AKT · Haematology/Transfusion, spleen & immunity

Transfusion reactions

Adverse reactions to blood components — immunological (ABO/febrile/allergic/TRALI) or volume (TACO)

Overview

Adverse reactions to blood-component transfusion, ranging from mild to fatal. They are recognised by their TIMING and features: acute haemolytic (ABO incompatibility — a never-event from a clerical error), febrile non-haemolytic, allergic/anaphylactic, TACO (circulatory overload), TRALI (transfusion-related acute lung injury), and delayed haemolytic/infection. The immediate response is STOP the transfusion and assess (ABCDE), then manage by the specific type.

Recognise

Acute haemolytic (ABO incompatibility): fever, loin/back pain, hypotension, dark urine, DIC — within minutes; usually a wrong-blood clerical error
Febrile non-haemolytic (commonest): isolated fever/rigors during transfusion. Allergic: urticaria; anaphylaxis (esp. IgA-deficient) — wheeze/angioedema/shock
TACO: pulmonary OEDEMA + hypertension + raised JVP (volume overload, elderly/cardiac). TRALI: acute hypoxia + bilateral infiltrates WITHOUT overload (within ~6 h, donor antibodies)

Red flags

STOP the transfusion immediately for any significant reaction and reassess (ABCDE); recheck the patient/unit identity
Acute haemolytic (ABO) reaction, anaphylaxis, TACO and TRALI are life-threatening emergencies

Differentials & how to tell them apart

TACO vs TRALIboth cause acute breathlessness — TACO has fluid OVERLOAD (raised JVP, hypertension, responds to diuretics); TRALI has normal volume (donor antibodies, treat supportively, no diuretic)

Febrile non-haemolytic vs acute haemolyticisolated fever (benign, slow/stop) vs fever + loin pain + hypotension + dark urine (ABO — emergency)

Allergic vs anaphylaxisurticaria alone (antihistamine, restart slowly) vs airway/breathing/circulation compromise (IM adrenaline; think IgA deficiency)

Investigations

Stop and reassess; recheck identity and the unit; return the unit + a fresh sample to the lab; FBC, DAT, repeat group & crossmatch, LDH/bilirubin/haptoglobin (haemolysis), coagulation (DIC), CXR (TACO vs TRALI), cultures if bacterial contamination suspected; report to transfusion/haemovigilance (SHOT).

Management

STOP the transfusion + ABCDE → manage by type (ABO resuscitate; anaphylaxis adrenaline; TACO diuretic; TRALI support)

1For any significant reaction, STOP the transfusion and assess ABCDE, rechecking the patient and unit identity. Classify by timing and features.Gate: Acute haemolytic (ABO) reaction — fever + loin pain + hypotension + dark urine within minutes — is a never-event emergency (resuscitate, report); separate TACO (overload → diuretic) from TRALI (normal volume → support, no diuretic).
2Manage by type: febrile → paracetamol (often continue); allergic → antihistamine; anaphylaxis → IM adrenaline (consider IgA deficiency); ABO → resuscitate + report; TACO → diuretic; TRALI → respiratory support. Report to haemovigilance (SHOT).

Acute haemolytic (ABO): STOP, resuscitate with IV fluids, supportive care, report — the never-event — recheck identity; treat shock/DIC/renal failure; haematology + transfusion lab

Febrile non-haemolytic: slow/stop, paracetamol — usually benign; can often continue cautiously

Allergic → antihistamine (restart slowly); anaphylaxis → IM adrenaline + stop — anaphylaxis — consider IgA deficiency (use washed/IgA-deficient components)

TACO → stop/slow + diuretic + oxygen; TRALI → stop + respiratory support (NO diuretic) — the diuretic distinguishes management — overload responds, TRALI doesn't

Key points

Any transfusion reaction → STOP + ABCDE + recheck identity. Recognise by timing/features: ABO acute haemolytic (fever + loin pain + dark urine + shock = never-event, clerical error); febrile non-haemolytic (isolated fever, benign); anaphylaxis (IgA deficiency → adrenaline); TACO (overload → diuretic) vs TRALI (acute hypoxia, normal volume → support, NO diuretic). Report to SHOT.

Monitor & prognosis

Observations during/after transfusion, haemolysis/DIC/renal markers, oxygenation; haemovigilance reporting.

Most mild and manageable; ABO/anaphylaxis/TRALI can be fatal — prevention (correct identity checks) is key.

Source: BSH transfusion; SHOT haemovigilance; cross-ref acute_care (transfusion panel)