Transfusion reactions and massive transfusion

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Target exams

Red flags

• Fever, rigors, flank or back pain, hypotension and dark urine within minutes of starting a red cell transfusion is an acute haemolytic reaction from an ABO mismatch until proven otherwise, most often from a clerical error giving the wrong unit to the wrong patient, and the transfusion must be stopped at once
• Acute breathlessness, hypoxaemia and bilateral lung infiltrates within six hours of a transfusion, with a clear volume history and no left atrial hypertension, is TRALI and needs the transfusion stopped and respiratory support rather than a diuretic
• Breathlessness, a raised jugular venous pressure, hypertension and bilateral crackles in a small child or one with cardiac or renal disease given blood rapidly or in large volume is TACO and needs the transfusion slowed or stopped, oxygen and a diuretic
• Anaphylaxis early in a transfusion, with bronchospasm, urticaria and hypotension, raises IgA deficiency with anti-IgA in a child exposed to blood products, and demands the transfusion stop and intramuscular adrenaline at once
• A shocked, bleeding child needing replacement of one blood volume or more needs the massive transfusion protocol activated without delay, with red cells, plasma and platelets delivered in a balanced ratio and tranexamic acid given early in trauma

Life stages

Care settings

Clinical exam formats

Board mappings

• Names the common acute transfusion reactions in children as febrile non-haemolytic, allergic, acute haemolytic, TACO and TRALI
• States that the first response to any suspected transfusion reaction is to stop the transfusion and keep the intravenous line open
• Names the ABO mismatch from a clerical error as the commonest cause of the acute haemolytic transfusion reaction
• Contrasts the complement-mediated intravascular haemolysis of an ABO mismatch with the donor anti-leucocyte antibody neutrophil activation of TRALI and the hydrostatic overload of TACO
• Coordinates the paediatric massive transfusion protocol with its balanced ratio of red cells, plasma and platelets and the early use of tranexamic acid in trauma
• Appraises the paediatric transfusion-reaction epidemiology of Stone and Wang, the haemolytic review of Panch, the Lancet series of Delaney and the TACO and TRALI reviews of Semple, Bosboom, Tung and Yu
• The first step in a suspected acute transfusion reaction is to stop the transfusion, keep the line open, check the airway, breathing and circulation, and return the unit and fresh samples to the blood bank
• Acute haemolytic reaction from an ABO mismatch presents with fever, rigors, back pain, hypotension and haemoglobinuria within minutes, and is managed with intravenous fluids to maintain urine output and renal perfusion
• TACO is circulatory overload managed with stopping or slowing the transfusion, oxygen and a diuretic, while TRALI is non-cardiogenic pulmonary oedema managed with respiratory support and no diuretic
• Builds the bedside rule that every nurse and trainee stops the transfusion at the first sign of a reaction and calls for help before the unit is disconnected
• Synthesises the breathless, hypoxaemic child after transfusion into the TACO versus TRALI distinction using the volume history, the blood pressure and the jugular venous pressure
• Coordinates the massive transfusion protocol activation in the shocked bleeding child with the laboratory, the transfusion service and the surgical and critical care teams
• Level 1: Recognition of the common febrile and allergic transfusion reactions and the stop-the-transfusion rule
• Level 2: Differentiation of acute haemolytic, TACO and TRALI and the stepwise management of each
• Level 3: Leadership of the paediatric massive transfusion protocol and the prevention of citrate, temperature and electrolyte hazards
• The mechanisms of acute haemolytic, TACO and TRALI and their distinguishing clinical features within six hours of transfusion
• The clerical-error root cause of the ABO mismatch and the role of donor anti-leucocyte antibodies in TRALI
• The balanced ratio of red cells, plasma and platelets in the massive transfusion protocol and the role of tranexamic acid in trauma
• Recognition of the deteriorating child during a transfusion and the immediate stop-the-transfusion response
• Structured assessment of the breathless child after transfusion to separate TACO from TRALI
• Communication of the transfusion reaction to the family and the reporting through the haemovigilance system
• Acute transfusion reactions in children classified by timing and mechanism, with febrile and allergic reactions the commonest
• Acute haemolytic reaction from ABO incompatibility, TACO and TRALI as the severe acute reactions and their management
• The paediatric massive transfusion protocol with balanced component ratios and damage-control resuscitation principles
• Recognition of the signs of an acute transfusion reaction during a paediatric transfusion and the stop-the-transfusion rule
• Differentiation and management of acute haemolytic, TACO and TRALI
• Activation and leadership of the massive transfusion protocol in the shocked bleeding child
• Canadian approach to haemovigilance and the reporting of transfusion reactions through the Transfusion Transmitted Injuries Surveillance System
• Stop-the-transfusion rule and the stepwise management of acute haemolytic, TACO and TRALI
• Paediatric massive transfusion protocol with balanced ratios, tranexamic acid and the prevention of hypocalcaemia and hypothermia