent; not cardiogenic); report to blood bank (implicated donor withdrawn) |
| TACO | Sit up; O2; furosemide; slow future transfusion rate; smaller volumes; consider pre-transfusion furosemide for at-risk patients |
| Product | Indication | Key Points |
|---|---|---|
| Packed Red Blood Cells (PRBCs) | Anemia; blood loss; Hgb <7 g/dL generally (<8 in cardiac patients) | Each unit raises Hgb ~1 g/dL and Hct ~3%; infuse over 2–4 hr; requires crossmatch; type-specific preferred |
| Fresh Frozen Plasma (FFP) | Coagulopathy; reversal of warfarin when time-sensitive; multiple factor deficiency; DIC | Contains all clotting factors; ABO compatible (type-specific); thaw requires 20–30 min; must infuse within 24 hr of thaw; 10–15 mL/kg dose |
| Platelets | Thrombocytopenia (<10,000 for spontaneous bleed risk; <50,000 for invasive procedure; <100,000 for neurosurgery); platelet dysfunction | Each unit raises platelet count by ~30,000–60,000; ABO preferred but not required; must agitate gently during storage; short 5-day shelf life; infuse over 30–60 min |
| Cryoprecipitate | Fibrinogen replacement; Hemophilia A (factor VIII); von Willebrand disease; DIC | Contains fibrinogen, Factor VIII, Factor XIII, vWF; 10-unit pool typically; infuse quickly |
| Albumin 5% / 25% | Hypovolemia; cirrhosis with SBP (25%); burns; nephrotic syndrome | 5% = iso-oncotic (volume expansion); 25% = hyperoncotic (draws fluid from interstitium); no crossmatch needed; no disease transmission risk |
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